Ian McWhinney and the doctor-patient relationship

McWhinney’s first principle of family medicine

The first principle of family medicine McWhinney characterized was “The person, not the problem.”³ What does that really mean? Phrases like the doctor-patient relationship and patient-centred medicine are now so ubiquitous they are often used as little more than token statements of aspirational intent, removed from the deeper meaning that Balint and McWhinney originally envisioned. There is a quote by Dr Iona Heath (which she attributes to Dr Eric Cassell) that resonates in this regard:

In hospitals the diseases stay, and the patients come and go. In general practice, the patients stay and the diseases come and go.⁴

It is that focus on the patient, not the disease, which is the central premise of family medicine. Of course, attention needs to be paid to both, and McWhinney’s corollary observation that the family physician is a skilled clinician is critical. The challenge placed upon family doctors is that, in addition to knowing the diseases well, they also need to understand the illness experiences of their patients by understanding who they are and their contexts.

Family doctors do much of their work alone in a 1-on-1 setting within the consultation. The consultation has become the signature tool of the family doctor, where for a brief period of time—and in a private setting—the patient is afforded the opportunity to explain to the doctor what is troubling them. The nature of that relationship, where both doctor and patient co-create a story and a plan together, is the essence of family medicine as a specialty.⁵ This work is not easy. The expertise that family doctors have when it comes to interpreting the complex interplay between patients’ emotions, psychology, life circumstances, and physical health requires intellectual and emotional energy, effort, and time.

Canadian primary care crisis

Primary care in Canada currently faces huge challenges.⁶ Tension exists between the dominant paradigm of evidence-based biomedicine—which fits patients into disease management plans using a hypothetico-deductive and rule-based algorithms—and the way experienced family physicians delivering personal generalist care actually think and work using abductive and divergent thinking.^7-9 As Dr John Meunch states:

Abductive inference starts with an incomplete set of observations and proceeds to their likeliest possible explanation. Given the complexity of patients’ life-worlds and the possible hidden variables that might be affecting them, generalists nearly always navigate in the face of incomplete information.⁹

Current approaches to the Canadian primary care crisis focus on delivering more disease-focused care at scale and speed, with an emphasis on remuneration models, technology-based approaches including artificial intelligence, proposals to increase recruitment, and strategies for more access. However, addressing care access without addressing continuity—a clear indicator of quality in primary care outcomes¹⁰—is inadequate. Without continuity, doctor-patient relationships become more fragile and less impactful.¹¹

We are now in an era of what Dr Phil Whitaker described as “taxi-rank medicine.”¹² At a taxi rank in an airport or train station, hailing the first taxi will do, and it does not matter which taxi shows up first. Emphasizing care access at the expense of continuity adds to the growing sense of an increasingly industrial and impersonal model of health care. The depersonalization of family medicine is a real and concerning trend. It is making the work of family physicians less satisfying and less meaningful.

The unique relationship between an individual patient and their doctor, characterized by patient-centred consulting and shared decision-making, and is exactly what contemporary family physicians have trained for and want passionately to deliver, is now in existential crisis.

Strengthening the doctor-patient relationship

How do we strengthen the doctor-patient relationship? This should be a foundational component of every family medicine residency training program in Canada. Despite the external factors at play (remuneration, administrative burden, patient demand, and the sheer volume and complexity of increasingly multimorbid patients), we must not neglect the basic principle McWhinney declared in his classic work: the person, not the problem.

What makes this challenging for the 21st century family medicine trainee? Dr Abraham Maslow’s hierarchy of needs¹³ suggests that to really pay attention to the person you need first to be comfortable with the medicine. The transition from final-year medical student to first-, then second-year resident is incredibly demanding, and dominated by 1 overriding preoccupation: Do not kill anyone. The key question we need to ask all aspiring family physicians, whether they are medical students, residents, or newly minted family doctors in their first few years of practice is, “What kind of doctor do you want to be: a transactional family practitioner or a healer?” However, there are some strategies that can keep the doctor-patient relationship front and centre during this crucial phase of transition from medical student to independent practitioner.

First, teaching the consultation should be a central tenet of any family medicine residency program. The consultation is the defining experience of family physicians, so it needs to be deconstructed, examined, and put back together so residents understand how best to use that privileged time with their patients. The study of the consultation is not just a soft skill or a nice-to-have; it should be prioritized in the same way we consider other important topics such as hypertension, diabetes, or menopause.

Second, doctors need to be curious about their patients as human beings, not just their diseases. When that happens, empathic responses and listening—crucially active listening—follows. In a recent Canadian Family Physician editorial,¹⁴ Dr David Ponka described the liminal space between the art and science of medicine. Powley and Higson¹⁵ state that, because primary care is about people, not just diseases, primary care education needs to base itself in the arts as well as the sciences. Art stimulates different ways of thinking, provides emotional support, and helps identify parallels and insights into everyday life. Humanities provide a bridge between science and the human experience. Drawing on the discipline of humanities allows learners and teachers the opportunity to gain intuition and understanding of how to help doctors think in ways that close the gap between disease and illness.

Yes, we need to know our medicine, and know it well, but understanding and appreciating the patient as a person with context, and not as a technical problem to be solved, remains the essence of family medicine as envisioned by McWhinney. British author Polly Morland’s book, A Fortunate Woman: The Story of a Country Doctor,¹⁶ is a compelling contemporary account of how the focus on whole-person medicine can still be an aspirational goal, despite current challenges in delivering personal generalist care.

Third, doctors need to be aware of the dynamics and tensions that occur during consultations. Consultations are complex constructs where both cognitive and affective factors are actively at play, and attending to the emotional components of each clinical encounter is fundamental. Awareness of emotional context and our feelings during consultations, including countertransference and defensive reactions, will affect outcomes. Balint’s idea of the doctor as “drug”¹ addresses the fact the doctor is not merely a treatment vector but also acts as an independent (unconscious) therapeutic agent. Regardless of what doctors do or not do medically during the consultation, there is a treatment effect that cannot be dismissed. Balint groups, run by experienced and trained leaders, can be used to provide a space to explore awareness of the psychodynamics of the doctor-patient relationship, encourage divergent inductive thinking, help doctors to hold uncertainty, provide support and wellness benefits, and place the humanity of what doctors do with their patients front and centre.¹⁷

Fourth, teaching and learning whole-person medicine does not naturally fit into a rigid model of competencies and entrustable professional activities, as the doctor-patient relationship requires time to develop. Prioritization of longitudinal experiences with patients is essential. The inductive reasoning approaches needed for generalist care require an amount of emotional and intellectual capacity for which adequate time, space, and resources must be allocated in family medicine residency programs.

Final thoughts

McWhinney’s book² remains a classic, and many decades after the first edition was published, it remains—in my opinion—the best articulation of what makes family medicine a specialty in its own right. The person, not the problem, remains a guiding principle as we work to strengthen personal generalist health care and train future generations of family physicians for this challenging, complex, but critical and deeply fulfilling role.