I’ve just read Patient-centered Interviewing. An Evidence-based Method, by Dr Robert C Smith (ISBN-13 978-0-7817-3279-6). This is one of the best medical textbooks I’ve ever read. I really hope that even in medical schools where the teachers haven’t even heard of this approach, that they will be teaching something very, very similar.
The premise of this book is very simple, and it is that the doctor-patient interview is at the heart of all medical practice. Unlike sick plants or animals, human beings are able to reflect on their own inner experience and to convey that experience using language. These latter qualities make medical practice different from other sciences and crafts. One of the first doctors to make this so very clear was the great George Engel, who proposed, back in the late 1970s, that we move from a biomedical model of human health, to a biopsychosocial one. It is this understanding which underpins “patient-centered interviewing”.
The subtitle of the book is also striking, however, “An evidence-based method”. Much is made of “evidence” these days, and it is arguable that the great ideals of Sackett and his colleagues for “Evidence Based Medicine” has become distorted at the hands of both managers who want to control finances and the practice of doctors, and those who have a narrowly materialistic view of the world, who only value what can be objectively measured. This book, however, takes meets that issue head on by presenting a truly evidence-based approach to the commonest medical procedure on the planet, the one which the average American physician carries out between 140,000 and 160,000 times in his or her working life – the interview.
The patient-physician relationship is the center of medicine. Relationships are central to medical practice…..At the core of any therapeutic relationship is the feeling that an individual can safely expose his or her vulnerability and that he or she is genuinely cared for. These qualities are not merely a matter of having a good bedside manner or of being nice. They have actually been associated with outcomes of care…….The core skill of relationship-building is empathy, which is an accurate recognition and acceptance of another’s emotional state.
Scientific methods usually involve the concept of data. As Smith says,
Although uniquely private and subjective, symptoms and concerns are the primary data – the hard data of the science of medicine – and clinicians and students can enhance their scientific value by good interviewing. These human data lead to most diagnoses and determine most treatments. By “human data”, I mean information that the patient communicates either in words of by nonverbal, but uniquely human, ways, such as a frown. These data are found in no other domain.
He makes what he terms the “humanistic argument” which is that we should “hear and understand our patients in a way that validates them as human beings rather than as objects of study” He points out that this leads to increased patient autonomy which in turn helps them to communicate more clearly what they are actually experiencing and, when it comes to treatment, are much more likely to follow through in their own interests. The biomedical model has produced a doctor-centered approach to interviews – the aim is for the doctor to establish the physical diagnosis – so, the doctor asks lots of questions and the patient is expected to give short, focussed answers. Studies of this method have shown that in over two thirds of interviews, the patient does not manage to complete their opening statement of concerns, being interrupted, on average, 18 seconds into their account. Smith is not derogatory about the doctor-centered approach and recognises its value in establishing urgency, clear physical diagnoses, and treatment plans. However, he argues, it often goes wrong because it fails to allow the doctor to comprehend the patient’s personal concerns and, in particular, the psychosocial contexts of their symptoms. This book lays out a method for a medical interview which begins with a patient-centered approach then moves to a doctor-centered one, concluding with a comprehensive, balanced summary of what has been understood through both approaches together. Crucially, he argues that a solely doctor-centered approach is unscientific because it produces biased data about the patient which is not so reliable and not so valid.
The patient-centered interview has five steps
1. Welcoming the patient, introducing yourself, making them comfortable.
2. Capturing both the patient’s and the doctor’s agendae.
3. Facilitating the narrative by using open-ended questions to explore the presenting complaint
4. Developing the personal story and the emotional story through relationship-building skills of emotion-seeking and emotion-handling.
5. Summary and transition to doctor-centered part of interview
I particularly like his little mnemonic of NURS for emotion-handling skills –
N = Naming – saying what the emotion is – “sad”, or “frustrated”, or whatever
U = Understanding – accepting and validating the emotion
R = Respecting – emphasising the positive elements of the patient’s coping
S = Supporting – offering support and partnership to work to bring about improvement
In Appendix B, Smith has included George Engel’s Foreword to the First Edition – which is a short essay worth buying the book for! In it, Engel explains how he developed the concept of the biopsychosocial approach. He quotes Heisenberg – “What we observe is not nature itself but nature exposed to our method of questioning”
Physicist Heisenberg’s dictum exemplifies a fundamental distinction between 17th- and 20th-centure scientific thinking, the latter of which is derived from such conceptual developments as evolution, relativity, quantum mechanics, general systems theory, far-from-equilibrium thermodynamics, and, more recently, chaos and complexity theory. Loosely speaking, we are applying biomedical and biopsychosocial as labels to contrast the two positions. Actually, what Heisenberg enunciates is what clinicians have known from time immemorial – namely, that the answers you get from a patient depend on the questions you pose and how you do. More broadly, it exposes the fallacy of the 17th-century natural science position that what scientists discover exists entirely external to and independent of themselves. In fact, rather than simply examing or observing something “out there”, scientists devise mental constructs of their experiences with the observed as a means of characterising their understanding of its properties and behaviour. This change in perspective began in physics with relativity theory, which required acknowledgement that the location of the observer cannot be ignored relative to what is being observed. The rediscovery of the obvious occurred in that transformation – namely, that science itself is a human activity. The lesson is that humanness and human phenomena cannot be excluded from science.
I find this book very timely. It might be over 30 years since Engel showed how the practice of medicine should change, and in that time both systems approaches, chaos and complexity theories and discoveries should have transformed our understanding of both health and disease. But we are only at a beginning, and the dominant viewpoint is still the 17th-century mechanistic one. Medicine needs to catch up with some of the new findings from science. Evidence, it turns out, is produced within the complex web which stretches from the subjective to the cosmological.
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