Family Practice© Oxford University Press 1986

Vol. 3, No. 1Printed in Great Britain

The Patient-Centred Clinical Method.1. A Model for the Doctor-PatientInteraction in Family MedicineJOSEPH H LEVENSTEIN*. ERIC C MCCRACKEN, IAN R MCWHINNEY, MOIRA A STEWARTAND JUDITH B BROWN

Levenstein J H, McCracken E C, McWhinney I R, Stewart M A (Department of Family Medicine, KresgeBuilding, Room K101, University of Western Ontario, London, Ontario N6A5C1, Canada) and Brown J B.The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine.Family Practice 1986; 3: 24-30.This article describes a patient-centred clinical method appropriate for family medicine. The method isdesigned to attain an understanding of the patient as well as his disease. This two-fold task is described interms of two agendas: the physician's and the patient's. The key to an understanding of the patient'sagenda is the physician's receptivity to cues offered by the patient, and behaviour which encourages him toexpress his expectations, feelings and fears. The physician's agenda is the explanation of the patient'sillness in terms of a taxonomy of disease. In the patient-centred clinical method, both agendas areaddressed by the physician and any conflict between them dealt with by negotiation. This is contrastedwith the disease-centred method in which only the doctor's agenda is addressed. Further articles willdescribe the patient-centred method in operational terms.

The task of the physician is twofold: to under-stand the patient and to understand the disease.In the process of differential diagnosis there is awell-tried clinical method for understandingdiseases, but no equivalent method for under-standing patients. For three reasons this lack isespecially serious for family medicine. As Car-michael1 has pointed out, a large proportion ofthe problems presented to family physicians arenot diagnosed in the usual sense of the term. Formany presenting symptoms, the proportion ofpatients who remain without a specific diagnosisis large. In these patients, a pathologicaldiagnosis is not a realistic goal. The physicianmust have some other way of reaching an under-standing of the illness. The key to this under-standing, we will suggest, is an understanding ofthe patient.

The second reason relates to the differentcriteria of success between family practice and

Department of Family Medicine, Kresge Building, Room K10I,University of Western Ontario, London, Ontario N6A SCI, Canada(reprint requests to Moira Stewart).* Unit of General Practice, Department of Community Health,University of Cape Town, South Africa.

other fields of medicine. For a family physician, aprecise pathological diagnosis may be indicativeof a failure rather than a success. Thus, theintellectual achievement of making the precisediagnosis may be marred by the fact that earliersigns of the abnormality, although not as yetdifferentiated into a classical disease entity, havegone unnoticed. Thus an opportunity of prevent-ing the disease may have been missed. These earlydeviations from the normal may only be signifi-cant if a patient is assessed in relation to his ownnorms, rather than by an objective standard. Thefamily physician should, for example, take noticeof a marathon runner complaining of dyspnoeaoccurring earlier on in his usual run as it may beindicative of oncoming illness. While the runner'sexercise tolerance is obviously far greater thanthat of most people, this occurrence is obviouslyof significance to him. Vague symptoms, such astiredness and headaches may be the earliestevidence of a breakdown in health. Early signs ofstress in a family, such as an underachievingchild, a young girl neglecting her contraception, amother who cannot cope with her baby, or afather who appears aggressive or despondent,may all be opportunities for preventing child

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PATIENT-CENTRED METHOD—PART ONE 25abuse, suicide or alcoholism. Thus, the familyphysician's goal is, wherever possible, to identifyemerging problems so that end-state pathologydoes not develop.

The fact that some of these goals are difficultto achieve does not make them any the lessdesirable. The undifferentiated illness encoun-tered by the family physician provides him withhis opportunity for prevention. His clinicalmethod, therefore, must be effective in identify-ing problems at an early stage in their evolutionand in conveying to patients that such problemsare a legitimate reason for seeking help.

The third reason relates to management,described by Stephens2 as 'the quintessence offamily medicine'. Management in family practiceis tailored to individual needs. Although techno-logical aspects of management may be standard-ized, there are numerous individual variations,even in patients with the same diagnosis. Thus,even when there is a clear-cut pathologicaldiagnosis, the family physician still needs toknow the patient as an individual, with a uniqueexperience of life, if his management is to be fullyeffective. The development of an integratedclinical method, designed both to understand thepatient and his disease, is a challenge of familymedicine.

