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I

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


Patient-Centred Interviewing
Part I: Understanding Patients' Experiences
SUMMARY RESUME
Effective patient care requires attending as L'efficacite des soins necessite qu'on s'occupe autant
much to patients' personal experiences of des experiences personnelles du vecu entourant la
illnesses as to their diseases. Diseases are maladie que de la maladie elle-meme. Le modele
ferreted out by using the conventional medical traditionnel sait comment rechercher les
maladies, mais leur comprehension exige une
medical model, but understanding illnesses approche differente. La methode centree sur le
requires a different approach. A patient- patient met l'emphase sur quatre aspects importants
centred method focuses on four principal des experiences vecues par les patients: leur
dimensions of patients' experiences: their perception de ce qui ne va pas; les sentiments qu'ils
eprouvent
ideas about what is wrong with them; their craintes; l'impact face a leur maladie, en particulier leurs
de ce probleme sur leur
feelings about their illnesses, especially their fonctionnement; et leurs attentes face ca ce qui devrait
fears; the impact of their problems on etre fait. La cle de cette approche est l'attention
functioning; and their expectations about portee aux indices donnes par le patient dans
what should be done. The key to this chacune de ces quatre dimensions; l'objectif est de
approach is attention to patients' cues suivre les indices donnes par le patient, et de tenter
de comprendre le vecu du patient a partir de son
related to these dimensions; the goal is to point de vue a lui. Cette methode ameliore la
follow patients' leads, to understand satisfation du patient, son niveau d'observance, et le
patients' experiences from their own point resultat ultime peut s'appliquer a la pratique
of view. This method improves patient quotidienne pour la majorite des soins de premiere
satisfaction, compliance and outcome, and ligne.
is applicable to the everyday work of family
physicians with "ordinary" patients. (Can
Fam Physician 1989; 35:147-151.)
Key words: interviewing, physician-patient relationships

The three authors of this paper hold background of this approach and pro- ogy: abnormal structure and function
appointments in the Department of vides practical advice for implemen- of tissues and organs. This model is a
Family Medicine of the University of tation. conceptual framework for under-
Western Ontario, London. Dr. standing the biological dimensions of
Weston is a Professor. Ms. Brown is a Disease and Illness sickness by reducing sickness to dis-
Clinical Assistant Professor. Dr. The basis of this conceptual model ease. The focus is on the body, not
Stewart is an Associate Professor. is a distinction between two modes of the person. A particular disease is
Requests for reprints to: Dr. Wayne ill health: disease and illness. Disease what everyone with that disease has
Weston, Byron Family Medical is an abstraction: the "thing" that is in common, but the illness experi-
Centre, 1228 Commissioners Road, wrong with the body-as-machine; ill- ences of each person are unique. Dis-
West, London, Ont. N6K 1C7 ness, on the other hand, is the pa- ease and illness do not always co-
tient's personal experience of sick- exist. Patients with undiagnosed a-
OR SEVERAL YEARS our ness: the thoughts, feelings, and symptomatic disease are not ill; peo-
1 group at The University of West- altered behaviour of someone who ple who are grieving or worried may
ern Ontario has been developing a feels sick (Figure 1). feel ill but have no disease. Patients
model of family practice.14 This pa- In the biomedical model, sickness and doctors who recognize this dis-
per outlines some of the theoretical is explained in terms of pathophysiol- tinction and who realize how com-
CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989 147
mon it is to feel ill and have no disease, their suffering. What is needed, he clear up this problem? Apart from
are less likely to search needlessly and maintains, is a different approach, in me, who else do you think can help
fruitlessly for pathology. However, which doctors give priority to "pa- you get better?"8
even when disease is present, it may tients' lifeworld contexts of meaning Several studies in primary care
not adequately explain the patient's as the basis for understanding, diag- demonstrate the inadequacy of the
suffering, since the amount of distress nosing and treating their problems." conventional medical model for ex-
a patient experiences refers not only Eric Cassell6 has a corresponding plaining many of the problems pa-
to the amount of tissue damage but to message: tients bring to their doctors.
