5
Judith Belle Brown, MSW W. Wayne Weston, MD Moira A. Stewart, PhD Patient-Centred Interviewing Part II: Finding Common Ground SUMMARY Developing an effective management plan requires physicians and patients to reach agreement in three key areas: the nature of the problems, the goals and priorities of treatment, and the roles of the doctor and patient. Often doctors and patients have widely divergent views in each of these areas. The process of finding a satisfactory resolution is not so much one of bargaining or negotiating but rather of moving towards a meeting of minds or finding common ground. This framework reminds physicians to incorporate patients' ideas, feelings, and expectations into treatment planning. (Can Fam Physician 1989; 35:153-157.) RESUME L'efficacite du plan de soins exige que les medecins et les patients s'entendent sur trois elements importants: la nature des problemes, les buts et priorites du traitement et les roles reciproques de chacun. On constate frequemment des divergences de vue entre les medecins et leurs patients. La recherche d'une solution satisfaisante n'implique pas necessairement une negociation mais plutot un cheminement pour en arriver a un terrain d'entente. Ce cadre conceptuel rappelle aux medecins de ne pas oublier d'incorporer dans le plan de soins les opinions des patients, leurs sentiments et leurs attentes. Key words: interviewing, physician-patient relationships, patient management _a~~~~~~~~~- -_------ The three authors of this paper hold appointments in the Department of Family Medicine of the University of Western Ontario, London. Ms. Brown is a Clinical Assistant Professor. Dr. Weston is a Professor. Dr. Stewart is an Associate Professor. Requests for reprints to: Dr. Wayne Weston, Byron Family Medical Centre, 1228 Comnissioners Road, West, London, Ont. N6K 1C7 DY USING a patient-centred ap- )proach, doctors can begin to ex- plore and understand patient's ideas, expectations, feelings and the effects of their illnesses on functioning. By this means the patient's perceptions CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989 of the problem are defined. At the same time, by using conventional clinical methods, including history taking, physical examination, and laboratory tests, physicians establish a medical definition of the patient's problem. The next task is to reach mutual understanding. This requires that two potentially divergent view- points be brought together in a rea- sonable management plan. Once agreement is reached on the nature of the problems, the goals and priorities of treatment must be determined: What will be the patients' involve- ment in the treatment plan? How re- alistic is the plan in terms of the pa- tients' perceptions of their illnesses? What are the patients' wishes and their ability to cope? Finally, how do each of the parties, patients and doc- tors, define their roles in this interac- tion? How does their relationship influence these decisions? Many authors describe the clinical encounter as a process in which doc- tor and patient negotiate to define what is important and what should be done.1-3 Like and Zyzanski,4 for ex- ample, define negotiation as the "process whereby two or more par- ties attempt to settle what each should give and take, or perform and receive, in a transaction between them." The emphasis here is on the potential conflict between the points 153 I n

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Page 1: Patient-Centred PartII: FindingCommon Common Grou… · el. For example, common problems ofliving maybemislabelled "chronic anxiety disorder" and treated with long-term anxiolytics

Judith Belle Brown, MSW W. Wayne Weston, MD Moira A. Stewart, PhD

Patient-Centred InterviewingPart II: Finding Common GroundSUMMARYDeveloping an effective management planrequires physicians and patients to reachagreement in three key areas: the nature ofthe problems, the goals and priorities oftreatment, and the roles of the doctor andpatient. Often doctors and patients havewidely divergent views in each of theseareas. The process of finding a satisfactoryresolution is not so much one of bargainingor negotiating but rather of moving towardsa meeting of minds or finding commonground. This framework remindsphysicians to incorporate patients' ideas,feelings, and expectations into treatmentplanning. (Can Fam Physician 1989;35:153-157.)

RESUMEL'efficacite du plan de soins exige que les medecins etles patients s'entendent sur trois elementsimportants: la nature des problemes, les buts etpriorites du traitement et les roles reciproques dechacun. On constate frequemment des divergencesde vue entre les medecins et leurs patients. Larecherche d'une solution satisfaisante n'implique pasnecessairement une negociation mais plutot uncheminement pour en arriver a un terrain d'entente.Ce cadre conceptuel rappelle aux medecins de ne pasoublier d'incorporer dans le plan de soins lesopinions des patients, leurs sentiments et leursattentes.

