John Goldie is a retired GP and medical educator.
Only in the later years of my career — and more clearly in retirement — did I understand what had been troubling me about general practice. It was not simply policy, contracts, or targets, but the slow disappearance of deep, relational knowing. General practice was never designed as a conveyor belt. Yet the consultation is now too often reduced to a data exchange: the patient provides information, the clinician generates a code. Efficient, perhaps — but it is not medicine.
Our task is to help patients decide which story best explains their distress: biological malfunction, moral injury, or a rational response to an irrational burden.
When relational knowing thins, medicine begins to forget what it is for.
Medicine now sits at a crossroads. Our systems reward numbers and throughput; good care depends on relationships and meaning. When the relational dimension is weakened, something essential is lost — not only for patients, but for clinicians too.
The Neurobiology of Presence
Across different traditions, thinkers such as Allan Schore and Iain McGilchrist give language to what many GPs intuitively know: the consultation is a neurobiological meeting before it is a cognitive transaction.1 Tone, posture, pacing, and emotional regulation shape the encounter long before a guideline is reached. This is physiology, not sentimentality.
Yet our consulting rooms often undermine this.2 The computer screen introduces a “triadic” tension, drawing the clinician’s gaze away from the patient. Simple changes — such as an open-triangle seating arrangement — can restore the primacy of the relational field. A regulated clinician can stabilise a distressed patient, improving rapport and diagnostic clarity. Regulation shapes attention, perception, and judgement.
In Martin Buber’s terms, this reflects an “as if” stance: disciplined presence rather than emotional merging.3 The clinician enters the patient’s world without surrendering their own ground. This protects both parties — the patient’s story is not prematurely reduced to diagnosis, and the clinician is not overwhelmed by suffering they cannot carry.
Respect without Collusion
To practise genuine care, we must adopt a non-judgemental stance, regardless of a patient’s choices. This is not moral neutrality; it is clinical precision. Judgement narrows perception. Non-judgement sharpens it.
Factory-speed medicine amplifies bias and premature closure. When we are rushed, we default to shortcuts and stereotypes. A non-judgemental stance preserves the patient’s story without colluding with the system’s reductive tendencies — and makes meaning-making possible. If we judge the story, we cannot help the patient author it.
The GP as steward of meaning
Symptoms rarely arrive alone; they come wrapped in moral narratives. We are no longer gatekeepers of information. We have become stewards of meaning. Our task is to help patients decide which story best explains their distress: biological malfunction, moral injury, or a rational response to an irrational burden.
Someone with chronic pain might say, “Google thinks it’s neuropathy.” What they need is not more information, but help deciding whether that label makes sense in the context of their life. Adding the patient’s story to the medical record helps the next clinician understand the situation and avoids unnecessary repetition.
A realist’s challenge
Symptoms rarely arrive alone; they come wrapped in moral narratives. We are no longer gatekeepers of information. We have become stewards of meaning.
Relational medicine will not survive on goodwill. It must pass three practical tests if it is to survive:
• Time is the physics of care: Complex sense-making cannot occur in ten-minute bursts. We must advocate for weighted scheduling— where clinical complexity dictates the clock — is not indulgence. It is safety.
• The intangible is clinical: The evidence is unequivocal: continuity reduces mortality, unnecessary tests, and repeat appointments. Treating it as optional is a policy choice that increases risk. Continuity is cheaper, safer, and more humane than fragmentation.4
• Meaning must change outcomes: If a patient leaves with the same fear they arrived with, the consultation has failed — regardless of tests ordered or boxes ticked. “Watchful witnessing” is an active clinical strategy, not a failure to act. Satisfaction should be measured not by “Did you get what you wanted?” but “Did you feel understood?”
This is not idealism. It is operational realism.
Micro-practices as Clinical Interventions
If relational medicine is to endure, it must be expressed through small, deliberate acts:
• The one-minute window: total presence in the first sixty seconds often determines whether a consultation unfolds efficiently or defensively.
• The heuristic of silence: a brief pause after a patient finishes speaking can reveal the deeper concern.
• The transparent pivot: once serious pathology is excluded, pivot to meaning: “We have ruled out dangerous causes; now let’s look at what this pain may be responding to in your life.” This invites the patient to move from consumer of fixes to partner in knowing.
Collective Unlearning
No clinician can sustain this work alone. The hidden curriculum—speed, detachment, proceduralism—overwhelms individual resolve unless balanced by collective practice. Reflexive discussion of challenging cases and Balint-style check-ins allow clinicians to explore the emotional landscape, exposing biases and reframing themselves as witnesses to suffering rather than ‘failed fixers.’
The Digital Witness
The consultation now includes a third presence: the algorithm. When a patient brings an AI-generated diagnosis, acknowledging it as a digital witness validates their agency. The GP can then return authority to the relationship using a simple metaphor: the algorithm provides a recipe, but only clinician and patient can taste the meal of a lived life. Plans may be generated elsewhere; meaning emerges only in relationship.
Presence is not a soft skill
Presence is not a soft skill. It is the core technology of general practice. If we lose it, we lose the discipline itself. In a world of algorithms and assembly lines, our most powerful clinical instrument remains our capacity to know our patients — not as data points, but as human beings. Algorithms can name suffering, but only relationships can house it. The quiet privilege of deep knowing is still available to us, one deliberate act, one moment of presence, one reclaimed human connection at a time.
References
- Schore AN. The interpersonal neurobiology of intersubjectivity. Front Psychol. 2021; 12:648616
- Kent L, Goulding R, Voorhees J, Hammond J, Drinkwater J. Why the spaces in which we deliver care matter: implications and recommendations for general practice. Br J Gen Pract. 2024.74(774):326-328.
- Buber M, Rogers C. The Martin Buber–Carl Rogers Dialogue: A New Transcript with Commentary, edited by Rob Anderson and Kenneth N. Cissna. State University of New York Press. 1997
- Pereira Gray DJ, et al. Continuity of care with doctors—a matter of life and death? A systematic review. BMJ Open. 2018;8: e021161.
Featured photo by Cherry Laithang on Unsplash