In this series of papers, we give an interimreport on our work in developing and testing aclinical method appropriate for family medicine.Like other writers, we call this the 'patient-centred' method. We emphasize that a patient-centred method must include the process ofdifferential diagnosis—its aim must be both tounderstand the patient and to diagnose his illness,if possible, in terms of physical pathology.

The two-fold purpose of the process is bestexpressed in terms of the doctor's and thepatient's agendas (Figure 1). When a patientconsults a physician, he has a certain agenda inmind. We have chosen to define this in terms ofhis expectations, feelings and fears. The doctoralso has his agenda, which in general may bestated as the correct diagnosis of the patient'scomplaints and the implementation of preventiveprocedures that are appropriate for the patient'sage, sex and risk factors. For individual patientshe may have a more specific agenda based onprevious knowledge of the patient and his family.

In the patient-centred method, the physician'saim is to ascertain the patient's agenda and toreconcile this with his own. In this initial phase ofour study, we have concentrated on developing amethod by which physicians can understand thepatient's agenda. In the family medicine

PATIENTPRESENTS

CUES OF UNWELLNESS

DOCTOR SEARCHESTWO PARALLEL AGENDAS

DOCTOR'S AGENDAHistory

Physical ExaminationLaboratory Investigation

DIFFERENTIALDIAGNOSIS

PATIENT'S AGENDAExpectations

FeelingsFears

UNDERSTANDINGILLNESS EXPERIENCE

INTEGRATION

FIGURE 1 The patient-centred clinical method

26 FAMILY PRACTICE—AN INTERNATIONAL JOURNAL

literature, the patient-centred method is con-trasted with the disease-centred or doctor-centredmethod. In the latter method, the doctor pursueshis own agenda and makes little attempt to under-stand the patient's. While adopting the sameterminology, we stress again that the patient-centred method includes the disease-centredwhenever this is appropriate.

The term 'patient-centred medicine' was intro-duced by Balint and colleagues,3 who contrastedit with 'illness-centred medicine'. An understand-ing of the patient's complaints based on patient-centred thinking was called 'overall diagnosis',and an understanding based on illness-centredthinking was called 'traditional diagnosis'. Theclinical method was elaborated by Stevens4 andby Tait.5 Byrne and Long6 developed a methodfor categorizing a consultation as doctor orpatient-centred, their concept of a doctor-centredconsultation being close to the 'illness' or'disease'-centred methods of other writers. Intheir book, Clinical Thinking and Practice—Diagnosis and Decision in Patient Care, Wrightand MacAdam7 also describe doctor and patient-centred clinical methods. The concept of apatient-centred clinical method has much incommon with Rogers' psycho-therapeutic con-cept of client-centred therapy.8

The findings of Byrne and Long,6 in theiranalysis of 1850 general practice consultations,suggest that many physicians develop a relativelystatic style of consulting and that this tends to bedoctor-centred. As they remark: 'The problem isthat the doctor-centred style is extremely seduc-tive'. Our observation is that clinical teaching inmedical schools tends to emphasize a doctor-centred approach (or disease-centred, as weprefer to call it). According to this model, thephysician ascertains the patient's complaints andseeks information which will enable him tointerpret the patient's illness in terms of his ownexplanatory frame of reference. This involvesdiagnosing the patient's disease and prescribing amanagement plan appropriate to the diagnosis.One of the criteria of success is a precisediagnosis, such as myocardial infarction, stroke,carcinoma of the colon, child abuse, attemptedsuicide or alcoholism. In pursuit of this goal, thephysician uses a method which is designed toobtain objective information from the patient.

While there is substantial agreement on theneed for family physicians to be patient-centred,little has been done to define what this means in

operational terms. It could be argued that thephysicians' styles are so different, and clinicalsituations so varied, that no single method couldcover all possible doctor-patient interactions.We do not accept this view. The method of dif-ferential diagnosis is designed to apply to anyclinical situation. We see no reason why familymedicine should not develop an equally rigorouspatient-centred method which can also be appliedto any situation. Indeed, we believe it is essentialfor our discipline that we do develop such amethod.

In these articles we describe a patient-centredmethod developed by one of us (J.L.)9 in his ownpractice, and further developed and tested duringvisits to the University of Western Ontario in1981 and 1982. We believe this method answersthe question, 'What is the minimum that can beexpected of any family physician at any patientvisit?'

