A patient consults an orthopaedic surgeon because of knee pain. The surgeon determines that no operation is indicated and refers her to a rheumatologist, who finds no systemic inflammatory disease and refers her back to her GP who in turn sends her to a physiotherapist, who administers the actual treatment. Each clinician has executed his or her craft with impeccable authority and skill, but the patient has become a shuttlecock. Probably a hassled, frustrated, and maybe bankrupt shuttlecock.

The themes are very old. The Hippocratic oath itself enjoins physicians to maintain their deportment and privileges while keeping the patient’s interests foremost. What is the proper relation between the doctor’s and the patient’s experiences of illness? Between a scientific understanding of disease and the subjective phenomenon of being sick? Between cure and care?

As a form of practice, ‘patient-centred medicine’ seeks to focus medical attention on the individual patient’s needs and concerns. As a rhetorical slogan, it stakes a position in contrast to which everything else is both doctor-centred and suspect on ethical, economic, organisational and metaphorical grounds.

The British psychoanalyst, Enid Balint, appears to have coined the term in 1969. She described a form of mini-psychotherapy that GPs could provide for people who had illnesses that were partially or wholly psychosomatic. Her concept contrasted with ‘illness-oriented care’ and meshed well with other critiques of modern medicine’s emphasis on pathophysiology. 

Contemporary forces have bolstered this movement. The growing demands for quality and safety in healthcare have refocused attention on patient outcomes. Concerns about the cost of medical care have led to considering if shifting care from the sub-specialist to the primary care physician could save money. Health insurers in the US and politicians in the UK have moved towards making primary care the main focus of health services by assigning budgetary control to GPs who ‘buy’ specialist services from hospitals. 

These recent trends support the new concept of the patient as consumer. New priorities emerge: customer satisfaction, comparison shopping, broad ranges of alternatives, choice and unimpeded access to goods and services.  

Although some have argued that consumers would make wise, cost-conscious and informed decisions in a free healthcare marketplace, the peculiar nature of State funding and medical insurance means that patients seldom pay directly for the goods and services they consume and that their incentives for cost restraint are therefore absent. If doctors often make expensive choices, so do patients, and they demand MRIs for their sore joints, antibiotics for their respiratory infections, and ‘brand-name’ medications for their hypertension, hyperlipidaemia and diabetes.

Patient-centred medicine is, above all, a metaphor. ‘Patient-centred’ contrasts with ‘doctor-centred’ and replaces a Ptolemaic universe revolving around the physician with a Copernican galaxy revolving around the patient. The flaw in the metaphor is that the patient and the doctor must coexist in a therapeutic, social and economic relation of mutual and highly interwoven prerogatives. Neither is the king, and neither is the sun. 

Health relies on collaboration between the patient and the doctor, with many others serving as interested third parties. Patient and physician must therefore meet as equals, bringing different knowledge, needs, concerns and gravitational pull but neither claiming a position of centrality. A better metaphor might be the double helix, whose two strands encircle each other.