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The patient-centred interview: the key to biopsychosocial diagnosis and treatment
Pekka Larivaara, Jorma Kiuttu and Anja Taanila
Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland.
Scand J Prim Health Care 2001;19:8– 13. ISSN 0281-3432 The article reports on some ideas and experiences gained from a holistic approach to working with patients and introduces a viewpoint that includes opinions on how postmodernism, the biopsychosocial model and a patient-centred interviewing style can change traditional, biomedical-oriented medicine. During the past 10 years, we have been instructing medical students in the use of this patient-centred interviewing model and have trained experienced general practitioners (GPs) in adopting it in 2-year family-oriented continuing medical education courses. We believe that doctors and other health care providers, particularly in primary care settings, need a comprehensive concept of human health and illness, and that skill in patient-centred interviewing is the product of a deep learning process. In conclusion, we have learned that a successful
patient-centred interview helps the GP to better understand the patient and helps to explain the data that the patient presents. Patient-centred orientation and interviewing also change the communication between doctor and patient in a direction which supports the patient’s and his/ her family members’ own resources in the healing process. Key words: patient-centred interview, doctor– patient communication, biopsychosocial approach, postmodernism, consultations, general practice, medical education. Pekka LariØaara, Family and Community Medicine, Department of Public Health Science and General Practice, UniØ ersity of Oulu, P.O. Box 5000, FIN -90014 UniØ ersity of Oulu, Finland. E -mail: plariØaa@cc.oulu.
Medicine in the Western world has for long been based on natural sciences, and teaching at medical schools has been mainly disease-oriented. The biomedical treatment model is deeply connected with modernistic thinking of human beings and illnesses. Modernism refers to a Western philosophical tradition that views knowledge as objective and xed (1). Knower and knowledge are independent, and language is a representation of objective truth and reality. Doctors are authorities as decision-makers and patients are in a deferential position. Typically, in this con guration, doctors are the culturally de ned experts who have empowering knowledge that is often private and unavailable to a patient (2). The emergence of a postmodern discourse in the human sciences is challenging the modernistic perspective of how we see and think about the world and our experiences in it. Postmodernism is an umbrella term referring not to an era but to a philosophical perspective that includes an ideological critique of the foundation of medical and social thinking – a continual questioning and re-examination of the familiar (2). From a postmodern perspective, everything is open to criticism. The doctor’s knowledge, diagnosis and treatment plans are not ‘‘objective truths’’ any more. Postmodernism favours the idea that a knower participates in creating the world he or she lives in, observes and knows. In that paradigm, both the doctor and the patient are equal knowers who, by communicating together, create shared expertise (3).
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In Europe, Michael Balint (4) was one of the rst pioneers with a postmodern perspective to medicine. He started analysing the communication between doctor and patient as long ago as the 1950s. Since then, many doctors and researchers have made a close study of the details of this communication process (3,5 – 7). Today, American medicine is also in the midst of a professional evolution driven by re-focusing medicine’s regard for the patient’s point of view (8). The biomedical model was concretely challenged there by George Engel (9), who addressed the psychosocial aspect of medicine and formulated a biopsychosocial diagnosis and treatment model in the 1970s. On the basis of the work of these pioneers during the last three decades, a patient-centred interviewing and treatment model has been created (10 – 13), and medical education has gradually taken a patient-centred and learner-centred turn (14). In this paper, we rst try to clarify the key elements and theoretical differences of the doctor-centred and patient-centred interviews. The patient-centred interviewing model formulated by us is based on the literature, our previous study outcomes and our teaching, supervision and clinical experiences. Secondly, we introduce an illustrative patient case that helps readers to understand how these two interviewing styles differ from each other and how a doctor’s patient-centred interviewing and attitude offer an opportunity to formulate a biopsychosocial diagnosis for the starting point of a comprehensive treatment plan.
