Dependence and caring in clinical communication: The relevance of attachment and other theories

Abstract

ObjectiveClinical relationships are usually asymmetric, being defined by patients’ dependence and practitioners’ care. Our aims are to: (i) identify literature that can contribute to theory for researching and teaching clinical communication from this perspective; (ii) highlight where theoretical development is needed; and (iii) test the utility of the emerging theory by identifying whether it leads to implications for educational practice.MethodsSelective and critical review of research concerned with dependence and caring in clinical and non-clinical relationships.ResultsAttachment theory helps to understand patients’ need to seek safety in relationships with expert and authoritative practitioners but is of limited help in understanding practitioners’ caring. Different theories that formulate practitioners’ care as altruistic, rewarded by personal connection or as a contract indicate the potential importance of practitioners’ emotions, values and sense of role in understanding their clinical communication.ConclusionExtending the theoretical grounding of clinical communication can accommodate patients’ dependence and practitioners’ caring without return to medical paternalism.Practice implicationsA broader theoretical base will help educators to address the inherent subjectivity of clinical relationships, and researchers to distinguish scientific questions about how patients and clinicians are from normative questions about how they should be.

Patients’ sense of relationship with breast cancer surgeons: The relative importance of surgeon and patient variability and the influence of patients’ attachment style

“…In this respect, patients' relationships with surgeons show the same, albeit smaller, influence of attachment as emerged in studies of explicitly psychotherapeutic relationships in mental health care [13]. In the subscales, the effect was clear only in 'goal' alliance, consistent with the view that the relationship centres on the surgeon's potential life-saving role rather than affective behaviour [1]. However, the effect of attachment style was small.…”

“…However, it is not clear to what extent patients' sense of clinical relationship reflects their experience of communicating with their clinicians. Indeed, it has been suggested that it arises largely from patients' own dependency needs [1].…”

“When patients and families feel abandoned”

“…In this schema, patients derive a sense of security by forming strong, helping relationships with their caregivers. These bonds are often strengthened in lifethreatening illnesses, such as cancer, which carry the stigma of death and suffering [11,12]. These strong relationships create expectations for care in patients that are not necessarily shared or even recognized by their clinicians.…”

Comunicación en el currículo médico

“…Si la información obtenida del paciente es confiable, la precisión diagnóstica será mayor. De esta forma disminuyen los [59][60][61][62][63][64][65][66][67][68][69][70] logro de capacidades y competencias que posibiliten el ejercicio profesional y la satisfacción personal.…”

“…El estudiante de medicina se ha comunicado durante toda su vida y en cuanto a esta experiencia [59][60][61][62][63][64][65][66][67][68][69][70] capaces de identificar docentes que son íntegros, es decir, compasivos con sus pacientes, competentes desde lo clínico y con habilidades para la enseñanza 47 . Estos docentes pasan a ser acompañantes del desarrollo de capacidades y competencias por medio de la retroalimentación constante 8,41,61 .…”