BTG: RESPONSE TO A LETTER TO THE EDITOR

A Discussion of Recency, Relevance, and Perspective

Dr. Gabrielle Fundaro, CISSN, CHC

Shannon Beer, LLB, MNU-Certified Nutritionist

Dan Feldman, MS, RDN

We emphasize the important roles of conscientiousness and collaboration in the attitude of Comprehensive Coaching © in order to promote careful, thoughtful, cooperative efforts with clients as well as other professionals in the field. Thus, we welcome constructive feedback and citiques from other practitioners who share our purpose of improving client care and the industry standards for coaching. Additionally, we value and apply empathy and understanding in our professional interactions regardless of the presence of opposing viewpoints. Recently, we received a letter that encouraged us to revisit our statements about the paradigm shift occurring in the medical field, specifically. This article serves to express our considerations and responses in order to establish a shared understanding and continued dialogue. You will see the original letter (unedited and presented in its written order) in italics, with our responses below each section. Additionally, we have provided the references included in the letter to the editor in a separate section as originally written, though we have also referenced those sources with in-text citations and footnotes to support our response.

------

“The third article in the “Bridging the Gap” series starts off by identifying how the traditional model of coaching mirrors that of the traditional model of healthcare. This is followed by the idea that coaches are still operating under a paternalistic model, where the coach is the expert and tells the client what to do, leading to a one-sided relationship. As the third paragraph in the article briefly acknowledges a paradigm shift in healthcare towards a more client-centered, holistic practice before returning back to coaching examples, the article gives off the impression that paradigm shift towards a client-centered approach is a recent phenomenon. While this shift may be novel in the coaching world, the nature of the doctor-patient relationship evolving towards a patient-centered approach has been at the forefront of discussion for decades.”

We are certainly in agreement with the author of the letter regarding the importance and emergent nature of this evolution; it is one that has been a topic of discussion in the medical, allied health, and coaching fields for some time. Coaching approaches and client experiences vary greatly, and accrediting bodies continue to provide educational opportunities to learn about client-centered approaches. Research regarding client experiences and client-centered care in the medical field remains ongoing, as presented by the author and us in later sections.

Our article stated, “Fortunately, a paradigm shift is taking place across a variety of industries, from clinical healthcare practice to online coaching. The rise of health coaching and the establishment of accrediting bodies in fitness, health and wellness have shifted the traditional model toward a more client-centered, holistic practice.[1]” We realize that the timeline here may be open to interpretation, but the specific timing or recency was not intentionally implied. It seems that we are also in agreement that this has been, and still is, an invaluable topic of discussion.

“In 1956, Drs. Szasz and Hollender initially proposed three models of the doctor-physician relationship: activity-passivity, guidance-co-operation, and mutual participation. The mutual participation model requires that “the participants [doctor and patient] have equal power, be mutually interdependent, and engage in activity that will be in some ways satisfying to both.” This model was also endorsed by Michael Balint in 1964, a psychoanalyst who focused the majority of his work on building the doctor-patient relationship. It is through his work that the term “patient-centered medicine” was coined, which appeared in medical textbooks as early as 1972. “

We appreciate the additional insight into these pioneering practitioners. Upon reviewing the information in the reference provided by the author of the letter, we noted that the Balint training and credentialing became available as of 1993, which could be considered recent relative to the Institute of Medicine’s introduction of the definition of primary care practice in 1961 [2], [3]. It could also be considered very recent against the timeline of the history of medicine, dating back to 2600 B.C..[4] Additionally, in a 2017 article provided by the author of the letter, present-tense is used when stating, “As the popularity of patient- and family-centered health care increases, it is expected that patients will become more engaged and satisfied with the delivery of their care, and evidence of its clinical efficacy should continue to mount[5].” The author of the letter to the editor provided a link to the Family Practice Management Topic Collection: Patient Centered Care, which is an incredible resource, and also apparently somewhat recent with the earliest publication dated 1999[6]. Their references also included a 2007 article describing the evolution of the doctor-patient relationship which stated that the, “...asymmetrical or imbalanced interaction between doctor and patient...has been challenged during the last 20 years,” which does seem to imply a fairly recent and perhaps ongoing change[7].

We also wish to note that Dr. Szasz and Hollander’s Mutual Participation Model does make pioneering and beneficial contributions by stating the importance of identifying with the sick patient[8]. However, the principles outlined in our articles go much further and include some aspects lacking in their model, such as taking a non-judgemental approach, understanding the “why” and “how” of the formation of behaviors, and distinguishing “adherence” from “compliance.” Szacs and Hollander also state that “the model of mutual participation...is essentially foreign to medicine”. While Enid Balint did discuss the implications of training doctors in patient-centered care, the extent to which it’s actually being utilized by general practitioners is still unclear (and will be addressed in a later section).

Based on the recency of information provided by the author of the letter to the editor as well as present-tense voice used in all references utilized, it seems that this paradigm shift is ongoing and likely iterative. We feel that, timelines and recency aside, we are in agreement with the author of the letter to the editor that the idea of client-centered care is neither an entirely novel construct nor one that has reached its nadir.

“Since then, there are numerous articles defining patient centered care, discussing how to improve communication. Patient-centered communication is at the forefront of most, if not all, medical curriculum. This is also especially ingrained in primary care, and there are articles providing firm examples of how exactly to go about doing this, which are similar to the examples provided in the author’s social media post entitled “Providing Information in a client-centered paradigm.””