Everything happens in the context of a relationship

Tim Senior is a GP, Tharawal Aboriginal Corporation, Airds, Australia.

I don’t need to tell a GP audience this, but it’s always worth a reminder. For us GPs the relationship is everything. Outside GPs this doesn’t seem widely understood. Everyone will agree that relationships are crucial, but usually in a way that means it can be written on a whiteboard without being understood.

All the visible things that happen in general practice are surface activities that look like they could be done by anyone. And to be truthful, they could be done by anyone. However, these tasks are all changed by the context of the relationship.

Whether it’s as simple as taking a patient’s blood pressure, or as complex as managing chest drains in palliative care, the significance for the patient depends on the trust they have in the practitioner, the explanations, and meanings of the treatments. Ultimately, the patient will remember how the practitioner makes them feel, as much as the interventions and procedures.

We’ll all have our own examples. I’ve had patients refuse to see other, more specialised professionals because they are anxious about getting to know a new person. I know other patients have tested me out with simple problems to work out whether I can be trusted with their more important ones.

What happens if we just see health care as a series of health-related interventions, and not as an ongoing relationship?

Patients will become less involved in decisions about their care, because any conversations about true shared decision making are conversations based on trust. Patients will be deemed to be less compliant because they’ve been given facts about the treatment options, but there’s no discussion with a trusted person, which is the key to acceptable advice. Opportunities for prevention will decrease. Vaccination or screening will become an intervention only offered at its own consultation, losing opportunistic prevention that depends on doctor and patient knowing each other. Most significantly, without deliberately prioritising relationships and trust, patients won’t have the security needed to disclose abuse or violence, or other problems that they might experience shame or embarrassment for.

As GPs, we probably need to get better at explaining the importance of relationships. In developing research evidence we’ve had to develop standardised, repeatable tools and interventions, which minimises the relational aspect, and makes them appear much more like a procedural intervention. It does sound like motivational interviewing or a Kessler-10 is something we do to a patient. The health professionals aren’t interchangeable in these consultations. That’s not to say that multidisciplinary teams can’t provide relationships. Again, team-based care is different in the context of a relationship. These aren’t individual practitioners working independently of each other. The GP can introduce the other team members as required to their patient as their own trusted colleagues.

How could relationships be prioritised systemically? Relationships are a feature of time. While GPs frequently work hard in individual consultations to establish rapport, relationships develop over multiple consultations. A system that encourages continuity of care with individual practitioners will go a long way toward encouraging relationship-based care. Do this, and we can trust that the rest will follow.

Featured photo by Akinori UEMORA on Unsplash.