In a brief article in the British Medical Journal in 1999, Cathy Charles, Tim Whelan, and Amiram Gafni outlined four types of doctor-patient partnerships for making decision about treatment approaches for treatment. The theoretical approaches they described provide an excellent starting point for discussing types of patient-physician relationships that we, as patients and health care consumers, experience. The approaches described by Charles and her colleagues are the paternalistic, informed, shared, and intermediate. If you think about the health care you have received over the years, particularly if you have a chronic illness, you’ll undoubtedly be able to categorize most of the experiences you’ve had at different times into more than one category.

Paternalistic Approach

For centuries, the primary approach to treating patients has been paternalistic. Characteristics of the approach are well known as it is the most widely used approach to receiving health care. This is especially the case when we go to a doctor or hospital for treatment of an acute health condition, such as being injured, experiencing tightness in our chest, or think we may have pneumonia. In the approach, we acquiesce to our physician’s choice of treatment because we believe that he or she will make the best decision regarding what is the most appropriate treatment for us. We may offer limited information to health care personnel about what we are experiencing although in seeing physicians with an acute illness, they may observe our suffering. In a paternalistic relationship, we are uninvolved in the actual decision making process regarding what treatment we will receive. Charles and her coworkers argued that a provider-patient interaction does not exist as the direction of communication is solely from the provider to the patient. They suggest that the paternalistic model represents an agreement between the provider and patient as to how the latter should be treated, but this would require an explanation of alternative forms of treatment. If we are sent to an emergency room following a serious accident, however, we are unlikely to care about an explanation of any alternatives; we only want to survive. Treatment options cannot be explained as the health care team is often operating within a short time frame to control the condition we present. We all are familiar with this approach to treatment. If we have a chronic illness, however, we may wonder if this is always the best approach for us.

Informed Approach

Charles and her colleagues pointed out that this approach involves establishing a partnership between health care providers and patients based on a division of labor. In the information exchange stage, the physician or health care provider leads and communication is one-way from he or she to the us. The provider describes information on all relevant treatment options, as well as noting their benefits and risks. The amount and type of data discussed gives us enough information to enable us to make an informed treatment decision. Charles and coworkers noted that the responsibility of health care providers in this model is simply to transfer any information relevant for decision making to patients. It is assumed that any evaluation of the information or decision making will be the sole prerogative of us as patients. While there is an exchange between ourselves and our health care provider, the latter are accorded no legitimate involvement in the decision making process. This would is generally not an ideal approach to making treatment decisions, but it has value in certain situations, such as end-of-life plans. It may also have value in providing the day-to-day care for a chronic illness where we wish more information as to how we might enhance our personal competence. Is there a better way, for example, to improve the self-management processes we perform to control migraine headaches? In these instances, our approach is working; we only want information as to how our efforts can be improved.

Shared Approach

The characteristic of the shared model is the interactional nature between providers and patients as both parties simultaneously share all stages of the decision making process. There is a two-way exchange of information, as both providers and we as patients offer treatment options. After a thorough discussion, both parties must agree on what decision to implement. In short, anything relevant for making the appropriate decision is described and discussed. The approach assumes that both health care providers and patients have a legitimate investment in the treatment decision as each party states their treatment preferences while attempting to arrive at a consensus on the appropriate treatment to implement. The challenge for health care providers, suggested Charles and coauthors, is to create an environment where patients feel comfortable expressing their treatment preference. The shared approach is likely the best to take in the daily management of a chronic illness.

Intermediate approaches

There are intermediate or mixtures of the three models. This was barely mentioned in the article by Charles and colleagues but, in reality, this is usually the overall approach that you follow in managing a chronic condition.

Discussion

You want to be included in the treatment equation, particularly as you are responsible for the the day-to-day management of the your illness. This involves your using a shared model with your health care providers. You add your input to that of your physician and agree on the best course of action for you. As only you know what you do on a daily basis to control the condition you experience, you want an equal say in making any treatment decisions. Is it any wonder that more and more of you are proactive with respect to your interactions with health care providers? To establish optimal control over your condition, you must be. The points that you agree on can be altered periodically to fit your illness, but you and your health care providers can decide upon any changes.

We have found that some patients who are very skilled at self-management only want information from their physician. These are patients who are highly competent in executing self-management processes; as there is no need to change what they are doing, they wish any information which would allow them to refine their self-management skills. These patients also through successful performance, have developed considerable self-efficacy that they can do what they need to do to manage their illness.

The paternalistic approach also has a role to play with respect to a chronic condition. Whenever you experience an acute exacerbation of the illness, you want a health provider’s assistance to alleviate or halt the episode. If you experience such a flare-up with diabetes or migraine, you want to rely the knowledge of physicians to provide their knowledge and expertise as quickly as possible. All of the approaches discussed have considerable value in controlling a chronic illness. If you become proficient at performing self-management processes and combine this with the maximal medical care, optimal control can be established over your condition.