The patient-centred inter×iew
THE DOCTOR-CENTRED INTERVIEW A doctor-centred attitude and interview is appropriate in acute clinical situations when there is imminent danger to the patient’s life and when very rapid action is needed, e.g. in emergency clinics. The goal of the doctor-centred interview is to make a clinical symptom or disease diagnosis based on an authoritative, modernistic and biomedical approach. The doctor leads the conversation and interrupts the patient’s story shortly (15) by starting to present a sequence of closed questions (11). The doctor makes decisions about what information and knowledge is necessary and important. With the exception of these few acute clinical instances, especially in primary care settings, the doctor-centred interview has several disadvantages: the patient’s own expectations, views of the symptoms, concerns, fears and other feelings are not fully elicited. Even his or her real reasons for coming to the physician may be ignored (15). The patient readily begins to believe that his or her ideas are not important while planning the treatment. He or she may become passive and lose con dence in his or her own strengths. Then symptoms and a feeling of illness often increase, resulting in heavy use of medical care (16). THE PATIENT-CENTRED INTERVIEW The essence of the patient-centred method is that the doctor tries to enter the patient’s world and tries to get a holistic picture of the patient. This includes information from all the levels of the biopsychosocial model: cell-organ level, psychological-individual level, and family-community level (9). The goal is also to reach shared expertise with the patient (3). Furthermore, in the patient-centred treatment model the physician has to support the patient’s autonomy (2,3,5,11,12), i.e. the personal authority and competence of the patient fully and responsibly to take a central role in his or her health and illness management. Key elements of the patient -centred encounter In this decade, a growing consensus has emerged on de ning some key elements of the patient-centred encounter (11). These include: (i) assessing the full spectrum of patient concerns, (ii) getting to the heart of the problem, (iii) delivering diagnostic information, (iv) developing treatment plans, and (v) educating and motivating patients. Gathering data Everyone agrees that a doctor has to be able to gather data accurately if s:he is to understand a
patient’s problem and to assess the full spectrum of the patient’s concerns. It has been estimated that two-thirds of diagnoses can still be made by the history alone, despite the technological innovations of modern medicine (11). However, taking a good history is not easy. Doctors seem not to be good listeners, and often interrupt their patients within the rst 18 seconds of the encounter (15). Therefore, in many cases, patients’ reasons for coming to the doctors are not fully elicited. A good interview should begin with a patient-led storytelling process in which the patient has in uence over the selection of the headlines and details of the story told. Skilled interviewers convey warmth and attention by their forward posture, eye contact and expressive face, gesture and tone (11,12). Their questions are single and to begin with open-ended, contrary to the closed ones used in the doctor-centred interview: ‘‘What can I do for you today? ’’ Questions invite the patient to describe their problems by using their own vocabulary and personal experience of the symptoms: ‘‘Tell me some more – whate×er you feel is important? ’’ By allowing the patient the opportunity to describe his or her own complaints, the skilled doctor can more ef ciently develop diagnostic hypotheses and recognise patterns that are relevant for that particular patient’s problems. However, very often the patient’s story includes ambiguity and jargon, in which case the doctor has to interrupt (not too early during the interview) and to present some clarifying comments: ‘‘I’m not clear about that – tell me again ’’ or ‘‘Let me see if I’×e understood that correctly …’’ or ‘‘Let me check to see if I understand what you ha×e told me so far.’’ Checking (11) gives an important message to the patient, including reassurance about the doctor’s active listening and interest in gaining an accurate understanding of the problem. At the end of the interview, the patient-centred interviewer often explicitly introduces the summary and invites the patient’s comment, not just medical but also social and emotional issues are included. Summarising also demonstrates that the doctor has been attentive (3,11,12). Responding to patients’ emotions All experiences of symptoms and illness produce many emotions in patients and their families. In order to get to the heart of the patient’s problems, the doctor must somehow perceive these emotions and respond to them either verbally or non-verbally. The manner in which the doctor responds to the patient’s emotions will, to a large extent, determine the quality of the overall doctor – patient relationship. Even a competent technical procedure may be felt unsuccessScand J Prim Health Care 2001; 19
