Sam visits their GP complaining about a recurring stabbing pain in their gut and frequent bouts of diarrhoea. The doctor asks a series of short questions about the nature of the pain and other symptoms, organises some blood tests, and on the second consultation tells Sam that they have IBS and prescribes a common antispasmodic (mebeverine).
What are the three models of doctor-patient relationship?
Paternalistic
Shared (also called mutualistic)
Informed (sometimes called consumerist)
Which type of doctor-patient relationship best describes the above example and why?
Paternalistic model
This is a doctor-led approach where the GP is focussed on the diagnosis and deciding on the best treatment for the patient.
What ethical principle underlies the above model? Based on the limited information, why might Sam’s GP have failed to live up to this ethical principle in this case?
The paternalistic model is based on the ethical principle of beneficence i.e. doing what is in the best interests of the patient.
However, acting in a patient’s best interests requires knowing what those interests are and there is no evidence from the scenario that the doctor knows what those interests are.
In this example, Sam may already be taking a large number of medications and not want to take more (mebeverine is typically prescribed to be taken 20 minutes before meals) or there could be dietary factors to consider, which might improve the patient’s well being overall.
After a month on mebeverine, Sam returns and sees the same GP to say that the drugs aren’t working; that they still have pain and diarrhoea. Sam wants to try a different treatment and asks what the options are. The GP reaches for the NICE guidelines, lists the various options (of which there are more than ten), answers Sam’s questions and then asks what Sam would like to do.
What type of doctor-patient relationship model best describes this new consultation and why?
The informed (or consumerist) model is the best description of this doctor-patient relationship. Here, the GP is acting as an information provider and the patient is making a choice.
A purely informed model is probably pretty rare in UK practice, given government funding of the NHS and strict NICE guidelines.
What ethical principle underlies this type of doctor-patient relationship?
Autonomy – a patient has the right to make decisions about things that would affect them
Has this ethical principle been fully respected in this consultation?
No – there is no evidence that autonomy has been facilitated. You can’t just give a person information and then expect them to use it. You need to check understanding and use appropriate language and methods of communication. Too much information or detail (as is the case here) might overwhelm the patient.
Doctors also need to be careful that they don’t push a certain agenda e.g. emphasise what they think is best. In this case, they were quoting from the NICE guidelines so the chances of pushing their own opinions could be minimal although you could argue there is a risk they might have favoured or understood some interventions better than others and given more detail as a result.
Describe one way the GP could have changed their consultation style to better respect this ethical principle. Would this have led to a different type of doctor-patient relationship and why?
There are numerous answers you could give. A non-exhaustive list includes:
- Asking about Sam’s ideas, concerns and expectations – this might help the GP list more suitable treatments
- Have the patient repeat back the options to make sure they have absorbed the information
- Ask Sam questions to check their understanding
- Ask about their lifestyle to find interventions that might be most appropriate
- Ask if they were interested in medication or alternatives to limit the amount of information they share
- Explore Sam’s understanding of IBS and current knowledge of available treatments
- What is the most important thing for Sam when deciding how to treat/manage IBS?
Your answer needs to suggest a way the GP could ensure Sam could act autonomously e.g. checking understanding or finding ways to limit the amount of unnecessary/pass the most appropriate information. This doesn’t mean the GP wouldn’t/shouldn’t give important information about risk or suggest alternatives.
If you answered that the GP should give Sam a single option/the next bext evidence-based option, that would be incorrect. You would not faciltiate autonomy.
Not all changes to the GP’s approach would necessarily lead to a change of doctor-patient relationship. Answers 2, 3 and 6 are simply enabling autonomy to they would still be in the informed model. However, answers 1, 4, 5 and 7 are edging the relationship towards a shared decision making/mutualistic model where an exchange of ideas is helping to decide the course of action.
In an exam, you would be unlikely to get a question as vague or as subtle as this but provided you can show how the first part of your answer relates to the informed and/or shared model you can give yourself a mark!
The three main models of doctor-patient relationship are supported by different ethical principles, running along a spectrum of beneficence and autonomy.
What ethical principle would justify the GP (or any other doctor) using the same doctor-patient relationship with all their patients?
Justice – this is the ethical principle that something must be available to everyone
What are three challenges to using shared decision making in all consultations?
The three main challenges are:
- the patient’s access to the information
- the patient’s ability to understand the information
- communication difficulties
You might also consider the following ‘challenges’ although whether they’d be acceptabe in an exam would depend on the question and marker:
- developing the right relationship with your patient
- respecting a patient’s wishes/values that differ from your own
Describe three benefits of shared decision making
Take your pick:
- increased patient satisfaction
- reduced patient anxiety
- improved adherence to medication
- improved self management of conditions
- improved clinical outcomes (for some patients)
- more efficient diagnosis with fewer referrals for tests