Key words: interviewing, physician-patient relationships,patient management

_a~~~~~~~~~- -_------

The three authors of this paper holdappointments in the Department ofFamily Medicine of the University ofWestern Ontario, London. Ms.Brown is a Clinical AssistantProfessor. Dr. Weston is a Professor.Dr. Stewart is an Associate Professor.Requests for reprints to: Dr. WayneWeston, Byron Family MedicalCentre, 1228 Comnissioners Road,West, London, Ont. N6K 1C7

DY USING a patient-centred ap-)proach, doctors can begin to ex-

plore and understand patient's ideas,expectations, feelings and the effectsof their illnesses on functioning. Bythis means the patient's perceptions

CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989

of the problem are defined. At thesame time, by using conventionalclinical methods, including historytaking, physical examination, andlaboratory tests, physicians establisha medical definition of the patient'sproblem. The next task is to reachmutual understanding. This requiresthat two potentially divergent view-points be brought together in a rea-sonable management plan. Onceagreement is reached on the nature ofthe problems, the goals and prioritiesof treatment must be determined:What will be the patients' involve-ment in the treatment plan? How re-alistic is the plan in terms of the pa-tients' perceptions of their illnesses?

What are the patients' wishes andtheir ability to cope? Finally, how doeach of the parties, patients and doc-tors, define their roles in this interac-tion? How does their relationshipinfluence these decisions?Many authors describe the clinical

encounter as a process in which doc-tor and patient negotiate to definewhat is important and what should bedone.1-3 Like and Zyzanski,4 for ex-ample, define negotiation as the"process whereby two or more par-ties attempt to settle what eachshould give and take, or perform andreceive, in a transaction betweenthem." The emphasis here is on thepotential conflict between the points

153

In

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of view of doctor and patient. Thisperspective is contractual rather thana true meeting of minds and is flawedby a simplistic "either/or" stance rath-er than a more holistic "both/and"perspective. We prefer to describe thisprocess as a mutual task of findingcommon ground between doctor andpatient in three key areas: defining theproblem; establishing the goals oftreatment; and identifying the roles tobe assumed by doctor and patient.

Defining the ProblemIt is a universal human characteris-

tic to try to explain personal experi-ences in order to give people a senseof having some control by labellingthose experiences. Most patientswant a "name" for their illness or atleast an explanation of their problemthat makes sense to them. Withoutsome agreement about the nature ofwhat is wrong, it is difficult for a doc-tor and patient to agree on a plan ofmanagement that is acceptable toboth of them. It is not essential thatthe physician actually believe that thenature of the problem is as the pa-tient sees it, but the doctor's explana-tion and recommended treatmentmust at least be consistent with thepatient's point of view and makesense in the patient's world. Peoplemay develop quite magical notions ofwhat is happening to them when theybecome ill. It seems better to them tohave an irrational explanation of theproblem than no explanation at all.Thus the quack who offers help willbe preferred to the cryptic physicianwho offers little. Some patients willeven blame themselves for the prob-lem rather than see the illness as sim-ply random or impersonal.

Problems develop when patientand doctor have different ideas of thecause of the problems. For example:* The patient says he is disabled by aback problem, and the doctor thinkshe is malingering.* The doctor has diagnosed hyper-tension, but the patient insists that hisblood pressure is probably only ele-vated because he is nervous in thedoctor's office and refuses to see it asa problem.* The parent of a six-year-old childthinks there is something seriouslywrong because the child has frequentcolds: six a year. The doctor thinksthis number is within normal limits,

and that the parent is overly protec-tive of the child.We often get into difficulty in defi-