the personal meaning of the illness. Blacklock11 found that in 50% of 109
Several authors have described this The story of an illness the pa-
tient's history has two protago- patients who presented to their fami-
same distinction between disease and ly physicians with chest pain, the
illness from different perspectives. nists: the body and the person. By
careful questioning, it is possible etiology was unproven after six
In analysing medical interviews, months follow-up. In Jerritt's study12
Mishlers identifies two contrasting to separate out the facts that speak
of disturbed bodily functioning of 300 patients who complained of
voices: the voice of medicine and the
voice of the "lifeworld". The voice of the pathophysiology that gives you lethargy, fatigue or tiredness, no or-
medicine reflects a scientific, de- the diagnosis. To do this the facts ganic cause could be found in 62.3%
tached attitude. Typical questions of about the body's dysfunction must of patients, who were evaluated in a
interest to the doctor include: be separated from the meanings general practice over a three-year pe-
"Where does it hurt? When did it that the patient has attached to riod. Wasson and colleagues13 investi-
start? How long does it last? What them. Skillful physicians have gating 552 unselected male patients
makes it better or worse?" The voice been doing this for ages. All too with abdominal pain who presented
of the lifeworld, on the other hand, often, however, the personal to an outpatient clinic, found no evi-
reflects a "common sense" view of meanings are then discarded. With dence for specific organic diagnosis in
the world which centres on individu- them goes the doctor's opportuni- 79%.
ty to know who the patient is. Several authors14'6 have suggested
als in a particular social context, the that in only half of all patients pre-
primary meaning of illness events, Kleinman and others have de- senting to a family doctor, can the
and how they may affect the achieve- scribed an ethnomedical model based physician find a disease to explain the
ment of personal goals. Typical ques- on their work in anthropology. 7-10 patient's problem. Rarely is this be-
tions to explore the lifeworld include: This model emphasizes the impor- cause the disease is hidden; .most of-
"What are you most concemed tance of eliciting patients' "explana- ten it is because the patient's feelings
about? How does it disrupt your life? tory models" of their illnesses and of- of ill health have their source in non-
What do you think it is? How do you fers a series of questions to ask medical factors: an unhappy mar-
think I can help you?" patients which they call a "cultural riage, job dissatisfaction, guilt or lack
Mishler5 argues that typical interac- status exam". The physician might of purpose in life. In a study of
tions between doctors and patients ask, for example: "How would you housewives, who kept health diaries,
are doctor-centred: they are dominat- describe the problem that has Freer17 found that this group of wom-
ed by a technocratic perspective. The brought you to me? Does anyone else en frequently described "symptoms"
physician's task is to make a diagno- that you know have these problems? such as headaches, feeling tired and
sis; thus, in the interview, the doctor What do you think is causing the run down, or various aches and pains.
selectively attends to the voice of problem? Why do you think this Most of these complaints they han-
medicine, often not even hearing pa- problem has happened to you and dled on their own by resting or put-
tients' own attempts to make sense of why now? What do you think will ting up with them. Many women re-
ported that doing housework or going
Figure 1 shopping made them feel better. For
Disease and Illness only one out of 40 complaints did
they seek medical advice.
Illness without The number of times a person visits
Disease
(e.g., grief reaction) a doctor in a year varies tremendous-
ly, depending on the doctor, the so-
cial class and the country. It would be
difficult to explain these differences
on the basis of disease prevalence: so-
cial and cultural factors have a
stronger influence on help-seeking
behaviour than has symptom severi-
ty. This may be one of the reasons
why hospital-trained physicians be-
come frustrated by primary care. It
does not take long for physicians in
the front lines of general practice to
(e.g., chronic realize that a strictly biomedical ap-
bronchitis) proach to illness is ineffective. This
148 CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989
highlights the importance of having self-centred and demanding, and al- think this flu is going to kill me." Or,
additional approaches to understand- though they may be aware of this re- indirectly, they may present a variety
ing human sickness. action and embarrassed by it, they of vague symptoms that are masking
cannot seem to stop it. They may a more serious illness such as depres-
Diagnostic Issues: withdraw from the external world sion. As physicians sit down with pa-
Understanding the and become preoccupied with each tients and ask them, "What brings
Dimensions of Illness little change in their bodies. Their you in today?" they must ask them-
sense of time becomes constricted selves, "Why did the patient come
The reasons patients present them- and the future seems uncertain; they now? What has precipitated this vis-
selves to their family doctors when may lose a sense of continuity of self. it?"
