CHAPTER EIGHT

The Patient-Centred Clinical Method

Every patient who seeks help has expectations, based on his understanding of the illness. Every patient has some feelings about his problem. Some fear is nearly always present in the medical encounter, even when the illness may seem to be minor: fea r of the unknown, fear of death, fear of insanity, fear of disability, fear of rejection.

Understanding the patient's expectations, thoughts, feelings and fears is specific for each patient. The meaning of the illness for the patient reflects his own unique world. Frames of reference from biological or behavioral science come from the do ctor's world, not the patient's. They may help the physician to explain the problem, but they are not a substitute for understanding each patient as a unique individual.

Figure 8.1

The patient-centred clinical method, like the conventional method gives the clinician a number of injunctions. "Ascertain the patient's expectations" recognizes the importance of knowing why the patient has come. "Understand and respond to the patie nt's feelings" acknowledges the crucial importance of the emotions. "Make or exclude a clinical diagnosis" recognises the continuing power of correct classification. "Listen to the patient's story" recognises the importance of narrative and context. "S eek common ground" enjoins us to mobilize the patient's own powers of healing. To these I would add another: "Monitor your own feelings" They may give you some vital cues; on the other hand, they may be anti-therapeutic (see page ).

The key to the patient-centred method is to allow as much as possible to flow from the patient, including the expression of feeling. The consultation on page is a good example. The crucial skills, described in Chapter 7, are those of attentive list ening and responsiveness to those verbal and non-verbal cues by which the patients express themselves. Failure to take up the patient's cues is a missed opportunity to gain insight into the illness. If cues do not provide the necessary lead, a question may help the patient to express feelings: "What is your understanding of your illness?"; "What is it like for you to ...?"; "Are you frightened ...?"

The following reconstructed example contrasts the doctor and patient-centred approaches to the same problem. A 68-year-old male patient, a retired priest who has recently gone to live in a home for aging clergy, has come for a follow-up visit after a bdominal surgery.

The Doctor-centred Approach

Doctor Hello Father Smith, how are you doing?

Patient Fine - except for some headaches...

Doctor How is your tummy?

Patient Fine.

Doctor Are your bowels working?

Patient Yes.

Doctor Every day?

Patient Yes.

Doctor Any constipation or diarrhoea?

Patient No.

Doctor How is your appetite?

Patient Not very good yet.

Doctor Why do you think that is?

Patient It's probably the move to the home.

Doctor Any pain or discomfort at the operation site?

Patient Not really.

(The doctor now examines the patient's abdomen.)

Doctor I think that is a very satisfactory result. Your bowel function has returned to normal and your weight is constant. I would expect your appetite to improve gradually. Any other problems?

Patient I'm getting these headaches.

Doctor Can you tell me about them?

Patient I've been getting them about twice a week at the back of my head and they bother me so I can't do anything, and have to lie down.

Doctor How long do they last?

Patient About four hours.

Doctor How would you describe the pain?

Patient It's a throbbing.

Doctor Do you have any disturbance of vision, such as blurring, before or during the headaches?

Patient No.

Doctor Any nausea or vomiting with the headaches?

Patient No.

Doctor How long have you been getting them?

Patient Ever since I moved into the home.

Doctor Have you suffered from similar headaches in the past?

Patient Yes, many years ago I remember having similar headaches.

Doctor I am sure these are what is known as tension headaches. They tend to occur at times of stress and may be related to all the recent changes in your life: your retirement, your surgery and your move into the home. Your blood pressure and recent blood work are quite normal, and I can reassure you that they are not anything serious. Lying down and taking a simple pain reliever like aspirin is the best way of dealing with them.

Patient Thank you very much.

Doctor Come back if they don't settle down in a month or so.

Patient I will, doctor.

Doctor That's a nice home you've moved into. Lovely garden: peaceful spot.

Patient Yes.

The Patient-centred Approach

Doctor Hello Father Smith. How are you doing?