ning patients' problems by inappro-priate use of the traditional medicalmodel. In using this model, we run arisk of applying improper treatmentfor problems that do not fit this mod-el. For example, common problemsof living may be mislabelled "chronicanxiety disorder" and treated withlong-term anxiolytics as if they weresome sort of infectious affliction thatcould be eliminated with chemicals.The analogy to antibiotic use for in-fections is striking. We need to be re-minded of the aphorism: "If youronly tool is a hammer, you see everyproblem as a nail."An exampleThe socially isolated, lonely patient

who has suffered chronic pain for 20years may need his pain to legitimizehis disability pension (his only in-come) and to provide an occasion tosit down with someone who caresabout him and his suffering. He longago accepted this situation as the bestof a bad job. The physician may real-ize that the pain which he experiencesas physical pain is a metaphor for hisintolerable life pain, but he does notneed to inflict this insight on the pa-tient if the latter cannot bear it. Itmay be sufficient that the physician'sinsight allows him to care more deep-ly for the patient and to avoid unnec-essary investigation to find a diseasethat is not there. If the physician re-sponds to the patient's cues and fol-lows his lead in discussing his person-al life and his feelings, he will helpthe patient to tell his own story at hisown pace and will avoid the risk ofpushing the patient beyond his limitsof tolerance.

In their book Getting to Yes, Fisherand Ury5 describe two common anderroneous approaches to negotiatingdifferences. The first is "hard bar-gaining": participants are viewed asadversaries, and the goal is victory.This approach generates bad feelingsand mistrust. The second approach is"soft bargaining": the emphasis hereis on building and maintaining the re-lationship and the goal is agreement.The risk of this approach is a sloppyagreement. Fisher and Ury recom-mend an altemative, which they call"principled negotiation". Four basictactics make up this approach:* First, separate the people from the

problem. It is better to see the prob-lem as being "out there" and the par-ticipants as working together to at-tack the problem, not each other.* Secondly, focus on interests, notpositions. People tend to stake out aposition and defend it as if it werepersonal territory. Often the underly-ing interests are forgotten in the bat-tle.* Thirdly, generate a variety of possi-bilities before deciding what to do.Having too much emotional invest-ment in one approach inhibits crea-tivity.* Finally, use objective criteria tojudge the solution rather than pittingone personal opinion against another.

Defining the GoalsWhen a doctor and patient meet,

each has expectations and feelingsabout the encounter; if these are atodds or inappropriate, there may bedifficulties. For example:* The patient has a sore throat andexpects to receive penicillin but in-stead is urged to gargle with salt wa-ter.* The patient is concerned about in-nocent palpitations but is found tohave high blood pressure. The doctorlaunches into a treatment of the hy-pertension without explaining to thepatient the benign nature of the car-diac symptoms.* The patient demands muscle relax-ants for chronic muscular pains, butthe doctor wants to use "talking"therapy to resolve the "underlying"problems.

If physicians ignore their patient'sexpectations, they risk not under-standing their patients, who in turnwill be angry or hurt by this perceivedlack of interest or concern. Some pa-tients will become more demandingin a desperate attempt to be heard;others will become sullen and unco-operative. Patients may be unwillingto listen to their doctors unless theybelieve that they have first been lis-tened to themselves. Hearing fullytheir patients' distress often chal-lenges doctors to use their imagina-tion and feelings to enter into theirpatients' inner lives: to experienceempathically their patients' pain, con-fusion, hopes, and fears. This experi-ence may be both threatening andemotionally draining for physicians.

Inexperienced physicians are oftenuncomfortable with the conventional

CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989154

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biomedical responsibility of makingthe correct diagnosis and are hesitantto add another dimension to a taskwhich seems already difficult enough.Physicians are sometimes concernedthat patients may ask for somethingthey disagree with; because they are

not comfortable with confrontationand saying no, they may prefer toavoid an issue. Perhaps they hope thatthe patient will get the message, indi-rectly, that any ideas not raised by thedoctor are unimportant. Students of-ten point out that if they ask patientsfor their ideas and expectations, theywill be told, "You are the Doctor!", a

remark that may leave the studentfeeling foolish and unable to respond.Timing is important. If the physi-

cian asks for a patient's expectationstoo early in the interview, the patientmay think that the doctor is evadingmaking a diagnosis, and may there-fore be reluctant to say much. On theother hand, if the physician waits un-

