A perfect fit

We wish to congratulate Drs Lussier and Richard for their cogent Commentary in the August 2008 issue of Canadian Family Physician.¹ We agree with the important premise—one shoe does not fit all patients. It is wonderful to hear this from other primary care providers.

We are, however, concerned that the notion of patient-centredness suggests a single style of practice. It does not. The very term patient-centred implies different conversations with different patients for all sorts of reasons, which the authors outlined very well. We are also concerned by the authors’ statement that a patient-centred approach “most closely corresponds”¹ to care of chronic conditions in which the psychosocial aspects of management might be important. A fundamental principle of our approach to patient-centred care is that it applies to every encounter between patients and physicians—in hospital or in the office—no matter how serious the circumstances. For example, if a patient with a sore throat wants a quick visit with minimum intervention, a patient-centred family doctor will ascertain this quickly. He or she will still provide all the required care for respiratory disease, but will not (because the patient has cued them) make inquiries about other problems or about feelings. On the other hand, if a hospitalized patient becomes uncomfortable and teary with panic after cardiac surgery and needs to express physical and emotional feelings, a patient-centred family doctor will be sure to explore these issues in depth to both avoid possibly serious physical consequences and relieve emotional stress. There are clearly exceptions to every rule; in fact, it can be said that every patient is the exception because each requires a unique response.

As well as finding a communication pattern that fits the patient and the context, the patient-centred approach seeks to integrate the world of the patient and that of the physician—it is not just about communication, it is a clinical method.

The College of Family Physicians of Canada’s certification examination makes it clear that patient-centred practice varies from patient to patient while, at the same time, providing a consistent structure from which a resident can learn. The dynamic interplay between simplicity and reality occurs when teaching and researching patient-doctor communication.

This paper is a great addition to the literature. Patient-centred care requires flexible physicians who are willing to modify their approaches to suit patients’ wishes, context, and urgency of problems. Being sensitive to suffering and personal circumstance is always relevant, no matter how serious the medical condition.