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Thursday Review: “Relationship-centered Care: A Constructive Reframing”

One of the most important concepts of my training in storytelling is one of the most overlooked.

The technical term is “The Space Between”. The idea is that one force alone is uninteresting, if not meaningless. It has to act with or against something else to be interesting and meaningful. This is a way of realizing that a story happens not because one person does something, but because a person does something to someone else. The Space Between, then, changes our thinking. Storytelling isn’t based on individuals, but is focused on the literal empty space between characters.

In a paper titled “Relationship-centered Care: A Constructive Reframing” in the Journal of General Internal Medicine, Dr. Mary Catherine Beach and Dr. Thomas Inui call for a similar shift. Medicine should be focused not on the individuals, but on The Space Between them.

The authors note that “patient-centered” medicine goes back to a 1969 paper by Enid Balint.1 This focus on patient-centered care is curious: if patient-centered care was a new objective, the authors ask, what had we been practicing before: doctor-centered care?

This question is simple, but profound: Who’s in charge?

It’s scary for a patient to be in charge of their own health care. Patients go to a doctor, after all, for the expertise of a rigorously-trained professional. Without that expertise, where would we be? The problem is, though, that if the doctor is the only one in charge, then the patient can become lost in what amounts to a social hierarchy. The patient is the person who’s lived through the symptoms, and has concerns and expectations about treatment. The authors summarize this well, that many social scientists [have] long been observing that the balance of power and discretion in medical care was…care centered on the preferences and values of the doctor.

The patient has lived through their symptoms, illness, and disease. The health care provider has lived though training introducing them to the minutiae of those diseases and symptoms. Ignoring either of them at the expense of the other is to ignore an important part of healthcare.

Within relationships, we exchange information, allocate resources, arrive at diagnoses, choose treatments, and assess the outcomes of care. None of these is carried out solely by 1 party…

The way to encompass both the patient and the provider’s areas of expertise is to focus on The Space Between: to focus on the relationship between those two.

The article by Beach and Inui is an overview of ways that we can begin to think about focusing not on the individual agents in healthcare, but on the relationships between them. The purpose of the paper is not to lay out a specific program for revolutionizing healthcare, but to “reframe” how we think about its parts. What matters is not that one party has power over another, but that the relationship is built in such a way that both parties can thrive:

In [Relationship-centered Care], clinicians ought not to aim for a sort of Aristotelian “friendship” between unequals (in which the physician remains the “expert”), rather the participants are encouraged to develop a sort of Aristotelian “friendship” based on virtue, that is one wherein the 2 parties develop each other’s character, and assist in the attainment of moral virtue.2 This does not preclude that the patient’s goals take priority (which ought to be the case); it simply acknowledges that the clinician also benefits in serving the patient.

The authors list characteristics and elements of Relationship-centered Care. Among the “Behaviors”, they mention that clinicians should Help [the] patient get [their] story across, [and] listen well (nonjudgmentally).

If we want to move the focus of care from individuals to relationships, we have to move our focus from individual activity to what happens in The Space Between them. The best way to focus on and develop relationships in medicine is to emphasize the story and narrative tools which teach us about what happens there.


The article reviewed: Beach, Mary Catherine, Thomas Inui, Richard Frankel, Judith Hall, Paul Haidet, Debra Roter, Howard Beckman, et al. “Relationship-Centered Care: A Constructive Reframing.” Journal of General Internal Medicine 21, SUPPL. 1 (2006).

1 Balint, E. “The Possibilities of Patient-Centered Medicine.” The Journal of the Royal College of General Practitioners 17, no. 82 (May 1969): 269–76.

2 Aristotle. Nicomachean Ethics, books VIII–IX.

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