til the end of the interview, time maybe wasted on issues unimportant tothe patient. The physician may even

make suggestions which will have tobe retracted. Physicians need to ex-

press their questions clearly and sin-cerely. For example, a physicianmight say, "Can you help me tounderstand what you hope I might dofor you today?" It is important thatneither the physician's words nor

tone of voice suggest any accusationthat the patient is wasting the doc-tor's time on something trivial or sil-ly. Often, it is helpful to pick up on a

patient's comments that suggest, or

hint at, their ideas, expectations, or

feelings. For example, "I have hadthis chest cold for three weeks now

and none of those cough medicinesyou recommended has helped!"The doctor should avoid becoming

defensive in trying to justify previousadvice. Instead, it is more helpful topick up on the patient's frustrationand the implied message that some-

thing must be done: "You sound fedup with the length of time this illnesshas dragged on. Are you wondering ifit is something serious? Are youwanting a particular means to clear itup?"

Thus, the goals of treatment musttake into account the expectationsand feelings of both physicians andpatients. If the hidden agendas are

not recognized, it may be difficult toreach agreement. What physicians

call "non-compliance" may be thepatients' expressions of disagreementabout treatment goals; in this sensethe patient always has the last word.The following two examples illustratesome problems in defining goals:Examples

Mrs. C. has metastatic breast can-cer, and her pain is poorly controlled.Her physician may believe that acourse of chemotherapy would help.The patient, however, may considerthis treatment too aggressive and thepotential side-effects unacceptable.In this case the physician may place ahigher priority on slowing the pro-gress of the disease, whereas the pa-tient would rather concentrate onsymptom control.Another patient, Mrs. Y., is a

young mother with three small chil-dren. She presents with tennis elbow.The doctor may recommend that thepatient reduce her activities for sever-al weeks to allow the inflamed area toheal. The patient, on the other hand,may consider this impossible becauseof her responsibility for child care.She wants analgesics to relieve thepain so that she can get on with herjobs.

In these two examples the physi-cian and patient must work togetherto find a treatment plan that is accept-able to both. This may require thatthe goals and priorities of each be re-examined. It is often helpful for thedoctor to explain the nature of theproblem clearly and to outline thepros and cons of different ap-proaches. It is important to acknowl-edge the patient's concerns first sothat the patient is aware that the phy-sician is taking these into account.

Defining the RelationshipSometimes there is profound dis-

agreement about the nature of theproblem or the goals and prioritiesfor treatment. When such an impasseoccurs, it is important to look at therelationship between the patient andthe doctor, and at their perception ofeach other's roles. Doctors, as in theexample of the cancer patient, maysee themselves wanting to bringabout remission, and may expect thepatient to assume the role of a passiverecipient of treatment. Patients, how-ever, may be seeking a physician whoexpresses concern and interest intheir well-being, and who is preparedto treat them in the least invasive

CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989

manner, viewing them as autono-mous individuals with a right to havea voice in deciding among variousforms of treatment. This is not such adilemma for doctors when the variousforms are equally effective, but physi-cians are understandably concernedwhen the patient chooses a treatmentthat they consider harmful.One of the major differences be-

tween family medicine and othermedical disciplines is the duration ofthe doctor-patient relationship overtime. This allows the physician to seethe same patient with different prob-lems in different settings over a num-ber of years, and also to see the pa-tient through the eyes of other familymembers. The physician's commit-ment is to "hang in" with the patientto the end. Patients need to knowthat they can count on their doctorsto be there when they need them.This ongoing relationship colours ev-erything that happens between them.If there are difficulties in their rela-tionship or differing expectations oftheir relationship, they will haveproblems in working together effec-tively. For example:- The patient is looking for an au-thority who will tell him what iswrong and what he should do; thephysician, on the other hand, wants amore egalitarian relationship in whichdoctor and patient share decisionmaking.* The patient longs for a deep andmeaningful relationship with a paren-tal figure who will make up for every-thing the patient's own parent nevergave; the doctor wants to be abiomedical scientist who can applythe discoveries of modern medicineto patients' problems.* The physician enjoys a holistic ap-proach to medicine and wants to getto know patients as people; the pa-tient seeks only technical assistancefrom the doctor.Commonly, physicians react in one

of two ways to problems in their rela-tionships with patients. First, theytend to blame the patient, who is of-ten characterized as a "crock". Thisresponse is often chosen to justify ig-noring complaints that are not "legiti-mate" (i.e., organic). Patients can berejected in a variety of ways: theymay be subjected to unnecessary andsometimes dangerous or punitive in-vestigations; they may be given pillsinstead of time; they may be referred