P. Lari×aara et al.
ful by a patient if the doctor is not supportive and emotionally available (16). The empathic doctor encourages the patient to describe his:her feelings about the illness and treatment. S:he has a small packet of tissues on the table of the consulting room for tearful patients. It helps the patient if the doctor states that an emotion is recognised and accepted. ‘‘This must be ×ery hard for you. Now I understand your situation better.’’ Respect and personal support The patient-centred doctor acknowledges and appreciates the patient’s efforts to cope with his:her symptoms and problems. Respectful comments add a great deal to improving the relationship. Sometimes it is good to move closer to the patient, even to touch and use warm tones while speaking. Once in a while, limited self-disclosure is appropriate and supportive (11): ‘‘When my mother had symptoms like yours some years ago, she and I felt upset like you do now.’’ Patient-centred doctors are also honest to patients and their family members (17). They tell them what is possible to manage in the ‘here and now’ and what issues are outside their knowledge. ‘‘I want to help you in any way I can. Please, let me know what you expect me to do to help.’’ Diagnosis, treatment plans, education and moti×ating The nal function of the patient-centred interview concerns a kind of summary of the information from the doctor to the patient. This is a special part of the communication process to which more attention should be paid, because, even when patients become fully informed, only 22– 72% of doctors’ recommendations are followed (14). Many doctors are frustrated, and often ask: ‘‘How can we get the patient to understand and remember the diagnostic information and advice?’’ There are at least six steps in the affective process of educating a patient about his or her illness (11): (i) establish the patient’s perception of the problem, (ii) provide a basic diagnosis, (iii) respond to the patient’s feelings about the diagnosis, (iv) check the patient’s knowledge of the illness, (v) provide details of the diagnosis, and (vi) check the patient’s understanding of the problem. In this phase of the interview, it is therefore important rst to elicit the patient’s ideas about the cause of the main symptom. ‘‘What do you think might be causing your problem or illness? ’’ At this moment, patients very often reveal their fears about some particular illness or severe disease. Patients are also often fearful and very anxious in listening to the doctor’s diagnostic information, especially if the information includes some bad news. Therefore this information and any instructions need to be brief and
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succinct. Every now and then the patient’s response is only non-verbal. The patient may be silent or may look sad, or anxious. When making treatment plans it is also important for the doctor to give due attention to the patient’s motivation. However, even experienced doctors know that one of the most dif cult tasks is to motivate a patient into making changes in their lifestyle. There are at least seven steps in a basic motivational sequence that the doctor can use to help motivate patients to adhere to treatment plans (18): (i) check adherence carefully; (ii) diagnose speci c adherence problems; (iii) respond to emotions and offer support, partnership and respect; (iv) elicit a statement of commitment; (v) negotiate solutions; (vi) obtain an af rmation of intent and follow-up; and (vii) reinforce the patient’s own strengths (empowerment). This means that the doctor has to create with the patient an atmosphere in which it is possible to discuss all problems regarding non-adherence openly. When patients describe their dif culties in trying to follow advice, the doctor should indicate an understanding of the problem. ‘‘I understand that this is dif cult for you. I ha×e seen the same kind of dif culties in se×eral other patients.’’ As the problems have been clari ed, it is easier for the doctor and the patient to develop a plan together to address them. When the patient has successfully accomplished even a small part of the plan, the doctor must respect this issue and praise the patient. ‘‘I am ×ery impressed that you ha×e succeeded in cutting down smoking so much.’’ Motivational efforts usually arouse many emotions in the patients. These can include for example sadness, anger, humiliation or enjoyment and happiness. Responding to all the patient’s emotions fosters a relationship and can result in better health outcomes.
AN ILLUSTRATIVE CASE The following example, based on recent experience in a health care centre, illustrates the differences between the doctor-centred and the patient-centred interview. The details have been changed so that the patient cannot be identi ed and conversations are presented as abridged versions. A 46-year-old female patient was rst interviewed by a young GP with no special training in patient-centred interviewing. After this, an experienced GP, who had received special training in a biopsychosocial approach and in patient-centred and family-oriented interviewing, met with the patient and performed a patient-centred interview without seeing the previous one. Both interviews were videotaped, transcribed and analysed.
