I'm a little confused about the current discourse around person-centred care. I agree it seems inappropriate to call people ‘patients’ – some feel it objectifies people as dependent, helpless, passive and devoid of their personhood; a relic of the old days of medical paternalism. It no longer reflects today's reality where people are capable of sharing decisions and being the active agent in their healthcare.
Taking it further, I'm less happy that some now regard ‘patients’ as consumers or customers – it doesn't reflect the deeper, complex reality of healthcare and is usually used by people who are far removed from direct contact with ‘service users’.
I’m a strong advocate of person-centred care but am worried that some may put undue focus on the individual. It may imply that the person is at the centre with professionals and services orbiting around their needs and wants. This is not bad, but undermines the fact that, in the healing context, healthcare takes place within relationships. The term ‘person-centredness’ diverts us from the needs and wants of the other side of that relationship: the healthcare professional. Doctors and nurses are people too.
There’s been a long-running debate as to who is the most important person in the consulting room or operating theatre. Most would initially say ‘the patient, of course’. The counter argument would then say ‘but if the needs of the doctor are not met, then the patient could suffer’. The point is, both are equally important and share an interest in each other's wellbeing. Person-centredness risks ignoring this reciprocal relationship and its therapeutic potential.
Many years ago, working as a hospital medical registrar, I was woken at 3am by a call from a GP. I’d been working flat-out since the previous morning and had just got to sleep. The GP was sending someone who was seriously ill with a heart attack, who he feared might die en route. I knew I wasn't going to get any more sleep and genuinely hoped, for my sake, that he would die in the ambulance.
I then started crying. It was the realisation that I had reached a point where, albeit temporarily, I had been drained of all empathy and compassion. Self interest and preservation had taken over and I was meeting a part of myself that had become detached from my humanity. I didn't like it and felt heartless, ashamed and angry. This was not what I had gone to medical school to become. It was time for a break.
Sometime later I was travelling in Kathmandu with my now wife. With a Western doctor who was doing ‘home visits’ to local Buddhist monasteries, we visited a very large and venerable Rinpoche, a high Lama. He sat in his maroon and saffron robes, cross-legged up on his raised dais in a dark monastery, lit by flickering butter lamps. We were allowed to ask the Lama a question. It felt surreal, like a moment from a 1970s kung fu TV series.
I couldn't resist. If anybody knew about compassion it was a high ranking Tibetan Lama. Through a translator, I asked him, ‘how, when I'm tired, overwhelmed and frightened, working flat out in a relentless NHS hospital, can I practise compassion?’
There followed a long silence. He closed his eyes, swayed his body and murmured deeply to himself. I had an idea he would tell me the importance of self care and meditation; to learn to regard my patients as if they were my own family; that compassion is something you have to practice. It seemed to take ages before he spoke. I felt stupid asking that question. How could he possibly know what it was like to work in a Western hospital?
Finally the answer came, just two words: ‘You can't’.
It was a powerful moment. Firstly, it was a reminder that not only do Buddhist Lamas know a thing or two about compassion, they also know about wisdom. It was also a profound absolution. I was not heartless – compassion had been drained from me by the inhumanity of the conditions I was working under. It's hard to feel sorry for someone else if you pity yourself more.
While self care and professionalism are important, they are not sufficient. Compassion and medical altruism cannot happen if the conditions and culture we work in undermine our humanity. A Tibetan monk, in a monastery in Kathmandu over twenty years ago, already knew what the events in Mid Staffordshire and the resulting Francis inquiry would discover, years later.
So, dare I suggest, we need to enrich the conversation about person-centred care. A focus on the ‘service user’ may lead some to neglect the frailties, vulnerabilities and humanity of the people looking after them. People, both ‘patients’ and their healthcare professionals, need one another. We have to place this relationship at the centre of healthcare and build a system around it for it to flourish.
Most health policies and strategies are not assessed for their impact on the therapeutic relationship. It's a shame, as I’d wager that anything that seeks to replace, distance or inadvertently undermine that relationship, will ultimately be a costly fail.
Graham is a GP and National Clinical Lead Self Management and Health Literacy, Scottish Government, www.twitter.com/KramerGraham.
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