Relationships formed in the context of health care are an important aspect of the experience of chronic illness for young and old alike. In the acute care context, human interaction does play an important role in determining satisfaction with health care. In chronic care, however, human interaction is the essence of health care, and in many instances represents the totality of what health-care professionals can offer.
Because chronic illness causes the individual or family to be involved in health care over extended periods of time, relationships with health-care providers tend to evolve. We have been studying the characteristic ways in which these relationships evolve to better understand the experience of chronic illness and apply that knowledge to nursing practice.
The Health Care Relationships Project is an ongoing, qualitative exploration of what happens over time in the relationships that develop between chronically ill patients and health-care providers from the perspective of the patient and family members involved. Fieldwork has included intensive interviewing with patients and their family members who are experiencing a wide variety of chronic diseases (such as multiple sclerosis, cardiovascular disease, inflammatory bowel disease, and diabetes) and receiving a wide range of health-care services (such as chemotherapy, radiotherapy, physiotherapy, surgical intervention, home care nursing, and nutritional counselling).
Among the 73 informants who participated in intensive interviewing, nine were over the age of 65 and another six were between the ages of 55 and 65 . Contributions from these elder informants have helped us develop conceptualizations about the evolution of health-care relationships for chronically ill persons across the life span. In addition, we have noticed some trends within the accounts of the elder subgroup that shed light upon unique aspects of their experience with shifting beliefs about health-care relationships.
Data analysis has confirmed the presence of an evolving process in chronic health-care relationships. We have found that people of all ages enter health-care relationships in a state of "naive trust," evolve through a period of "disenchantment," and eventually enter into a third stage that we have called "guarded alliance."1·2 In this final stage, new kinds of relationships with health-care providers are constructed: relationships that are characterized by constant vigilance and refined expectations.
We believe that people undergo these shifts in perspective largely because they enter health-care relationships with major misconceptions about the values and priorities they assume are held in common with their health-care providers. In essence, patients and family members expect care to be managed and provided by altruistic professionals who share the patient's own view of what "best interest" entails. Sooner or later, there is an inevitable clash between the expectation that a shared understanding of the patient's best interest is the ultimate priority directing care and the reality of professional services in the context of bureaucratic systems. Informants of all ages described similar misconceptions characteristic of the beginning phases of health-care relationships in chronic illness. Accounts of the elder subgroup, however, led us to believe that there is a distinct difference in the values and beliefs they hold. This difference helps explain unique aspects of their experience with relationships in health care.
The Elders' Perspective
When elder informants explained their health-care relationships to us, two distinct stances toward those relationships were apparent. Some of the elders described, in glowing detail, how wonderful their health-care providers were; others believed that theirs were absolutely dreadful. Both groups however, used similar standards with which to explain their opinions. Standards they described appeared to reflect values shared by these elders with regard to how health-care providers were supposed to relate to patients, and how patients were supposed to treat their health-care providers. As one explained, "I'm not the kind of person that usually goes around being an adversary or a combative-type person, but 1 like to be treated as a thinking person and not as an object of research!"
Almost all of the elders saw the general practitioner as the most important health-care provider in the health-care system. While younger informants described relationships with specialists and members of various other healthcare professions as pivotal in their experiences, older informants generally considered these professionals as part of the service that their own doctor had arranged for them. They usually referred to their family physician as "my own doctor," and seemed to believe that an effective relationship with that doctor was the key to negotiating the rest of the health-care system. One elder explained:
Rheumatologists are very strange people. I'm used to support. My family doctor is really neat, and we'll talk. But the ones I've run into ... the Rheumatologists . . . they seem to think, that in an area where there are no real answers anyway, that they have the right answers!
Another informant confirmed that theme in this way: "This particular doctor doesn't like to be told what he should do because he's a specialist, and they like to feel that what they do is the best."