The patient-centred inter×iew
Doctor -centred inter×iew Doctor : How are you today? Patient : I have had stomach-aches. It is an old trouble and it has bothered me, perhaps, four years. It is a kind of sense of burning here (pointing to the pit of the stomach ). There must be something. Doctor : Hmm. Let us look at it. Patient : Now it bothers me all the time. It is a terrible pain. Doctor : How long you have suffered from it? (The doctor starts to dominate the inter×iew.) Patient : For a long time, but during the last two weeks it has been especially serious. I feel that it has been even dif cult to walk, my legs do not bear me, and it is troublesome to see in my way. Doctor : Was it the pain which made walking so dif cult? (A closed question) Patient : Perhaps, yes. I don’t know. (The doctor doesn’t react to the patient’s ×ague answer) Doctor : Can you eat anything? Patient : Yes, but I think that fatty food makes the aches worse. When I ate grilled sausages at our summer place, the trouble began. (No attention to the patient’s suggestion about her life situation) Doctor : Have you lost any weight? (A close question) Patient : I don’t think so. I have had some pills and they have helped a bit. Then they discuss the pills for a while. The patient says that a gastroscopy was performed about four years previously and that the doctor recommended a repeat procedure in a year. Doctor : Is the pain either during the night and day or at what time? (A closed question) Patient : It is, perhaps, less dif cult in the night. Doctor : Have you seen any blood in your stools? Any nausea or vomiting? (A closed question) Patient : No. Doctor : Well, let us look at your stomach. Then the doctor performed a physical examination and recommended some laboratory tests and suggested a further gastroscopy. Psychosocial issues were not elicited. Patient -centred inter×iew Doctor : Hello, what can I do for you? Patient : I have had stomach-aches for about two weeks or even longer. It is a sense of burning here (pointing to the pit of the stomach ). There must be something. It is dif cult to sit and when walking I feel myself too weak. It has been a very dif cult situation during the last few days. (Feeling ) Doctor : Hmm. I understand. So two terrible weeks. (Empathy, facilitating beha×iour ) Patient : Yes, it has been bad, perhaps, since I ate some fatty sausages at my summer place.
Doctor : I see. Did you have a party there? (Facilitat ing beha×iour ) Patient : No, not anything special, I was there only with my friend. We sometimes eat some grilled food after sauna. (Life situation ) Doctor : You mentioned your friend. (Facilitating beha×iour ) Patient : Yes, I am engaged to him. Doctor : Yes, and… (In×iting her to continue ) Then she describes that she has been divorced for about 2 years. The marriage had lasted 20 years. She has two adult daughters who have already moved out of the home. Doctor : So, your life situation has changed a lot recently. (Facilitating beha×iour ) Patient : Yes and my father died of cancer a year ago and one of my friends passed away just recently with breast cancer. (Feeling ) Doctor : You must have had a hard time. (Empathy and support ) Her eyes are lled with tears and the doctor gives her a tissue. She dries away her tears and then tells how her father died. However, not until her friend died did she remember that a gastroscopy had been performed on her about 4 years previously and that a follow-up was recommended in a year but she never went there. Patient : I have been thinking that it may be stress behind my stomach-aches. My stomach has always been a bit sensitive. Now, I should get married and trust in my new friend. I should also sell my house and my daughters don’t like this idea. I am faced with very dif cult decisions and I have been thinking about that all the time. (Feeling ) Doctor : I understand, and these changes in your life situation may affect your stomach. (Empathy, starting to consult about diagnosis and treatment plan ) After negotiation they jointly agree that a gastroscopy should be performed soon. She believes that she does not need any further medication right now. (Shared understanding and treatment plan ). The consultation nishes with the following discussion: Doctor : Do you have any other comments or questions? Have we discussed all the topics and concerns you were thinking about before the visit? (Checking ) Patient : Yes, thank you for your help. I hope it is only stress. However, very often it seems that there is something extra there (pointing at the stomach ). Actually, I believe that when I have solved my problems and made the important decisions, my distress will ease off and my stomach will be better. But they are such dif cult decisions. I don’t want to make the same mistakes that I did with my ex-husband, and just recently when my anger towards him has disappeared I have started to miss him and my daughters… (She has dif culty nishing her story).
