Relations in consultations: initiating professionalization of relational competence for general practitioners

The doctor-patient relationship is thoroughly researched in the field of patient-centered medicine, where the responsibility to handle the relationship befalls the doctor, as it is asymmetrical. Despite the vast literature about patient-centered medicine, the scientific studies on the doctor’s experience with handling the relationship, and how they play a part in the relation themselves, is sparse. In pedagogical literature, teachers handle a similar relation to their students, which is also asymmetrical. In the steady growing field of Teachers Relational Competence, it is described how the teacher must relate their actions and their
own role to the handling of the relationship, in order to maintain and develop rewarding relationships between them. This is to attain the goals in the teacher’s job, which is given by the institutional context. The aim of this thesis is to investigate how relational competence can be professionalized for general practitioners in general practice as an institutional context. This is conducted through three studies, each of them designed to uncover different aspects of relational competence. A Danish study on Teacher’s Relational Competence is used as the primary inspiration for the investigation. The three studies aim to answer three research questions with different angles for the professionalization of relational competence for general practitioners:
1) Which core elements from Teachers’ Relational Competence appear in general
practice literature?
2) Which actions that contribute to involvement of the patient’s narrative and to obtain an overview of their needs and concerns in extended consultations? (The results of this study is discussed further, which will relate them to the aim of researching relational competence.)
3) How does general practitioners approach the interrelatedness between the doctor-patient relationship and the institutional goal, and how does this affect their emotional experience?
I have conducted a systematic literature review, recorded 35 consultations and interviewed 9 doctors to answer these questions. The empirical studies were qualitative and analyzed with conversation analysis and abductive analysis respectively, and the literature review was analyzed with exploratory deductive thematic analysis. The results show how a framework for relational competence for general practitioners can be initially conceptualized, although no complete theory can yet be formed. In the systematic literature review, a range of
relationally competent attitudes and actions came to light, all of them with useful details for the theoretical frame for relational competence for general practitioners. The four attitudes were attention to emotion, devotion, mentalization, and time-oriented presence. The four overarching categories of actions were being open, attunement, offering support, and using humor, with each category having further details describing the actions. In the interactional
study, it was found that the GP can perform attunement to the patient through the speech act formulations, as they make inferences about the patient’s narrative based on the patient’s telling. Both GP and patient can subsequently collaborate on continuation of the narrative, giving the patient opportunity to disclose more details about their narrative. In the interview study, it was found that relational competence for general practitioners seems to be a dynamic
interplay between prioritization of goals for the patient’s health and the relationship as informing on how to approach the prioritization. The results of the thesis show that relational competence for general practitioners is an interplay between relationally competent attitudes and actions, and that both should be visible in the general practitioner’s conduct in order to be
classified as relational competence. The results applies for patients with complex health issues in particular, but some results can also be applicable for other patient groups. Relational competence for general practitioners can potentially be included in curriculum of medical students and postgraduate medical education for general practitioners. Furthermore, the conclusions of this thesis gives new perspectives to the research into continuity, and that continuity can be regarded as an outcome of quality in the doctor-patient relationship that has
been achieved through meaningful interactions promoted by the general practitioner’s relational competence.