Relationship based care – how general practice developed and why it is undermined within contemporary healthcare systems

Abstract

Objective: Investigating the state of generalism in medicine from the outlook of general practice. Line of argument: General practice developed when its pioneers, in continuing relationships, learnt to know their patients through the variety of medical situations. From the 50s, there is an increasing literature on the virtues and challenges of relationship based general practice, and register-based research indicate its benefits. Generalist perspectives and person-centeredness are implemented in specialised care and medical education but need to be complemented by an input from relationship based general practice. The politically defined aim of primary care is not to balance the draw-backs of specialisation, but to provide medicine at the primary care level. In Sweden, and increasingly even in traditional strongholds of general practice, team-based primary care is thought to respond to increasing demands, filtering out non- and minor disease through triage, practicing task distribution, and moving the GP to a secondary level working with the ‘really sick’, in all a decline in direct contact between patient and GP. Conclusions: When this happens, clinical medicine as a whole becomes drained of the practice of its human dimension. The lack of absolute proof of medical benefits cannot justify a disregard of the value of mutual knowledge and trust in the relationship, but still, in several countries, relationshipbased general practice will be hard to achieve for GPs planning their career. If the political winds should change, a sustaining profession of GPs preserving their relational ethos inside the team model, may be prepared to reform primary care. KEY POINTS Proclaiming both biomedical breadth and the trustful relationship between doctor and patient, as a specialty, general practice embodies medical generalism. A direct input from the patient’s personal GP is necessary to make specialised care become more comprehensive and individualised. In reality, the team, practicing triage and task distribution, is increasingly replacing the doctor-patient relationship as working mode in primary care When the disease rather than the doctor-patient relationship, becomes the organising principle of primary care, medicine as a whole will be drained of the practice of its human dimension.

Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review

“…Within a 'relational' model, ongoing and open-ended interactions allow link workers to assess, adapt and respond iteratively to patients' ever-changing needs and make appropriate recommendations. In contrast, within a 'transactional' model, the service to be exchanged (e.g., assessment of patients' needs and referral to community-based interventions) has pre-established limits (e.g., a maximum of 6 session with a 'Wellbeing Coordinator'( 7)) resulting in a lack of dynamism and flexibility that may hinder the co-production and customization of care provision (31,32). Therefore, we considered 'relational' SP best practice.…”

Increased importance of digital medicine and eHealth during the Covid-19 pandemic

“…This aspect of eHealth was one of the challenges recently discussed by Rudebeck claiming that 'relationship based general practice may be no more than a historical parenthesis'. [15]. My own reflections as a practicing GP yields a more optimistic view by citing Terentius 'Homo sum: humani nil a me alienum puto'.…”

Our core values will endure

“…When taken together, the principles of Family Medicine represent a worldviewa system of values and approaches to problemsthat is identifiably different from that of other disciplines [2] During the following decades, societal trends have impacted both the context and the standards of care, that is, workload, tasks and organization within healthcare in general, and in General Practice in particular. Some of these trends have been described in this journal [3][4][5][6][7][8][9][10].…”

“…Relationship-based care is one of the cornerstones of general practice [ 5 , 8 , 9 ]. Yet, due to societal trends in many countries, the organization of contemporary healthcare systems threatens the doctor-patient relationship mode of care.…”