The relationship between practitioner and patient forms the foundation of health care and is vitally important to both parties. This relationship is the vehicle for exchanging information, feelings, and concerns; a factor in the success of treatment; and an essential component in the satisfaction of both patient and practitioner. While some aspects of the changing health care system--such as an emphasis on health promotion and attention to the outcomes of care--may encourage and strengthen clinician-patient relationships, other characteristics may threaten these relationships and clinicians’ ability to help students learn about them. Cost-containment efforts, pressures for greater productivity, a managerial rather than professional perspective on health care, and increased reliance on technology all have the potential to inhibit the capacity of practitioners to develop and demonstrate effective, caring relationships with their patients (Tresolini et al., 1994).

In the face of these threats to the clinician-patient relationship, teaching students to develop productive relationships with their patients is as important as ever. In recent years, research findings have confirmed and extended our knowledge of the importance of communication and relationships in health care. Good communication has been found to result in better health outcomes, a greater likelihood that patients will follow recommendations, and reduced risk of malpractice suits (Frankel, 1994). These findings are especially significant in light of the growing emphasis in the contemporary health care system on improving quality and outcomes, increasing patient satisfaction, and reducing or containing costs.

Hospital-based clinical education, with its focus on short-term episodic care, can no longer provide students with sufficient opportunities to learn about the development of sustained relationships with patients. Although students’ clinical experiences in community settings also may be of short duration and without opportunities to see a patient multiple times, students in such settings may observe their preceptors interacting with patients with whom they have developed long-term relationships and may benefit from the insights that derive from these observations. Primary care practitioners in particular are well-positioned to teach students about the development of relationships with patients over time. In fact, such relationships are an integral part of the definition of primary care:

The term "sustained partnership with patients" refers to an established relationship, expected to be continued over time, that is predicated on the development of mutual trust, respect, and responsibility. Such a partnership, which may be healing in itself, also facilitates the tailoring of interventions and advice to individual needs and circumstances and is essential when guiding patients through the health care system (Institute of Medicine, 1994).

Preceptors often work with students from several different courses, schools, and professions, each of which may have its own set of objectives regarding what students should learn about developing effective relationships with patients. The learning goals presented here are broad ones that bridge the various specific aims of different disciplines and programs. They are derived and adapted from a framework developed by Stewart and colleagues (1995). Called the patient-centered clinical method, this framework aims to clarify and make explicit what is implicit in effective clinical care. The six learning goals presented here parallel the method’s six components: exploring both the disease and illness experience, understanding the whole person, finding common ground regarding management, incorporating prevention and health promotion, enhancing the clinician-patient relationship, and being realistic.

Patients and clinicians each bring their own perspective to the clinical encounter, and students should learn to understand both. Practitioners typically focus on the identification, treatment and prevention of disease, attempting to explain problems or potential problems in terms of abnormalities of structure and/or function of organs and systems, and learning to do so is naturally of primary importance to students. Patients, however, focus on the experience of being ill; consequently, understanding illness also must be a focus of health professions education. The patient-centered clinical method focuses on four dimensions of the illness experience:

Exploring these four dimensions can result in increased patient satisfaction and greater likelihood that patients will follow treatment recommendations (Stewart & Roter, 1989), but it requires skilled interviewing and remaining alert to cues offered by the patient about the four dimensions. Helping students learn how to ask questions of the patient to elicit information about the four dimensions is of central importance.

Although understanding both the patient’s disease and the illness experience is crucial, concepts of disease and illness must be integrated with an understanding of the patient as a whole person in the context of the life cycle and individual social-cultural milieu. Students should develop an understanding of the developmental tasks and responsibilities at various points in the life cycle, which can help them better understand a patient's multiple responsibilities and the impact of an illness on daily life and more effectively tailor a treatment regimen to fit the patient's circumstances. The patient's social-cultural milieu includes his or her family, friendship networks, employment, education, religion, culture, community, physical environment, and the health care system. Being aware of the influence of cultural characteristics, including support systems, role expectations, dietary habits, and so on, is important in understanding patient beliefs, behaviors, responses, and expectations. Over time, as students learn about various aspects of the patient's context, this knowledge may assist them in understanding idiosyncratic responses to illness or therapy or in helping the patient make sense of and deal with his or her illness.

Students also should learn about the family and community resources available to the patient that may be used to develop a comprehensive approach to managing an illness. Conversely, in the presence of negative factors, clinicians can help to improve the patient's situation by finding ways to ameliorate these factors. In working with the patient to promote wellness or prevent illness, understanding the whole person may help the student better work with the patient, for example, by developing dietary or exercise programs that are best suited to the patient's individual circumstances, habits, and preferences.