they do are often more important They can no longer trust their bodies,
than the diagnosis. Frequently the di- and they feel diminished and out of We propose four dimensions of ill-
agnosis is obvious or is already control. Their whole sense of their ness experience that physicians
known from previous contacts; often personal identities may be severely should explore: patients' ideas about
there is no biomedical label to ex- threatened. One reaction to this state what is wrong; their feelings, espe-
plain the patient's problem. Thus, it of mind in some patients is rebellion: cially their fears, about their prob-
is often more helpful to answer the a desperate attempt to have at least lems; their expectations of the doc-
question "Why now?" than the ques- some small measure of control over tor; and the effect of the illness on
tion "What's the diagnosis?" In their lives even if it is self-destructive functioning. When physicians address
chronic illness, for example, a change in the end. these aspects of illness, patients are
in a social situation is a more com- more likely to be satisfied with their
The third stage is reorganization. doctors, more likely to comply with
mon reason for presenting than a In this stage patients call upon all of the treatment recommendations, and
change in the disease or the symp- their inner strengths to find new also more likely to recover.20
toms. meaning in the face of illness and, if
Illness experience has many dimen- possible, to transcend their plight. What are the patient's ideas about
sions. Illness is often a painful crisis Their degree of mastery will be af- their illness? What meaning do they
that will overwhelm the coping abili- fected, of course, by the nature and attach to the illness experience?
ties of some patients and challenge severity of the illness. But in addi- Many persons endure illness as an ir-
others to increased personal growth. tion, the outcome is profoundly reparable loss; others may view it as
an opportunity to gain valuable in-
It is helpful to understand these reac- influenced by the patients' social sup- sight into their life experience. Is the
tions as part of a developmental pro- ports, especially loving relationships illness seen as a form of punishment
cess that has three stages: awareness, within their families, and by the type or as an opportunity for dependency?
disorganization, and reorganization.18 of support their physician can pro- Whatever the illness, knowing its
The first stage, awareness, is charac- vide. meaning is paramount for under-
terized by ambivalence about know- These stages of illness are part of a standing the patient.
ing: on the one hand, wanting to normal human response to disaster What are the patients' feelings? Do
know the truth and to understand the and not another set of disease catego- they fear that the symptoms they
illness and on the other, not wanting ries or psychopathology. But this de- present may be the precursor of a
to admit that anything could be scription emphasizes how the human-
wrong. At the same time patients are ity of the ill person is compromised more serious problem such as cancer?
often struggling with conflicting and points to an added obligation of Some patients may feel a sense of re-
wishes to remain independent and a physicians to their wounded patients. lief and view the illness as an oppor-
longing to be taken care of. Eventual- tunity for respite from demands or re-
ly, if the symptoms do not go away, So great is the assault of illness sponsibilities. Patients often feel
the fact of the illness hits home and upon our being that "it is almost as angry or guilty about being ill.
their sense of being in control of their if our natures themselves were ill, What are their expectations of the
own lives is shattered. as if the strands or parts of us were doctor? Does the presentation of a
being forced apart and we verged sore throat carry with it an expecta-
This disrupts the universal defence on the loss of our own humanness. tion of penicillin? Do they want the
- the magical belief that some- A phenomenon so great in its ef- doctor to do something or just listen?
how we are immune from disease, fects that it can threaten us with What are the effects of the illness
injury and death.. .The patient the loss of our fundamental hu- on function? Does it limit patients'
who has struggled to forestall his manness clearly requires more daily activities? Does it impair their
awareness of serious illness and than technical competence from family relationships? Does it require
then has finally recognized the those who would "treat" illness.19 a change in lifestyle?