Patient Fine, except for some headaches.

Doctor What about your headaches?

Patient I've been getting them about twice a week at the back of my head and they bother me so I can't do anything, and I have to lie down.

Doctor You can't do anything? What's that like for you?

Patient It's frustrating, they're interfering with the writing I'm trying to do, and nobody seems to understand....

Doctor Understand?

Patient The other priests are so much older than me. All they can talk about is their aches and pains. I'm ashamed to say they make me sick.

Doctor Why ashamed?

Patient Well I shouldn't talk that way. They mean no harm. They just don't understand that I wish to write.

Doctor It must be frustrating....

Patient Yes it is, and my headaches make it worse.

Doctor How long have you been getting them?

Patient Ever since I moved into the home.

Doctor Why do you think that is?

Patient I don't know. I haven't really thought about it. Could there be a connection?

Doctor I think there could. They sound like typical tension headaches.

Patient The whole situation at the home does trouble me.

Doctor Would you like to talk more about it?

Patient No, not now, perhaps later.

Doctor All right. Let me ask you a few more questions about the headaches. Have you ever had them before?

Patient Yes, many years ago.

Doctor Do you remember the circumstances? Can you tell me about those?

Patient I can't remember, it was so long ago.

Doctor Do you get any disturbance of vision before or during the headaches?

Patient No

Doctor Any nausea or vomiting with the headaches?

Patient No.

Doctor How long do they last?

Patient About four hours.

Doctor Have you found anything that relieves them?

Patient They do go if I lie down.

Doctor Everything points to tension headaches. Were you concerned that they might be anything serious?

Patient Well, one does wonder, especially after the scare with my bowel. But you've reassured me. I feel better about them now.

Doctor Now, how are things with your tummy?

Patient Fine.

Doctor Are your bowels working?

Patient Yes.

Doctor Any constipation or diarrhoea?

Patient No.

Doctor How is your appetite?

Patient Not very good yet.

Doctor Why do you think that is?

Patient It's probably all connected with the home.

Doctor Any pain or discomfort at the operation site?

Patient Not really.

Doctor That doesn't sound too convincing.

Patient Well I do have a numb feeling around the scar.

(The doctor now examines the patient's abdomen.)

Doctor I think that is very satisfactory. Your scar is well healed. The numbness is due to a little nerve supplying the skin being cut during the operation. Nothing serious. Your bowel function has returned to normal. Any questions?

Patient No doctor. I'm really pleased with the result.

Doctor Do feel free to come back if you're still troubled about those headaches or about those feelings.

In the doctor-centred example, the physician assumes that the patient's expectations are all related to his postoperative course. He pursues this agenda, cutting off the patient's early reference to headaches. When the headaches are discussed, cues to the patient's feelings are missed. The patient is not invited to ask questions or express fears. When he does mention the retirement home, the doctor pre-empts any expression of feeling by giving his own views. None but the most assertive patients w ould contradict him.

In the patient-centred example, the physician tries to understand the patient and his suffering, and to form a therapeutic relationship. He allows the consultation to be guided by the patient and ascertains that he expects his headaches to be discuss ed. He responds to cues by encouraging the expression of feelings. The one problem ostensibly related to the operation - loss of appetite - takes on a different meaning when seen in the patient's social context.

In addressing the patient's agenda, the physician is formulating and testing hypotheses based on the cues he receives and on his previous knowledge of the patient or of the symptoms. To an experienced physician some symptoms are associated with parti cular fears, such as the fear of cancer. This knowledge may enable the physician to identify the patient's fears very rapidly. But we must always guard against the fallacy of treating a hypothesis as an assumption. In the above example, the doctor-cent ered physician assumed without attempting validation that the main item on the patient's agenda was to follow-up on his surgery. This is a common pitfall with doctor-initiated visits of all kinds (Stewart, 1979).

The patient-centered is also illustrated in the following clinical example.