Familiarity with one specific family doctor was highly valued by the elders, and many referred to the longevity of their involvement with the same doctor as the most important measure of the quality of the relationship they shared. One woman stated, "I've been with this one doctor for 20 years, you know. He's very good with me, except that he doesn't listen to my problems." Another informant's story further illustrates the perceived importance of longevity:
Now three times he's missed a diagnosis on me! I don't have the courage to change [doctors] yet because I've had all these problems, and my doctor does know all my problems, but I would like to have one who is interested in geriatric medicine.
Most of our informants described the use of first names as an important reflection of the interest that the physician had in their case. One man justified his long search for the right kind of doctor this way: "Now I have a doctor who calls me by my first name and says 'What's the problem?' And he'll talk to you!"
While it seems unlikely that use of the first name in and of itself constitutes the desired quality of relationship, the elders' focus on this issue implies the value of relationships which include a sufficient degree of intimacy to progress to a first-name basis.
In addition to knowing them by name, these elders believed that "their doctor" should know something about their family background and heritage, and that they had the right to similar information about the physician. Knowledge that his current doctor had once been a socialist, for example, was the reason one gentleman felt so satisfied in his relationship with his particular physician. These personal aspects of the health-care relationship mattered more to the elder informants than did the actual technical competencies and professional services provided by the relationship.
The nature of the service elders expected from their doctors was considerably different from that expected by younger informants. Elders in our study were highly suspicious of physicians who were quick to prescribe medications or who rushed them through the consultation.
As one woman explained when describing what made her relationship with her doctor effective: "Well she doesn't prescribe pills for one thing. And she just gives you a checkup. She's personally interested, and she doesn't prescribe medicine unless it's absolutely necessary." In agreement with the expectations of a one-to-one relationship, another informant explained: "Now I see [Dr X] and I think he's wonderful. You go in, and he's not in any hurry. He'll talk to you. He's an older doctor."
Considering the effort they had made to come out to the physician's office, the elders in our study expected to be treated with hospitality and at least a little social interaction. They rarely expressed a concern about the treatment or information they were offered, but indicated a sincere desire to have their complaints taken seriously.
As one man explained: "I'd go in for a checkup. I'd tell him what was wrong: ? have this pain here.' and he'd say "You're fine. Away you go.' and I got tired of this 'fine' business. I changed doctors."
In general then, the elder informants shared a similar set of values with which they evaluated the relationships developed while obtaining health care. Their shared concerns about familiarity and longevity in their relationships, focus on social niceties as a priority, and disinterest in unnecessary therapies distinguished them from the younger informants in similar circumstances. In addition, their allegiance to the general practitioner as the pivotal health-care team member served to explain some of the different perspectives they held with regard to health-care relationships.
An examination of the evolution of health service and medical care over the last several decades makes it evident that the elders' values about relationships with health-care providers are consistent with the ingrethents of the role as it was enacted earlier in the century. While it may seem remote history to us, the pioneering years of "country" medicine were the environment in which today's elders formed their attitudes and constructed their understanding of how transactions in health care ought to be conducted.
Prior to the 1930s, doctors were rarefy expected to cure illness.3 Because the physician had little in the way of treatment to offer to the person with chronic illness, a one-to-one relationship was the expected service.4 The country doctor served as a wise counsellor ". . . . with his superior education and his carefully schooled expression suggesting that he knew exactly how to put it right, whether he did or not."5 While chemotherapy came into vogue in the 1930s and the technological revolution began in the 1940s, the type of health problems that afflict the elderly were rarely amenable to medical intervention prior to the 1960s.6
Our analysis leads us to believe that while younger informants expect "professionalism" in the health-care provider, elders value and expect the more "paternalistic" attributes of the traditional "country doctor," and continue to use those attributes as standards upon which to judge the quality of the healthcare relationships they experience. Further, we have found that elders demonstrate a variety of rather imaginative strategies with which to re-create this "country doctor" ideology in today's health-care relationships.
