The Personal Doctoring Manifesto: A Perspective from the Keystone IV Conference

Understanding When Relationships Matter Most

The personal doctor desires to change lives with conversations and acts of kindness in ways that patients esteem.² But how much do we truly know regarding if and when patients value a relationship with a personal doctor?^3,4 There is considerable evidence that continuity of care leads to better outcomes.⁵ There is also growing evidence about the benefit of having personal doctors actively engaged in hospital care decisions and transitions after hospital discharge.^6,7 Most patients want a personal doctor.^8,9 More evidence about personal doctoring relationships is needed. What is the impact of relationship on patient satisfaction, clinician satisfaction, intermediate outcomes, and overall health? How do we define a relationship? How do patients define healing relationships? When does relationship matter the most? How can we ensure that personal doctors are there for patients when it matters most? What are the most valid and pragmatic scales and metrics for assessing relationship? To answer these important questions, personal doctors must engage patients in efforts to better define and measure the value of relationship-centered care. Research on personal doctoring relationships will be most illuminating when both partners in the relationship collaborate on this research agenda.

Strengthening Relationships Through Technology

Health information technology (IT) is often a double-edged sword.^{10⇓⇓⇓⇓–15} These technologies represent a significant change from traditional face-to-face interactions, and many physicians question the value of these tools.^{12⇓⇓–15} At the same time, IT creates opportunities for connection between a patient and personal doctor that transcends the intermittent examination room visit to include alternative modalities (eg, smartphone, text, video conferencing, secure messaging through the electronic health record [EHR]), enabling more frequent and accessible communication.¹¹ Health care professionals are effectively using virtual touches to strengthen relationships and provide more continuous care.¹² The availability of an expanded array of technologies is truly an opportunity for the personal doctor to be more responsive to patient needs. Personal doctors must take action to ensure that health IT enhances rather than diminishes relationships and patient care. We can participate in the development of new EHR functionality that better supports personal doctoring and relationships,¹⁶ insisting that this functionality be prioritized over the billing and transactional features that have dominated EHR design. Personal doctors can help to enable technology and data to inform our collaborations with patients, families, and communities.^17⇓–19

Strengthening Relationships Through Team-Based Care

Personal doctoring is no longer an exclusive relationship between a patient and a physician, but rather a relationship that includes many other team members. Team-based care has always existed in primary care, but teams have grown in size and complexity. To meet the growing demands of primary care, a “Share the Care” model has emerged^20⇓–22 and requires reenvisioning how a team can best provide personal doctoring. If implemented well, team-based care can liberate the personal doctor from tasks that do not have a high value in the relationship, allowing personal touches to focus on being present during the time when patients value the relationship most. For example, under the Share the Care model, delegating tasks related to determining whether a patient is due for a mammogram and processing an order for a mammogram frees up time that can be spent with a woman with an abnormal mammogram result, discussing diagnostic and treatment options.^21,22 There is a need for more focused investment in research that elucidates how to successfully implement primary care teams. Personal doctors, teams, and patients can work together to rethink the role of the personal doctor, helping everyone to shift our expectations and mindset.²³

The New Counterculture Movement: Building Relationships and Partnerships

“We have glimpsed a new vision of what medical care can and ought to be—and we have turned toward it, but as every mountain climber knows, the big ones have false summits which must be passed to scale the real top. We've all had our clear days when we could see forever, but then the clouds swirled in and obscured the higher elevations”¹ (p. 108).

We must reach the summit and strengthen every aspect of the personal doctoring relationship; however, we cannot declare victory. We contend that to truly transform the health care system, we must also invent a new notion of personal doctoring that creates partnerships with patients and families to drive forward a social movement demanding health care focused on the whole person in the context of his or her community. Now is the time for strategic thinking and tactical planning about what it will take to build and advance this powerful social movement, akin to what Gayle Stephens referenced as the movements of feminism, civil rights, and agrarianism that shaped the context for the birth of family medicine in the United States. We are at a transformative moment in the history of health care in this nation, when the system is poised to be fundamentally restructured on a foundation of empowered family medicine, primary care, and personal doctoring. We will not realize this vision without a new counterculture movement focused on building relationships and partnerships.

How do we harness the ingredients that make personal doctoring relationships successful to also build partnerships with patient advocates who are committed to a shared vision? This requires movement away from timid, conventional approaches toward bold, radical actions. Gayle Stephens¹ observed: “I doubt that many of us have an image of ourselves as revolutionaries. Most of us deal, on a day-to-day basis, with a much smaller quantum of reality; and, in truth, are much more motivated by purely personal goals than the heady stuff of national purpose. I suspect that that is the way all revolutions look from the inside. But let us look at the bigger picture for a moment …” (p. 106).

The bigger picture is shown in the Keystone IV personal doctoring manifesto: Those of us who strive each day to build relationships that make personal doctoring fulfilling must also engage in deep coalition building with patients, consumer groups, and the public at large to continue to drive the health care system to a very different orientation and set of values. Change will occur when patients insist on great primary care and a personal doctoring approach as essential priorities for what they expect from their health plans and the health care system overall—that anything less is unacceptable. Partnering together, physicians and patients can demand that all health care organizations and payment policies enable personal physicians to be at the patient's side (bedside, screen side, team side, family side) during crucial times and life transitions (birth, loss, grief, illness, death) and support the personal physician's integral role in helping patients and families make critical health and medical care decisions throughout life and in all settings (eg, homes, hospitals, hospice care settings).^{24⇓⇓⇓–28} Although debate continues about how best to define the exact scope that constitutes comprehensive care,²⁹ we consider the commitment of personal doctors to be involved at critical junctures in a patient's life and health course to be a sentinel feature of a comprehensivist.

Keystone IV, like previous Keystone conferences, catalyzed a resetting of our compass, a call to action, a reminder to be our better selves. It pushed us off the mountain and back to our daily work with a renewed vision and inspiration to act. It challenged us to reclaim personal doctoring as a vocation instead of just a job. It challenged us to make every encounter one that supports relationship. We can be both rigorously scientific and unapologetically relational. Keystone IV sparked ideas about a new social movement that reinvigorates our roots in counterculture. Personal doctoring is about building relationships that matter; personal doctoring is also about building partnerships to advocate for systems of health care, payment, technology, and training that support better health.