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inappropriately to a variety of special-ists. They therefore become dissatisfi-ed with physicians, continue topresent numerous unresolving com-plaints, do not comply with treatmentand switch doctors frequently.

Alternatively, it is common fordoctors to blame themselves. Theyfeel that they must have done some-thing wrong: that if only they knewmore or were more skilled in inter-,viewing or therapy, they could savethese people from themselves. Therescue fantasy that led many physi-cians into medicine is severely testedby these patients. Many physicianstake courses to improve their patient-management skills, hoping to find"The Answer". Only after repeatedfailure with a variety of approachesare they able to come to terms withtheir limitations.A third, more effective and satisfy-

ing, reaction is to realize that theproblem is not one-sided. As Pogosaid, "We have seen the enemy, andthey are us!" On realizing this, physi-cians can give up their need to be per-fect and instead be prepared to dotheir best, to be "good enough", tobe real persons to their patients rath-er than needing to find someone toblame for the limitations of medicine.

Different patients want differentkinds of relationships with their doc-tors. Physicians are often admonishedto be more humane, less paternalis-tic, and more accepting of the rise ofconsumerism in medicine. These crit-icisms sometimes ignore the patient'sbest interests or even fail to take intoaccount whether this approach iswhat the patient wants. We advocatethat physicians be sensitive to pa-tient's cues about what they want totalk about, and to what extent theycan, and wish to, handle their owncondition. This step in understandingtakes time and is one of the reasonsthat continuity of care is so impor-tant. Mayeroff3 emphasizes this prin-ciple:

Caring assumes continuity and it isimpossible if the other is continu-ally being replaced. The othermust remain constant, for caring isa developmental process.

The final two examples illustratethe key concepts of finding commonground: defining the problems, thegoals, and the roles of the patient anddoctor.

Example One: A demandingpatient

Mrs. A. came to the office after anurgent phone call, made that sameday, demanding a repeat prescriptionfor steroid eye drops. She had had apainful red eye two months earlierand had seen an ophthalmologist, byreferral, who diagnosed acute iritisand prescribed steroid eye drops.When similar symptoms recurred afew days previously, she started usingthe drops again. By the time she wasseen she no longer had any symptomsand her eyes looked normal. She wasout of drops and was concernedabout a flare-up, as she was leavingfor a vacation in Bermuda that after-noon. The resident who saw her hadbeen taught in medical school thatfamily doctors should never prescribesteroid eye drops and insisted thatshe see an ophthalmologist. He wasconcerned that the patient's historywas vague and was not convinced thatshe had a recurrence of her iritis.The patient adamantly refused to

"waste two hours" in emergency andpreferred to take her chance withouteye drops if he would not prescribethem. The resident, believing that hewas in a no-win situation, was furi-ous. If he gave her eye drops (whichhe was not even sure she needed) andshe had complications, he would feelbadly; on the other hand, if he re-fused, the patient might have a flare-up that would ruin her vacation andperhaps even permanently damageher eye. He feared that this type of"unreasonable" patient was likely tosue him either way. The staff physi-cian who had known the patient forseveral years, realized that she rarelybacked down. Even after explainingthe doctor's concerns (the uncertaindiagnosis and the potential harm oftreatment or non-treatment), the pa-tient remained adamant in her re-quest. The physician decided that onbalance, and under these restrictedcircumstances, the patient's interestswould best be served by prescribingthe steroid eye drops and cautionedher on what symptoms to look for.

