On the first contact day we saw how primary care is so effective. Put simply, countries with a good primary care systems have lower total mortality rates, lower deaths after birth and higher patient satisfaction than countries who don’t (Starfield, 1994).

So how does good primary care work?

One of the factors is the approach taken in primary care to caring for individual patients. This approach concentrates on the illness and the patient as a person. This is called the holistic approach, or the biopsychosocial approach – incorporating evidence-based medicine, psychology and sociology into one unified approach to patients.

However, getting to know about our patient’s social lives and their emotions is difficult and can’t be done in just one appointment. Trust needs to develop between doctor and patient so over time they feel safe, secure and able to share sensitive things. In short, it is difficult for primary care to be so effective without a good relationship between doctor and patient. For example, did you know that where patients have good long-term relationships with a doctor (continuity of care) – actually live longer (Pereira Gray et al., 2018).

In recent years, our understanding of why this approach is so effective has been greatly aided by insights from immunology.

Research in immunology has shown that social or psychological problems reduce immunity a lot. When immunity goes down we fall ill. We all know this from getting colds and other illnesses after exams and periods of stress. Lets have a closer look at the evidence for this:

• Long term stress caused by social issues (job stress, relationship problems, unemployment) are all associated with multiple immune problems, including reduced T-cell activity (Kiecolt-Glaser et al., 2002)

• The average age at death in the poorest part of the UK is 58, the age of death in the richest is 85

• Social isolation produces a 2-3 fold increase in overall mortality (Berkman, 1995, Berkman and Breslow, 1983)

• Short term stress in medical students due to exams produces reductions in Interleukin 1, reduced response to vaccinations and a 40% reduction in wound healing (Marucha et al., 1998, Glaser et al., 1992)

• The probability of contracting a viral illness is directly related to psychological stress (Coker, 1991)

We can see that social and psychological problems result in increased mortality from all causes (cancer, inflammatory and infective diseases).

On the other hand, positive social and psychological events increase our immune function and produce better health outcomes. This is through reducing the levels of stressor hormones such as cortisol and adrenaline and increasing levels of substances like growth hormone, which improve immune function. Again, here is the evidence:

• Relationship continuity with a family doctor produces a statistically significant reduction in all-cause mortality (Pereira Gray et al., 2018)

• Close social ties result in increased levels of Natural Killer cell function in those caring for spouses with cancer (Baron et al., 1990)

• Learning mindfulness techniques can lower cortisol and inflammatory markers and increase T cells (Black and Slavich, 2016)

So diseases are profoundly affected by social and psychological factors and the relationship patients have with their doctors. Some of the principles that flow from acceptance of this paradigm are therefore:

• A different clinical method that takes this into account

• A different way of relating with patients – patient-focussed relationships

• Building relationships through continuity

• Involvement with the social aspects of care – improving our patients housing, water supply

• Dealing with a complexity (physical, social and psychological) and therefore uncertainty

• Dealing with multiple conditions over time

These core principles concerning the care of our patients are further outlined in the Document Teaching General Practice and its accompanying resource Learning General Practice – which explains each principle in more detail.

www.rcgp.org.uk/undergraduate

Take a look over Theme 1 in Learning General Practice ‘Personal Care’ and maybe focus on the principle 1C Relationships and then take some time to have a think about what you have read:

• How do healthcare workers interact with patients in your own country?

• Are there opportunities for doctor-patient relationships or continuity?

• Are there other principles of personal care that apply in your country?

• How might you improve the relationships between health care workers and patients in your own practice or in your own country?