THE PATIENT-CENTRED METHOD—THEPATIENT'S AGENDAThe essence of the patient-centred method as itrelates to the patient's agenda is that thephysician tries to enter the patient's world, to seethe illness through the patient's eyes. He does thisby behaviour which invites and facilitates open-ness by the patient. The central objective in everyinteraction is to allow the patient to express all thereasons for his attendance. The doctor's aim is tounderstand each patient's expectations, feelings,and fears. Every patient who seeks help has someexpectations of the visit, not necessarily madeexplicit.

Every patient has some feelings about hisproblem or problems. Sometimes his feelingsmay be the major factor in the illness, as when aperfectly tolerable symptom is mentioned onlybecause the patient fears cancer. Although fear isan aspect of feeling, it is such a universalcomponent of illness that we feel justified ingiving it a separate heading.

Understanding the patient's expectations, feel-ings and fears will be specific for each patient.Obviously each patient's account of hissymptoms and their underlying meanings reflecthis own unique world. Categorization may helpthe physician, but the classification of clinicalphenomena, be it physical, psychological orsocial, comes from the doctor's world, not thepatient's. It is not a substitute for the under-standing of each patient as a unique individual.

PATIENT-CENTRED METHOD—PART ONE 27Entry into the patient's world is a difficult art,requiring of the physician human qualities ofempathy, non-judgemental acceptance, con-gruence and honesty.8 It also requires a skill in thepractice of certain techniques, and it is ourconviction that these techniques can be learnedand taught. Moreover, the physician cannot bepatient-centred unless he has self-knowledge andis prepared to make the changes in attitude andbehaviour needed for such an approach.

The key to the patient-centred method, as itsname implies, is to allow as much as possible toflow from the patient. The crucial skill is to bereceptive to cues offered by the patient. Byattentive listening, the doctor is able to respondto these cues, thereby helping the patient toexpress his expectations, feelings and fears.

Failure to take up a patient's cues results in thedoctor cutting off the patient and thereby missingan opportunity to gain full insight into his illness.It can also result in frustration for the patient,since the doctor is giving precedence to his ownpriorities. The following example, based onrecent experience, will serve to illustrate themethod:

A 68-year-old male patient, who had recentlybeen operated on for a benign stricture of thesigmoid colon presented for a routine follow-upoffice visit. The patient, a retired RomanCatholic priest, had very recently taken upresidence in a retirement home for ageing clergy.All these facts were known to the doctor. Theinteraction has been reconstructed in two ways toillustrate the disease- and patient-centredmethods.

The Disease-Centred MethodDoctor Hello Father Smith, how are you

today?Patient Fine—except for my headaches . . .Doctor . . . and your operation, how's that

going?Patient Fine.Doctor Bowels working?Patient Yes.Doctor Appetite?Father A bit poorly.Doctor Have you lost any weight?Patient No.Doctor Well, obviously your loss of appetite

hasn't affected anything, so it can't betoo bad? Any nausea or vomiting?

Patient None.

Doctor Any pain at the operation site?Patient Not really.Doctor Are you eating the bran we

recommended?Patient No.Doctor You must please stick to our

recommendations. We don't want anyrecurrences.

Patient (sighing) Yes.Doctor Good, well the operation seems to have

been a success and there don't seem tobe any complications. Have you anyother complaints?

Patient I have this headache.Doctor Is your vision affected?Patient No.Doctor Any weakness or paralysis of your

limbs?Patient No.Doctor Where are your headaches?Patient At the back of my head.Doctor Do they throb?Patient Yes.Doctor How long do they last?Patient About four hours.Doctor What takes them away?Patient I just lie down.Doctor How often do they come?Patient About twice a week.Doctor How long have they been there for?Patient Ever since I've been at the home.Doctor Good, well you needn't worry—it can't

have anything to do with youroperation. They are tension headaches.Perhaps we can give you someparacetamol for it. The home you havejust moved into seems to have beautifulgardens.

Patient Yes.Doctor It really is good of the church to care for

its elderly and it must be comforting tohave company.

Patient Yes.Doctor Well good. Come and see me in a

month's time and we'll see how thingsare going. Take care.

The Patient-Centred MethodDoctor Hello Father Smith, how are you

today?Patient Fine, except for my headaches.Doctor What about your headaches?Patient Well, I've been getting them about

28 FAMILY PRACTICE—AN INTERNATIONAL JOURNAL

twice a week at the back of my head andthey bother me so I can't do anything,and I have to lie down.