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Doctor : Yes, I understand. Well, I think we have to end this consultation, but I would like to see you soon after the gastroscopy. It seems to me that despite all your aches and problems, you are strong enough to make the right decisions. (Empowering ). The doctor-centred patient’s encounter was typically biomedically oriented. The doctor listened to the patient’s story for only a few moments and while hearing the patient mentioning the stomach-ache and pointed at her stomach, she started leading the conversation. The doctor’s questions were mostly closed and she only paid attention to symptoms and physical examination. Psychosocial issues were ignored and therefore no picture was received of the patient’s life situation. After the gastroscopy the patient might have got the answer that nothing serious could be found. The patient might have been relieved, but probably her symptoms would have continued without her being able to connect them to her life stress. She might then have re-visited the doctor and the physical examinations and biochemical tests would have been continued. Based on our experience (16) this kind of process may be the iatrogenic starting point for heavy consumption of medical services. In reality, 2 weeks later, another patient-centred consultation took place. A gastroscopist did not nd anything abnormal in her stomach. Most of the time the patient wanted to talk about her life situation. She had not yet made all the decisions, but she seemed to feel relieved. The doctor felt that it was important to listen to her, to be empathic and to avoid giving direct advice. He believed that by empowering the patient she would manage to solve her life problems herself. In addition, the doctor told her that now it was easy to understand her having symptoms like these in that kind of stressful life situation. DISCUSSION Communication is both the most common and the most important procedure used by doctors to diagnose and treat illness. It is probably also the single most important factor in uencing patient satisfaction and patients’ ratings of their doctors’ performance. Furthermore, good communication is now seen as a right by patients, and therefore criteria for competence in communication have been developed for doctors (10). The medical interview is part of a communicative process and the most essential clinical tool available to health practitioners (11). The development of high-quality, low-cost audio and video recordings has made possible the observation and analysis of a range of encounters (14). Traditionally, teaching in medical schools has been mainly biomedically oriented and the qualifying docScand J Prim Health Care 2001; 19
tors have in most cases adopted a doctor-centred way of working with their clients (16). The doctor-centred attitude and interview is appropriate in hospital emergency rooms when there is an imminent danger to the patient’s life and when very rapid action is needed. In these situations the goal of the interview is to make a quick clinical symptom, trauma or disease diagnosis. However, on many other clinical occasions the doctor-centred interview has several disadvantages and the patient’s real reasons for coming to the physician may be ignored (6,9,13,15). Until now, consultations have often been assessed as mostly doctor-centred (3,16,19). Doctors almost always do most of the talking. Furthermore, most interviews focus solely on biomedical issues (20). The situation becomes more dif cult because patients seldom verbalise their emotions directly and spontaneously. They tend to offer clues instead, and if invited to elaborate they may then express their emotional concern directly. In addition, although more and better information is usually obtained in a given time using patient-centred techniques (4 – 6,11,14), many doctors still believe that using patient-centred interviewing techniques is time-consuming and inef cient. Postmodernism (2), the biopsychosocial diagnostic and treatment model (6,9), including patient-centred working style (5,11,13) may provide current medicine with revolutionary ideas and challenge the traditional, authoritarian doctor-centred treatment model. Recent studies have shown that patients are most satis ed by interviews that encourage them to talk also about psychosocial issues in an atmosphere not dominated by the doctor (21,22). On the contrary, when doctors only ask questions about biomedical topics, this has been shown to relate negatively to patient satisfaction. An additional bene t of the patient-centred treatment model is that this approach is more satisfying for the doctor, too (11,21); the enhancement of the therapeutic relationship works both ways. Based on our own studies and experiences, we believe that a doctor-centred working style may be the cause of ‘doctor-shopping’ behaviour (16,21, 23,24). The authoritarian, purely biomedical orientation of the health care system may in this way iatrogenically increase patients’ feelings of illness and produce heavy usage of medical care. If the patient’s stories are not listened to and understood by the doctor, and their concerns and fears are not elicited, they begin to think that their ideas and opinions are not important at all in the treatment process. Their often basically holistic idea of an illness disappears; they become biomedically oriented and somehow start to trust only medical tests and procedures. We
The patient-centred inter×iew
have often observed that heavy users of medical care, and their families, have almost totally lost their own strengths (16). We believe that by using patient-centred interviewing and a biopsychosocial approach, the doctor can get a better outcome and save on health care costs. A central theme of this article is the message that doctors and other health care providers, particularly in primary care settings, need a comprehensive concept of human health and illness, and that skill in interviewing is essentially a product of professional learning, rather than an innate ability that some possess from birth, but others lack. In Finland, and we believe in many other countries, too, we really need biopsychosocial thinking and clinical models today, when primary care is moving towards the ‘personal doctor’ system. This change should be taken into account in the education of new doctors. The professional identity, the way of thinking and working develop during the education process, and so it is important that teaching in medical schools is based on the biopsychosocial model (9).
ACKNOWLEDGEMENTS We are indebted to Dr. Peter Pritchard, honorary secretary of UK-Nordic Medical Educational Trust for reading the manuscript and for assisting us in working it up in its present form.
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