After weaving together disease and illness conceptualizations within the framework of a

whole-person view of the patient, a clinician can begin to bring together two potentially divergent viewpoints--the clinician’s and the patient’s--to construct a mutually-agreed-upon prevention or management plan. To do so, clinician and patient must reach agreement in three areas: (a) defining the nature of the problem (e.g., disabling back pain or difficulties at work?), (b) establishing the goals and priorities of treatment (e.g., slow the progress of metastatic breast cancer or control symptoms?), and (c) identifying the roles of the clinician and patient (active/passive or shared responsibility?). Negotiating and reaching agreement in these areas requires a great deal of expertise and experience, but students can begin to learn the issues involved and the skills needed in finding common ground with patients. This learning task is made easier when students are paired with preceptors who have long-standing relationships with patients and who openly describe the process and intricacies of bringing together patient and clinician viewpoints.

Collaboration between patient and clinician to promote health and prevent disease can be a powerful means of strengthening the clinician-patient relationship. The same characteristics that make the patient-centered approach effective in addressing illness and disease (i.e., integrated, whole-person, collaborative) make it effective for health promotion and disease prevention as well. An understanding of the patient as a whole person--including present and potential disease, potential for health, and life context--and skill at finding common ground facilitate the choice and implementation of health promotion and disease prevention strategies. As students gradually learn strategies to incorporate health promotion and disease prevention in practice, they may come to appreciate the role these activities play in extending their knowledge of and relationship with patients. Every encounter between clinician and patient may be used to address some level of preventive care, whether it is health enhancement (e.g., beginning an exercise program), risk reduction (e.g., smoking cessation), early detection of disease (e.g., bone densitometry), or amelioration of the effects of disease (e.g., strengthening exercises).

In community-based primary care practice, clinicians work to build effective long-term relationships with patients. In seeing the same patients again and again over time, practitioners incrementally acquire considerable knowledge that is helpful in managing subsequent problems. Clearly, students may only obtain a glimpse of this dynamic in their short-term placements in community practices, but when preceptors address explicitly the skills involved in building these relationships, students may learn a great deal. Some of the concepts that are important for students to become familiar with include:

Despite the importance of building effective relationships with patients, clinicians do not have unlimited time, energy, or resources. Although exploring both the disease and illness experience, understanding the whole person, and finding common ground are not associated with a clinical encounter that is any lengthier than one using the conventional biomedical model (Greenfield et al., 1988; Stewart et al., 1989), clinicians cannot address all patient concerns and issues in every visit. Students need to learn that relationships with patients must be built gradually, using each encounter for further learning about the patient and his or her concerns, and focusing each encounter on the most pressing issues. In addition, collaborating with and enlisting others to provide team-based care is an essential strategy.

The four teaching roles described in Module 2: Effective Teaching in the Community Practice provide a good starting point for thinking about strategies for helping students learn to build effective relationships with their patients. As a role model, the preceptor acts out and articulates the knowledge, skills, and values involved in relationship-building. This may include speaking candidly about the need to be realistic and the barriers to and difficulties inherent in maintaining good relationships in the context of a busy practice. As an expert, the preceptor provides critical information about the patient and demonstrates specific skills, such as interviewing techniques, that facilitate interactions between clinician and patient and help to solidify their partnership. Care must be taken to refrain from providing too much information and thereby depriving the student of the opportunity to learn about the patient directly from the patient. As facilitator, the preceptor may suggest possible explanations and provide feedback based on his or her more intimate and long-standing knowledge of the patient. Finally, as consultant, the preceptor may draw upon knowledge of the patient to react to a student’s conceptualizations of or plans for the patient.

Incorporating attention to relationship-building using the "one-minute preceptor" approach Neher et al., 1992), also described in Module 2, is another valuable approach. In proceeding through the five microskills of this approach, the preceptor may draw the student’s attention and thinking to relationship issues. The first microskill is to get a commitment from the student about what is going on with the patient. At this point, the preceptor may open the door to encouraging the student to speculate about the patient’s ideas about what is wrong, feelings (especially fears) about the illness, expectations of the clinician, and the effect of illness on functioning. Ideas about the patient’s history and context may also be brought in. The second microskill, probing for supporting information, provides an opportunity for further encouraging the student to explore social-cultural or contextual issues and to think about how common ground can be reached with the patient. In proceeding through microskills 3-5, teaching general rules, reinforcing what was right, and correcting mistakes, the preceptor may choose to emphasize issues related to the six learning objectives described above.

Finally, Freeman (1994) suggests that teachers ask students to use a restructured case report as a tool to help them attend to and learn about patient-centered concepts. Its principal components are as follows: