The primary care clinician
5.4 Clinical method III: the patient-centred method
(‘the art’) in clinical encounters. On the contrary, as Medawar famously ar- gued in relation to scientific induction, unique elements in the patient’s per- sonal story ignite the clinical imagination, producing entirely rational (but of- ten intuitive) hypotheses about what might be wrong and possible options for management.39
Here’s a worked example. Returning to the story in Box 5.3, my subcon- scious hypotheses about what might happen incorporated both generalisable, research-derived truths (such as the known masking impact of steroids and the low validity of physical signs elicited in less than ideal circumstances) and unique, contextual ones (including the lack of any previous consulta- tions, the wife’s profound concern and the patient’s stoical ‘grunt’ on exami- nation). When I predicted his impending death, I was not consciously aware of the intermediate steps that led me to my hypothesis, but when I learnt the outcome and sought a debriefing with his regular GP, the pieces of the jig- saw were revealed to both of us.The work of Patricia Benner29 and Michael Eraut37(among others) suggests that the insight I gained from critical reflec- tion and discussion with a professional colleague is to be expected. Reflect- ing retrospectively on the process of clinical intuition (asking, for example,
‘Why did I make diagnosis X rather than diagnosis Y at that point?’ or ‘What prompted me to start/stop that drug?’) is a powerful educational tool. In particular, critical reflection on past intuitive judgments highlights areas of ambiguity in complex decision making, sharpens perceptual awareness, ex- poses the role of emotions in driving ‘hunches’ (perhaps also demonstrating the fallibility of relying on feelings alone), encourages a holistic view of the patient’s predicament, identifies specific educational needs and may serve to
‘kick-start’ a more analytical chain of thought on particular problems. I re- turn to this theme in Section 11.4 when I consider learning and professional development.
Both this section and the previous one have taken the perspective that clin- ical method is something that occurs inside the clinician’s head and with- out any significant interaction with the patient. Another view holds that clinical work is usually a dialogue, and the input of the patient has impor- tant influence on the diagnostic and treatment decisions made as well as on how these are communicated to the patient. Sections 6.2 (which takes a so- ciolinguistic approach to the clinical interaction), 6.3 (which covers Balint’s psychodynamic approach) and 6.4 (which covers a ‘literary’ perspective on clinical interaction based on the notion of active listening) could all be classi- fied as variants on clinical method as well as variants on the clinician–patient interaction.
argued in the previous section that neither humanism nor intuition preclude or oppose the use of rational reasoning, and I now want to introduce one approach that attempts to unite them. It is important not to see the patient- centred method as something different from either a rationalist or a humanist approach. Patient-centred clinical method is the name given to an approach that combines both rational, objective reasoning and a humanist perspective to- wards the patient, as well as taking account of the wider social context that may have generated the illness and brought the patient into the consulting room in the first place. It is based on a multifaceted theory that incorporates both
‘sides’ of the epistemological divide in Table 2.2 (page 47), and which also takes a multi-level perspective on the nature of illness, considering both individual symptoms and behaviour and the wider context within which these occur (see Section 3.9).
The biopsychosocial model of illness is usually attributed to Professor Ian McWhinney and his team at the Department of Family Medicine at the Uni- versity of Western Ontario; an excellent textbook summarises its origins, principles and applications.8These authors acknowledge the earlier work of George Engel, who was perhaps the first to apply systems theory (the no- tion that complex phenomena can be conceptualised as multiple interacting systems) to the diagnosis and management of illness (originally in psychi- atry and subsequently in family medicine).40,41 Engel recognised the multi- level nature of what doctors call illness, from the gene to the environment, and suggested that clinicians analyse problems on each of these multiple levels and then integrate insights from each. McWhinney’s team also drew on Michael Balint’s psychodynamic model of the doctor–patient interaction (see Section 6.3)42 and Kleinman’s study on patients’ explanatory models of illness, undertaken from an anthropological perspective, which demon- strated that patients typically construct their illness very differently from health professionals.43
Figure 5.1 shows the biopsychosocial model in diagrammatic form. Let us work through one common problem in primary care – smoking-related illness – and see how this model may help illuminate the issues and inform the process of clinical reasoning. Why do people smoke? Perhaps, partly because smoking is an addiction that is to some extent inherited.44Pharmacological treatments for people seeking to quit smoking are designed at the level of the molecule and (in the future) may be specifically targeted (as in ‘designer drugs’) towards particular genetic variants of drug receptors.45 At the level of the individual, interpersonal influence both from peers and within the family seems a critical factor prompting people to start smoking,46,47as does stress and traumatic life experience.48But poverty, too, is a strong influence on smoking behaviour, in that the lower a person’s socioeconomic status the more likely they are to start smoking (and to resist advice to quit).49–51Some interventions aimed at reducing smoking have been designed at the level of economic policy and have had varying success.52,53 Increasingly, research
Community Environment
Identity Sick role
Attitudes and lifestyle Economic and political influences
Support, expectations Housing
Life opportunities (or lack of them) Family
Individual
Organ/
organ system Physiology
Homeostasis
Genetic make-up Biochemical
pathways Microscopic
(gene/molecule/cell) Accessibility of health and social services
Resources for self-care and rehabilitation Opportunities for unhealthy lifestyle, e.g. drugs
Figure 5.1 A biopsychosocial model of illness. (Adapted from Engel41and Stewart.8)
into smoking behaviour and how to influence it uses multi-level theories that integrate the molecular, psychological, sociological and environmental influences on individual behaviour.54,55
In a recent review of the biopsychosocial model in the Annals of Family Medicine, Borrell-Carrio and colleagues remind us that this model, which has become especially popular in primary care in recent years, is not merely a practical clinical guide but also a philosophy of clinical care.56Epistemolog- ically (see Section 2.7), the model contains what purists would see as incom- mensurabilities between mental and physical aspects of health (e.g. subjective experience depends on, but can never be reduced to, laws of physiology). But at a more practical level, it can usefully inform decision making within (and beyond) the clinical consultation.
The six interactive components of the patient-centred method are shown in Box 5.4. To some extent, the patient-centred method is not truly a multi-level approach since it begins and ends with the consultation – hence it can only bring in ‘higher’ levels (such as the social determinants of health) indirectly and partially. However, as the authors themselves emphasise, whatever the cause of an illness, the person who is ill tends to land up in the waiting room of the primary health care team, so it is probably not so unreasonable to take the clinical consultation as the focus of analysis.
Box 5.4 The six interacting components of the patient-centred clinical method.
1 Exploring and interpreting both the disease and the illness experience a Differential diagnosis (rationalist perspective)
b Dimensions of illness, e.g. ideas, expectations, effects on function (human- ist perspective)
2 Understanding the whole person
a The ‘person’ (life history, personal and developmental issues) b The context (family, other support, physical environment)
3 Finding common ground with the patient about the problem and its man- agement
a Problems and priorities b Goals of treatment
c Roles of clinician and patient (what will each be responsible for?) 4 Incorporating prevention and health promotion
a Health enhancement b Risk reduction
c Early detection of disease d Reducing the impact of disease
5 Enhancing the clinician–patient relationship a Aspects of the therapeutic relationship b Sharing power
c Caring and healing relationship
d Transference and countertransference (see Section 6.3) 6 Being realistic about time and resources
a Time b Resources c Team building Summarised from Stewart et al.8
In their ‘25 years on’ review of the patient-centred method, Borrell-Carrio and colleagues suggest that whilst the humanistic and participatory approach to clinical method aligns with recent social and cultural changes in Western healthcare (see Box 1.2, page 7), such an approach may not be universally ac- cepted. They propose a less culture-bound adaptation of this method whose pillars include: (1) self-awareness; (2) active cultivation of trust; (3) an emo- tional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) the use of ‘informed intuition’; and (7) communi- cating clinical evidence to foster dialogue, not just the mechanical application of protocol.
One very important research tradition has stemmed directly from the Cana- dian work on patient-centred clinical method. It is built around the concept of
‘shared decision making’ – the active and equal involvement of the patient in decisions about his or her care, which requires effective communication about both the problem and the options for management, as well as mutual respect and trust and a recognition of the ‘lifeworld’ agenda (see Section 6.2) by the clinician.57–64
It is probably apparent from this brief section that there are many poten- tial variations on the theme of the patient-centred method, and that all will include the judicious (rather than formulaic) application of rationalist ap- proaches such as evidence-based medicine, the reflective use of subjectivity and intuition and a consideration of the social causes of illness and consulting behaviour.