Some of our elder informants described bringing gifts, telling jokes, or initiating social inquiry as methods of letting their health-care providers know the type of interchange they expected. They also found these strategies to be useful ways to manipulate health-care professionals into revealing personal information about themselves. By collecting personal bits of information about the doctor's heritage or gossip about his or her family background, they felt an increased familiarity with the doctor as a community member. The importance of the personal aspects of the relationship is illustrated by our finding that some of the elders maintained loyalty to their relationship with their doctor even after repeated evidence of disinterest or even incompetence.
Other elder informants refused to negotiate with physicians who would not show the desired level of personal interest and sought their health care elsewhere. In these instances, however, they made it clear that they relied upon the other health-care professionals, such as nurse clinicians or social workers, only because, as one said: "the doctors today just aren't any good." Many of their strategies reflected the desire to find a physician who would conform to their values or not bother with them at all. In several instances, the elders had become quite militant in their consumerism and well informed about their health-care needs.
Implications for Practice
As physicians who share the "country doctor" heritage retire or die off, there are fewer and fewer authentic health-care relationships available for elders to rely upon. The concerted effort of some elders to generate healthcare relationships that reflect the "country doctor" values suggests that we, in the health-care professions, could learn something about how to respond more directly to their needs.
Since elders' appreciation of healthcare service may depend upon their relationship with their general practitioner, overt recognition of the importance of that member's role in the health-care team may be reassuring to some patients. Particularly in the case of those who actually have minimal contact with that health-care team member, reminders of the physician's role in making care decisions may be comforting. While nurses appreciate and value their autonomous role, for the elder client traditional role structures continue to hold meaning. By emphasizing our ongoing communication with the patient's "own doctor," we permit the patient to retain the comfort and security developed in that healthcare relationship while fostering gradual development of new relationships.
In addition, all health-care professionals involved in the patient's care could make use of the country doctor legacy to modify some aspects of their behavior toward meeting the special needs of elders. For example, longevity in relationships could be enhanced to some extent by planning staffing and programming policies. Continuity in our relationships also would make meaningful social interchange more likely in the context of health-care service. Maintaining a professional distance may be appropriate in some health-care contexts but it seems particularly hard on our elder clients. By strategic disclosure of information about ourselves, we may be able to foster trust and confidence in the healthcare service we provide.
Social amenities, built into our service agencies, also could be especially geared to the interests of our older clients. Awareness of how we use time and space in our encounters with elderly clients is an important beginning toward identifying ways in which our current services could meet their expectations of what health-care relationships should entail.
Finally, we should recognize in a more formal sense that what elders expect from us is not cure or medical treatment, as much as reassurance that they have someone who will advocate on their behalf. Rather than allocate our resources on the basis of physical care needs alone, we should search for ways to bring recognition of the importance of relationships into our program plans and administrative decisions with regard to the health of the elderly client population.
Whether they approach us with cheerful compliance or as militant consumers, elder citizens seek relationships in health care that acknowledge their personhood more than their pathology. We in the health-care professions seem to have lost sight of what matters beyond curing. The values of our elders, however, could serve as a rich resource to help us to remember.
- 1. Robinson CA1 Thome SE: Strengthening family "interference." J Adv Nurs 1984; 9:597-602.
- 2. Thorne SE, Robinson CA: Health care relationships: The chronic illness perspective. Res Nurs & Health, in press.
- 3. McKechnie RE: Strong Medicine: History of Healing on ihe Northwest Coast. Vancouver, JJ Douglas, 1972.
- 4. Johnston WV: Before the Age of Miracles: Memoirs of a Country Doctor. Toronto, Fitzhenry & Whiteside, 1972.
- 5. Jack D: Rogues, Rebels, and Geniuses: The Story of Canadian Medicine. Toronto, Doubleday, 1981, p 624.
- 6. Fleck LM: Decisions of justice and health care. J Gerontol Nurs 1987; 13(3):40-46.