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

Patient It's frustrating, they're interfering withthe writing I want to get done andnobody seems to understand . . .

Doctor Understand?Patient All the other priests are so old and

decrepit in that place. All they can talkabout is their aches and pains. I'mashamed to say they make me sick.

Doctor Why are you ashamed?Patient Well, I shouldn't really talk that way

about them, they mean no harm . . . Ifeel so guilty about it.

Doctor What do you mean guilty?Patient I feel that my anger is unjustified, I'm

so frustrated that no one understandsthat I wish to write.

Doctor It must be frustrating . . .Patient Yes, it is and my headaches—my

headaches make it worse.Doctor When did they first start?Patient Ever since I've been at the home.Doctor Why do you think that is?Patient I . . . don't know, I haven't really

thought about it . . . do you think it'stension? . . . 1 mean the people at thehome . . . is it possible?

Doctor What do you think?Patient Well the whole situation at the home

does trouble me.Doctor Would you like to talk about it more?Patient No, not now, perhaps later.Doctor Well, feel free to discuss it anytime you

like.Patient Mmm, mmm, I will.Doctor Well, how are things going after your

operation?Patient It seems okay.Doctor What do you mean, it seems okay?Patient Well I don't seem to be eating well and

I can't stand that bran. In fact I have noappetite for food.

Doctor What do you think that could be dueto?

Patient I wonder if it's due to the tension I'mfeeling?

Doctor Mmm, mmm.Patient I will really think about what we've said

and come back to see you again.

Doctor Fine, anything else today?Patient Fine, everything is fine, except I get a

funny feeling on my scar.Doctor A funny feeling?Patient Yes, it seems a bit numb . . . I hope it's

not serious.Doctor It's probably a little nerve that supplies

the skin that was cut during theoperation. Nothing to be concernedabout.

Patient I'm glad it's only that. I was quiteworried.

Doctor Anything else you'd like to discuss?Patient No, everything else is fine.Doctor Good, would you like something for

your headaches?Patient Thank you, but I don't think it's

necessary.Doctor I'd like to see your wound in a month's

time, but we can get together earlier ifyou'd like to.

Patient Fine, I'll be in touch, Doctor.

The doctor using the disease-centred methodassumes that the expectation of the visit is tocheck out any possible post-operative problems.This is the physician's utmost priority and any-thing unrelated to it or anything not of organicsignificance is of secondary importance. He thusrelentlessly pursues his objectives. When hefinally does discuss the headaches he does so in aclosed-ended way, not allowing the patient anyopportunity to express his own feelings or fears.He misses subtle cues throughout. In discussingthe patient's social context, the doctor pre-emptsany expression of feeling by the patient by usingvalue judgements to describe his circumstances.None but the most assertive patients wouldcontradict him.

The first interview could certainly have beensaid to have been appropriate from the con-ventional doctor's world. There are no post-operative complications and he has treated thepatient's tension headaches with paracetamol.However, the patient's world was not enteredinto it at all.

The physician using the patient-centredmethod has allowed the interview to be guided bythe patient. He has recognized that the patient'sexpectation of the visit is that his headaches willbe dealt with and, by using open, non-directive,facilitative verbal (and non-verbal) behaviour,has elicited several feelings and fears related to

PATIENT-CENTRED METHOD—PART ONE 29the patient's life. He has picked up cues, albeitsubtle ones, and allowed the patient to expand.He also concentrated on the one aspect ostensiblyrelated to the post-operative course, that is, lossof appetite. However, it appeared to have anentirely different connotation when explored inthe context of the patient's world.

In short, while the doctor was aware of his ownagenda, he understood that to learn about thepatient and his illness, he had to do it through thepatient's world.

THE APPROPRIATE CONTEXTIn gaining an understanding of the patient'sexpectations, feelings and fears, the physician isobtaining a picture of the context of the illness. Insome cases, the context may be the key to under-standing the whole illness, in others it mayenlarge the management options, in others it mayseem to have little practical significance. Thequestion then arises: what is the appropriatecontext? Our answer is that the context should belarge enough for the physician to offer to thepatient the maximum number of managementoptions, and the greatest opportunity for identi-fying emerging problems.