truth is one of the most fragile, de- The following examples of physi-
fenseless, and exquisitely vulnera- Interviewing Methods cian-patient dialogue contain specific
ble people one can ever find. This Patients often provide physicians questions that physicians might ask to
is a time of terror and de- with cues and prompts about the rea- elicit this information.
pression.18 son they are presenting. These may To the doctor's question, "What
At this stage patients typically re- be verbal or non-verbal signals. The brings you in today?", a patient re-
gress to childhood defenses and react patient may look tearful, sigh deeply, sponds, "I've had these severe head-
to their caretakers as parents rather or be short of breath. They may say aches for the last few weeks. I'm
than as equals. They often become directly, "I feel awful, Doctor. I wondering if there is something that I
CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989 149
can do about them." To examine the 10 years. Until eight months ago, that so many things have been taken
patient's ideas about the headaches, when he had a massive myocardial in- away from me that I really would
the physician might ask (waiting after farction and required triple coronary miss not being able to do that."
each question for the patient's reply): artery bypass surgery, he had been a The doctor responds, "Mr. R., it
"What do you think is causing the healthy man with few problems. He is seems that in the last several months,
headaches? Have you any ideas or married, with grown children and has you have experienced a lot of changes
theories about why you might be hav- returned to work as a plumber. He and a lot of losses. I sense it has been
ing them? Do you think there is any has come to the office for diet coun- very difficult for you."
relationship between the headaches selling about his elevated cholesterol.
and current events in your life?" The interaction begins with the "Yes, Doc, it has. It's been tough.
The patient's feelings about the doctor stating, "So, Mr. R., you're in I've gone from being a man who is re-
headaches can be elicited by ques- about your diet. Looks like your cho- ally healthy and has no problems to
tions such as: "What are your con- lesterol levels are dropping nicely." having a bad heart attack and a big
cerns about the headache? Do you "Yes," responds Mr. R. "That's operation and being a real weight
think that something sinister is caus- good news and I'm feeling pretty watcher. It has been a big change,
ing them? Is there something particu- good about my weight. I'm down five and it has had its tough moments, but
larly worrisome for you about the more pounds and almost at my goal." I'm alive and I guess that is what mat-
headaches?" The doctor proceeds to explore Mr. ters," answers Mr. R.
To determine how the headaches R.'s diet in some detail. "It seems that you still have a lot of
may be impeding the patient's func- The interview then shifts to Mr. feelings surrounding your heart at-
tion, the physician might ask: "How R.'s weight-loss program, and he tack and the surgery and the changes
are your headaches affecting your states that he has been dutifully fol- that have occurred," comments the
day-to-day living? Are they stopping lowing his exercise regimen through- doctor. "Yes, I have," says Mr. R.,
you from participating in any activi- out the summer months and is walk- "...I have."
ties? Is there any connection between ing up to four miles a day. The doctor "Would it be helpful at some time
the headaches and the way your life is asks, "Will you be able to continue for us to talk about that more, to set
going?" your walking during the winter?" aside some time just to look at that?"
Finally, to identify the patient's ex- "Oh yes," says Mr. R., "I don't asks the doctor.
pectations of the physician at this vis- mind walking in the winter. I quite Mr. R. replies, "Yes it would. It's
it, the doctor might enquire: "What enjoy it. I just have to be careful on hard to talk about, but it would be
do you think would help you to deal those very cold days." helpful."
with these headaches? Is there some "Yes, you do need to be cautious
specific management that you want during the severe weather," replies "Just briefly, are you encountering
for your headaches? In what way may the doctor. Mr. R. looks away and any problems with sleep or appetite
I help you? Have you a particular test appears sad. The doctor pauses and Mr. R.?", inquires the doctor.
in mind? What do you think would asks, "Is there something concerning "No, none at all," replies Mr. R.
reassure you about these head- you, Mr. R.?" The doctor asks a few more ques-
aches?" "Oh well...no," says Mr. R. quick- tions exploring possible symptoms of
Certain illnesses or events in the ly. "No, not really." depression. Finding none, he again
lives of individuals may cause them "Not really?" says the doctor. offers to talk further with Mr. R. at
embarrassment or emotional discom- "Well," replies Mr. R., "I was just their next visit. Mr. R. answers af-
fort. As a result, patients may not al- thinking about the winter and...well- firmatively.