Case 8.1*

An elderly woman complained of a suffocating feeling in the chest, occurring in the early hours of the morning, which was relieved to some extend by sitting by an open window. She first came in the middle of a busy office session when time was short. Given the above cues, the doctor formed a first hypothesis of nocturnal cardiac asthma and after a physical examination revealed no signs to support the diagnosis, sent the patient for a chest x-ray. When this too was normal, he asked the patient to com e in for a longer interview.

On this occasion he obtained the following history. Her main complaint was of very active peristalsis and abdominal discomfort occurring at night and keeping her awake. After lying awake for hours she would get more and more tense, get a suffocatin g feeling, and have to get up and go to the window. The abdominal symptoms had been present for twenty years, but the insomnia was of more recent origin. Many years previously she had had a cholecystectomy which failed to relieve her symptoms and a mast ectomy for carcinoma. She had a fear of surgery and on direct questioning admitted to an anxiety that her abdominal symptoms might be due to cancer. She had been widowed several years and lived in an apartment by herself. Recently her landlord had rais ed her rent without giving her any notice. Her two children were both married and living away. Recently her daughter had moved near to her after living away for some years. During the interview, she expressed hostility toward her landlord, who, she fel t, had been very unfair to her.

*I am indebted to Dr. John Biehn for this case history.

The process in this case is shown as a flow diagram in Figure 8.2.

Figure 8.2

Four questions are commonly asked about the patient-centred clinical method. First, is it always necessary to use the method? Suppose the problem is very straightforward: an injury, for example, or an uncomplicated infectious disease. The answer i s that we do not know unless we ask. Patients have fears and fantasies even about common and minor problems. In emergencies, of course, the medical priority must take precedence, as in the above clinical example. But when these needs have been met, no patient is in greater need of being listened to than the one with sudden and severe acute illness or trauma.

Second, what if there is a conflict between the patient's expectations and the medical assessment? Suppose, for example, that a patient wishes to manage his diabetic keto-acidosis without admission to hospital. The physician must then try to reconci le the two conflicting views. The more he can understand about the reasons for the patient's position, the more chance there will be of a satisfactory conclusion. The reluctance to go into hospital, for example, may be due to a feeling of responsibility for a child or elderly parent. In some cases there will be an irreconcilable conflict, as in a demand for a narcotic drug, and the physician will have to refuse to meet the patient's expectations. In the more usual situation, doctor and patient have di fferent interpretations of the illness, or conflicting notions about its management. The patient, believing his pain indicates an organic disease, cannot accept the doctor's view that this is not the case. The doctor is reluctant to prescribe oxycodone f or a patient who finds they relieve his periodic headaches. Our contribution to reconciling conflicting views is threefold. First, we can acknowledge the validity of the patient's experience and take his interpretation seriously, even if we cannot accept it. Second, we can be aware of the danger that our own prejudice, rigidity, dogmatism or faulty logic may be the cause of the difference. A mild narcotic used occasionally by a sensible person may be an appropriate remedy for headaches (see page ). T he patient may actually be correct in saying that his symptoms are organic in origin (see page ). Third, we can make sure that the patient has all the information we can provide. Conversely, some humility may be called for, as when a very well-inform ed patient knows more than we do about his condition.

Third, is there not a risk of invading the patient's privacy? Suppose the patient does not want to, or is not ready to, reveal her secrets? If privacy is invaded, then the method has been misunderstood. The essence of it is that the doctor responds to cues given by the patient, allows and encourages expression but does not force it. If cues are not given, feelings are explored with general questions which invite openness. If the patient does not wish to respond, the matter is not pursued. At lea st the doctor has indicated that such matters are admissible.

Fourth, what about the time problem? How can we afford the time to listen to the patient? It is difficult to answer this, since little research has been done on the relation between consultation time, clinical method and effectiveness. From work do ne so far, we can say tentatively that patient-centred consultations take a little longer, but not much longer, than doctor-centred ones. Beckman and Frankel (1984) found that, when uninterrupted, patients' opening statements lasted only two and a half m inutes on the average. Stewart (1995) reported that nine minutes or more was the critical duration for patient-centered consultations. What we do not know is how much time is saved in the long run by an early and accurate identification of the patient's problems. My hunch is that the patient-centred clinical method will prove to be a time saver in the long run.

