In the last blog, we looked at how the doctor-patient relationship is often built upon an arbitrary hierarchy where the doctor assumes a position of power and the patient one of submission. In Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer, Barbara Ehrenreich further articulates this power dynamic in anthropologic terms: as a ritual that has evolved over time to heighten the magical powers of the doctor, but which may have outlived its utility.
In thinking about models of care, we can ask: What is the therapeutic goal of the clinical encounter? Or, in plain English, why do people go to the doctor? In the traditional biomedical model, the answer is to cure disease and treat symptoms—a disease-centered approach to care. As this has been the dominant model of clinical care in medicine for the past century, it is telling that the word clinical is also used to mean “efficient and emotionally detached.” The master clinician in this model has a singular focus to see through people to root out disease.
In patient-centered care, the goal is to support the patient (literally one who suffers), a person defined by their illness. Stemming from a biopsychosocial model,(1) the clinician now acknowledges that the system of ailing cells sitting in front of them is not simply an organism, but a person with subjective perspectives living in a social context. The goals of medicine now shift from cure to care, and particularly to understanding and alleviating suffering. (2)
In person-centered care, the clinician doesn’t define the person in front of them by their illness or constrain their humanity through the role of patient, but rather intentionally acknowledges them as a whole, complete and competent person. The goals of medicine are now able to be much broader and defined by the person living with illness but may move beyond the relief of suffering towards personal growth, spiritual growth, joy, and meaning.
Before getting too righteous, it’s worth pointing out that these models of care are complementary, like different tools in a toolbox. For example, most people who get bacterial pneumonia and go to the doctor want and expect their disease to be cured by antibiotics and would probably not appreciate a lengthy discussion of their life before the pneumonia and what’s most important to them moving forward. However, if a doctor only has a hammer (or a prescription pad, or a surgeon’s knife), then everything becomes a nail. Opportunities to alleviate suffering that go beyond disease, and opportunities to promote aspects of life that transcend the removal of suffering, are not simply missed, they are completely invisible because intention determines perception.
References:
1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136.
2. Cassell EJ. The Nature of Suffering and the Goals of Medicine. 2nd ed. New York, NY: Oxford University Press; 2004.