Is there a risk in this method of invading apatient's privacy? Not, we believe, if theprinciples are followed. The physician does notprobe or dig, he invites the expression of feelingsand opinions. If the patient does not wish torespond, that is his prerogative and the subject isdropped. The doctor is only, in fact, acting onwhat the patient gives him.

RECONCILING THE TWO AGENDASAlthough the exploration of the patient's agendacan be applied to all cases, it is obviously notsufficient in itself. At some stage the physicianwill need to apply his agenda, the disease-centredmethod, bringing the patient's problems into hisworld by trying to arrive at a pathologicaldiagnosis or applying appropriate preventivestrategies. There is not necessarily a sequentialorder, with the patient's agenda being exploredfirst, the doctor's agenda second. Cues may beprovided by the patient at any stage of theprocess. Under usual circumstances however, thephysician will need to begin with the patient'sagenda, since the understanding gained by it maydetermine how he follows his own agenda. If, forexample, he has discovered that his patient'sreason for attendance is to obtain a sickness

absence certificate for an illness that is alreadysubsiding, he may not need to apply the disease-centred method at all.

We believe it to be quite common, even infamily medicine programmes, for physicians touse the disease-centred method first in all cases,then move to the patient's agenda only if theformer does not yield a clear pathologicaldiagnosis. Given the predominance of thedisease-centred method in medical education, itis, not surprisingly, the approach used byresidents at the beginning of their training. Ourconviction is, however, that the patient-centredmethod, integrating the doctor's and the patient'sagenda, should be universally applied in familypractice. In some cases, there will inevitably be aconflict between the patient's expectations andthe physician's assessment of his needs. If thepatient's main concern is his itchy feet, and thephysician finds that he has a blood pressure of230/140 mm Hg, the doctor will obviously try toconvince him that his hypertension is a morepressing concern than his presenting problem. Aconflict of this nature will normally result in aprocess of negotiation followed by an agreement.This does not mean that the patient's expecta-tions are not dealt with; at some stage, they mustbe addressed, but only after more urgentproblems have been dealt with. It is, of course,possible that the physician may not be willing orable to meet the patient's expectations. Forexample, he may be unwilling to prescribepenicillin for a cold. Even in this case, however,the physician will be able to deal with thesituation more effectively if he knows that this iswhat the patient expects.

Our observations of many doctor-patientinteractions lead us to the view that a failure toapply the patient-centred method correctly leadsto a dysfunctional interview and an unsatis-factory outcome. This is supported by the findingof Byrne and Long6 that a failure to ascertain thepatient's reason for attendance leads to dys-functional interviews. It is also in accordancewith Stewart's10 finding that patient-centredinterviews are associated with a higher level ofpatient satisfaction and greater compliance withtreatment.

The next questions we wish to address are: Canthe patient-centred method be defined in preciseoperational terms? Can we develop a reliablemethod for scoring the 'patient-centredness' ofinterviews? Can a physician learn to apply the

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patient-centred method if given the appropriateinstruction? The remaining articles in this seriesdeal with these questions.

ACKNOWLEDGEMENTSWe are indebted to Wayne Weston for permissionto use Figure 1, and also for his valued criticisms.

REFERENCES1 Carmichael L P. The relational model: a paradigm of

family medicine. J Fla Med Assoc 1980; 67: 860-862.2 Stephens G G. The intellectual basis of family practice.

Tuscon, Arizona: Winter, 1982.3 Balint M, Hunt J, Joyce D, et al. Treatment or diagnosis:

a study of repeat prescriptions in general practice.Toronto: J. B. Lippincott, 1970.

4 Stevens J. Brief encounter. J R Coll Cen Pract 1974; 24:5-22.

5 Tait I. The history and function of clinical records. MDthesis, University of Cambridge, 1979.

6 Byrne P S, Long B E L . Doctors talking to patients.London: Royal College of General Practitioners, 1984(reprint of 1976 edition).

7 Wright H J, MacAdam D B. Clinical thinking and practice:diagnosis and decision in patient care. Edinburgh:Churchill Livingstone, 1979.

8 Rogers C. Client-centred therapy—its current practice,implications and theory. Cambridge, Mass: RiversidePress, 1951.

9 Levenstein J H. The patient-centred general practice con-sultation. S Afr Fam Pract 1984; 5: 276-282.

10 Stewart M A. What is a successful doctor-patient inter-view? A study of interactions and outcomes. Soc SciMed 1984; 19: 167-175.