It is important to distinguish between active and passive listening. Attentive listening, as described on page , is not a commitment to listen indefinitely to a rambling monologue. That would be passive listening. A flow of words usually expres ses something, even if its significance is the feeling rather than the content. A response to the feeling may enable the patient to express herself in a different way. Making a home visit to a ninety-year-old man with lung cancer, I was detained by his wife who went on at great length about what she tried to get her husband to eat. Eventually I broke off the conversation and left. As I was driving away, the penny dropped. Surely she was trying to express her feeling of impotence at being unable to ca re for her husband in the way she believed to be best.

Validation

The ultimate validation of a diagnosis in the conventional clinical method is the pathologist's report. In the clinico-pathological conferences modelled by The New England Journal of Medicine, a clinician is presented with a case report and dev elops a differential diagnosis, which is then confirmed or otherwise by a pathologist. The clinico-pathological conference can be regarded as the quintessence of the conventional method. Other forms of validation are available, notably the response to th erapy and the outcome of illness.

The ultimate validation of the patient-centred method is also the patient's report that his feelings and concerns have been acknowledged and responded to. This may be ascertained by qualitative studies and by periodic surveys of patients. In the norm al course of practice, validation comes from the natural history of the illness and the doctor-patient relationship. If common ground has been attained, therapy is likely to go more smoothly, reassurance to be more effective, and the relationship to be f ree from tension.

A physician wishing to have some external validation of his clinical method may choose to have his consultations evaluated by an observer using one of the rating scales developed for this purpose (Stewart et al., pp. 191-203). If these are used as a basis for coaching by an experienced teacher, they can be a source of valuable insights. It is difficult for any of us to be fully aware of recurring faults in our clinical practice. Until the coming of audio and video recording technologies, the consul tation - the central event of general practice - remained hidden from view. After the fact reporting of the process could not possibly convey its nuances. An observer in the same room was liable to change the process, and discussion afterwards was limit ed by the inability to verify the observer's recollection of the process by recourse to a recording. Thanks to the evolving technology, all of us can now develop as clinical artists in the way that artists have always learned - by submitting our work to the judgement of a respected teacher.

Learning the Patient-Centered Method

It is important to distinguish between the process by which a physician learns a clinical method and the process by which he practises it. To assist learning, the process is broken down into a number of rules, tasks and stages. Learning these compone nts is not the same as acquiring the process itself. No list of components can include all the tacit knowledge which can only be acquired by experiencing and "dwelling in" the process. One problem faced by the student is that it is impossible to be awar e of the components and the whole process at the same time. Polanyi (1962) has clarified this issue by distinguishing between focal and subsidiary awareness. Focal awareness is awareness of the process as a whole. Subsidiary awareness is awareness of the components. Riding a bicycle can be described in terms of rules for correcting imbalance and of the adjustments made by the body in response to changes in equilibrium. Learning the rules, however, is not the same as riding a bicycle, since the rules ca nnot embody all the tacit knowledge involved in performing the task. To perform the task, one must be focally aware of the whole process, while remaining only subsidiarily aware of the components. Focusing on the components may actually cause one to fal l off the bicycle. Similarly, when practising a clinical method, one cannot do so while trying to keep in mind the subsidiary rules and components. These can be learned beforehand and referred to afterwards, but in the performance of the task must remai n at the level of subsidiary awareness. The tension between these two levels of awareness, and the need to alternate between them, can be difficult for students at first. When the skill is acquired, the tension resolves. The doctor "dwells in" the proc ess and focal awareness is maintained throughout. Subsidiary awareness is brought into being only when teaching the skill to somebody else, or when reviewing one's own process after the fact.

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