Personalised care in the view of a ‘specialist generalist’

Personalised care – what does this actually mean – both to me as a qualified medical doctor and to all Australians as they consider their health care into the future?

I am extraordinarily privileged to work as a specialist GP (which just means I have chosen to specialise in being a generalist!)  in the Australian health care system. I studied as an undergraduate at the University of Sydney and was taught as a student and junior doctor at Royal North Shore, Westmead and Royal Prince Alfred hospitals, then worked in the UK under the “NHS” in paediatrics for two years before returning to train as a GP in Australia in the mid-late 1990’s.

As a GP I am privy to hearing narratives of many people who entrust me with the gift of assisting them in navigating the health and welfare systems for all or some of their health care needs.

Personalised care means enabling people to have choice and control over the way their care is planned and delivered. It is based on what matters to them and their individual strengths and needs.

Over the years I have witnessed a change in culture over the interaction between the “medical doctor” and the “patient” with the emergence of so called “patient-centred care” rather than “doctor centred care”. From my perspective, this does beg the question – what is different about this emphasis and does it matter? I am particularly interested in this question as I have seen many of my medical colleagues espousing to practice “patient centred” care when I don’t think the experience of the patient reflects this view point at all.  I think that this is captured much better by the concept of personalised care.

So what is the implication of personalised care to me as a GP and what does it mean to my patients or to the general public with respect to navigating medical health care choices?

It is my experience that patient narratives are often privately held and unexamined by the majority of health professionals.  So it can be a challenge to see if we can assist people address these narratives when facing medical diagnoses or conversations about medical management options.

When I graduated from university I did not have a clear doctor-patient communication strategy apart from the notion of using open and closed questions whilst interviewing patients. The outcome of my interview was to obtain a full and comprehensive medical history which focused on the “reason for presentation” and assisted me in making a medical diagnosis.

In other words, the communication method that I was taught was all about understanding the problem of the moment and not necessarily anything more or less. The notion of the value of having a social and family history was included but lacked significance to me as the medical student / junior doctor tasked with obtaining a diagnosis and management plan to present to my senior colleagues.

When I was asked to comment on what personalised care meant to me as a GP I needed to unpack not only what it meant but how it has affected the way that I now work as a GP within my community.

Personalised care means enabling people to have choice and control over the way their care is planned and delivered. It is based on what matters to them and their individual strengths and needs. In other words –

  1. involvement of the patient and
  2. the need to individualise care

What it is NOT is doctor centred, hospital centred, technology centred, or disease centred.

In practical terms this means that as a GP I need to ensure that I understand the following concepts for each of the people that I see – Who are you?, What matters to you?, What are your health goals?, What do we need to do in order to achieve these goals?, Are these goals realisable?

There are four key areas that are addressed in the primary care setting 1. Problems that are acute and are affecting you NOW, 2. Problems that don’t yet exist and can be prevented, 3. Management of known chronic diseases and 4. Management of dying. I will acknowledge up front that most people don’t want to talk about dying but it is something that historically has and WILL affect 100 per cent of us and so really does need to be discussed at some point in time by everyone!

Personalised care is the ability to take all four of these key areas into account whilst prioritising and planning for health care.

For example, let’s consider Mary (not her real name), aged 72. She has entrusted me with assisting her in both diagnosis, management and navigation of all her health care needs. Currently she has problems that affect her eyes, teeth, oesophagus, stomach, bowel, pancreas, heart, hips, knees, bones and brain. She has consulted with multiple specialised colleagues who have all added great knowledge with respect to the “bit” of her that they have expertise in. My role is to assist in ensuring she has appropriate health literacy (the ability to process and understand the health information and health services that inform health decision making) and health activation (engagement in managing her health care with the appropriate knowledge, skills and confidence).

This was particularly important for Mary when considering options regarding medication for the bones which had consequences for her teeth, her heart, kidneys and brain. She had to make choices about when to abide by the “Best practice guidelines” versus deciding that the potential risks/side effects of the recommended management do not align with her overall health goals. 

This is where the personalised care story really emerges.  By asking “What does this mean to you? What do you make of that? And, what’s that like for you?” Mary has been able to make choices about her health care that are not of my personal making but rather hers, shaped by the input that I can bring to her understanding of these choices – shared decision making, care and service planning, appropriate social prescribing (assistance in accessing housing, financial and employment support, legal advice, exercise and dietary input etc) and advance care planning.