ways feel at ease with themselves or ...no, I guess I'll be able to skidoo if I In this example the patient's situa-
their physician and may cloak their just keep warm." tion can be summarized by using the
primary concerns by presenting mul- "Why are you concerned that you patient-centred model as a frame-
tiple symptoms. The doctor must, on won't be able to do that, Mr. R.?", work:
occasion, respond to each of these says the doctor.
symptoms to create an environment "Well, I don't know. I'd just miss it A) Disease
in which patients may feel more trust- if I couldn't participate." 1. Coronary artery disease with pre-
ing and comfortable about exposing "It sounds as if that activity is im- vious MI
their concerns. Often, the physician portant to you," responds the doctor. 2. Status post CABG
will provide them with an avenue to "Well, yes, it has been a very im- 3. Obesity
express their feelings by commenting: portant family activity. We have 4. Hypercholesterolemia
"I sense that there is something trou- some land and a little cabin up north
bling you or something more going of here, and it's really how we spend
on. Can I help you with that?" our winter weekends - the whole B) Illness
The following case illustrates pa- family together." 1. Ideas:
tient-centred interviewing in more "It sounds as if not being able to "No longer a healthy man."
detail: participate in something that's been Seems to see himself as disabled.
an important family activity would be 2. Feelings:
Case History: Mr. R. very difficult for you," reflects the Sad about his losses.
Mr. R. is a 58-year-old man who doctor. Fears that he will not be able to par-
has been a patient in the practice for "Oh, yes it would be. I just feel ticipate in family activities. Perhaps
150 CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989
fears another NI or even death.
3. Expectations:
in family medicine. Fam Pract 1986;
3(1):24-30. Hypertension
Co-operates with doctor re diet. 3. Brown J, Stewart M, McCracken E, Detection and Management
Agrees that "talking it out" might McWhinney I, Levenstein J. Patient-cen-
help. tred clinical method. 2. Definition and
Application. Fam Pract 1986; 3(2):75-9.
4. Function:
Walks four miles a day. 4. Stewart M, Brown J, Levenstein J,
Sexual function should be explored on McCracken E, McWhinney I. Patient-
centred clinical method. 3. Changes in
the next visit. residents' performance over two months
The doctor already knew the pa- of training. Fam Pract 1986; 3(3):164-7. PROCEEDINGS
tient's disorders before the interview 5. Mishler EG. Discourse of medicine: di- NOW AVAILABLE
began. He picked up on the patient's alectics of medical interviews. Norwood,
sadness and his hesitancy in exploring NJ: Ablex Publishing, 1984. This important symposium
how he was experiencing his illness. 6. Cassell EJ. Talking with patients. I. -took place at the University of
At the same time, the doctor ruled Clinical technique. Cambridge, MA.: The Calgary in October 1984.
out serious depression by asking a MIT Press, 1985.
Sponsored by the College of
few diagnostic questions and offered 7. Kleinman AM, Eisenberg L, Good B. Family Physicians of
Canada,
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By considering the patient's illness 8. Good BJ, Good M. Meaning of symp- the Alberta Heritage
experience as a legitimate focus of toms: a cultural-hermeneutic model for Foundation
clinical practice. In: Eisenberg L, Klein-
for Medical
enquiry and management, the physi- man A, eds. Relevance of social science Research, it brought together
cian has avoided two potential errors. for medicine. Boston: D. Reidel Publish- researchers from cardiology,
First, if the conventional biomedical ing, 1981.
genetics, public health and
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tress, the doctor might have labelled ly physician. J Fam Pract 1986; 22:159-65. symposium produced three
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tors are often very limited in what all of the
they can do about a patient's disease. tice. Practitioner 1981; 225:731-7. policy statements and the full
Lowering this man's cholesterol is un-
likely to have a great effect on his 13. Wasson JH, Sox HC, Sox CH. Diag- texts of the 12 papers plus the
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CAN. FAM. PHYSICIAN Vol. 35: JANUARY 1989 151

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