Example Two:A case of "severe" poison ivy

Mrs. M., a 38-year-old woman pre-sented to the office with a small patchof poison ivy 3 cm in diameterpresent for 3 days on her left calf. Shewas angry with the doctor she hadseen the previous day because he had

156

refused to prescribe oral corticoster-oids, and she stated that the rash had"tripled in size overnight". (His de-scription of the lesion in the medicalrecord stated that the rash was 3 cmin diameter when he had seen it.) Shewas to play in a golf tournament thenext day, wanted to wear shorts, andwanted the rash to be gone; she de-manded oral prednisone.When the doctor explored her con-

cern that the rash might spread, Mrs.M. reported that her son had had abad case of poison ivy, initially treat-ed with topical steroid, and then re-quiring prednisone. She could not bereassured that this was very unlikelyto happen in her case, especially afterthree days.The doctor had known this patient

for many years and was aware of hertroubled marriage and her great diffi-culty in trusting anyone. He alsoknew that she was often concernedabout her appearance and hated get-ting older. Experience had taughthim that any exploration of these is-sues was fraught with danger: Mrs.M. would almost certainly becomeangry and accuse him of not takingher concerns seriously. He decided tofocus on her concerns until he wassure she knew he understood and wasnot taking them lightly. Then he di-rectly addressed their difference ofopinion about what was likely to hap-pen and about appropriate manage-ment. He asked her to read the ad-verse effects of prednisone in theCompendium of Pharmaceuticals andSpecialties. He promised to see heragain early the next morning if therash doubled or tripled in size again,and to reconsider oral steroids if thatoccurred. He made a point of careful-ly measuring the lesion, telling her itsdimensions, and making sure that shenoticed him recording this in hisnotes.

Reluctantly Mrs. M. accepted topi-cal treatment and did not call back.Several months later, when seen for aseparate problem, Mrs. M. men-tioned that the poison ivy had be-come worse the next day but "not toobad".

In both these cases there was somedisagreement about the nature or se-verity of the problems and appropri-ate goals or methods of treatment.There were also difficulties in thedoctor-patient relationship that couldeasily have reached an impasse. By

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clarifying their differences of opinionwhile, at the same time, showing re-spect for the patient's point of view,the physician was able to avoid aharmful power struggle and perhapssowed the seeds for a more effectiveworking relationship in the future.

Being RealisticWhat can physicians realistically

achieve in ordinary office visits? Wedo not suggest that all areas of patientconcern be explored in every visit. Infact, one of the strong points of fami-ly medicine is the use of several visitsover time to explore complex ordeeply personal issues. Often, after aclose and trusting relationship has de-veloped, doctor and patient can getto the heart of a matter very quickly.Time and timing are two key factors.While it is not realistic to cover everyaspect of the patient's story on everyvisit, physicians must be sensitive tothe importance of timing and be ableto recognize when a patient requiresmore time even if it means disruptingtheir office schedule. Timing alsospeaks to the issue of the patient'sreadiness to share certain concerns orexperiences with the doctor. When apatient presents with multiple symp-toms and concerns, the physicianmust learn how to establish which arethe most pressing issues at that time,address them, and pave the way forthe patient to return to the office toexplore the remaining concerns. Phy-sicians must learn how to createquickly an atmosphere in which pa-tients feel heard and understand thatthe physician sees their problems asimportant and worthy of further ex-ploration. d

References1. Heaton PB. Negotiation as an integralpart of the physician's clinical reasoning. JFam Pract 1981; 6:845-8.

2. Quill TE. Partnerships in patient care:a contractual approach. Ann Int Med1983; 98:228-34.3. Anstett R. Teaching negotiating skillsin the family medicine centre. J Fam Pract1981; 12:503-6.4. Like R, Zyzanski SJ. Patient requestsin family practice: a focal point for clinicalnegotiations. Fam Pract 1986; 3:216-28.

5. Fisher R, Ury W. Getting to yes: nego-tiating agreement without giving in. Mark-ham, Ont.: Penguin Books, 1983.6. Mayeroff M. On caring. New York:Perennial Library, Harper and Row,1971: 34.

CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989

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