Family Practice Vol. 17, No. 5, 430-434
© Oxford University Press 2000
Discussion paper |
Reflexivity—a strategy for a patient-centred approach in general practice
Department of General Practice, University of Copenhagen, Copenhagen, Denmark.
Charlotte Baarts, National Institute of Occupational Health, Lerso Park Alle 105, DK-2100, Copenhagen, Denmark.
Baarts C, Tulinius C and Reventlow S. Reflexivity—a strategy for a patient-centred approach in general practice. Family Practice 2000; 17: 430–434.
Received 4 November 1999; Revised 11 April 2000; Accepted 16 May 2000.
Abstract
Reflexivity as a strategy in general practice can be used to implement a patient-centred approach in the consultation. General practice has long represented a tradition attempting to integrate both illness and disease. For the GP, it is natural to focus on the patient's whole situation, and the GP's experience with patients is often based on a long-term relationship. Reflexivity implies having a self-conscious account of the production of knowledge as it is being produced. We believe that GPs can gain access to additional knowledge by consciously using reflexivity as a strategy in the consultation. In the present article, we discuss reflexivity in relation to the notions of empathy, personal experience and self-knowledge. By using reflexivity in order to rely on personal experience, the GP can gain access to patients' understanding of their health. Reflexivity can be a valuable concept for the GP in patient-centred medicine and can contribute to bridging the gap between the patient's perspective and the doctor's understanding of the patient's health.
Keywords. Experience, general practice, medical anthropology, patient-centred care, reflexivity.
Introduction
Reflexivity nowadays is an inherent part of anthropological research. In the present article, we argue that the GP can gain access to additional knowledge by consciously using reflexivity as a strategy in the consultation. We, the three authors, represent an interdisciplinary link between medical anthropology and general practice on which we base our experiences with health research. Through our experiences from research in health care and through our knowledge and experiences of general practice, we believe that the doctor–patient relationship can benefit from the doctor's ability to use reflexivity as a strategy in the consultation. The present discussion is not a methodological discussion about GPs conducting research on their own patients but a discussion about similarities between the anthropologist obtaining local knowledge during fieldwork and the GP obtaining the patients' perspectives on illness.
Medical anthropology and fieldwork
During the last two decades, there has been an increasing interest in medical anthropology. In the early 1980s, the anthropologist and psychiatrist Kleinman1 conducted fieldwork in Taiwan studying the relationship between biomedical and local perceptions of illness and disease. The anthropologist Lock did fieldwork in urban Japan studying varieties in medical experience,2 Scheper-Hughes did fieldwork in psychiatric settings in Ireland,3 and Ohnuki-Tierney did fieldwork in Japan studying the health system.4
Conducting anthropological fieldwork implies participating in the local everyday life in order to attain local knowledge of and local perspectives on the social world of the people studied. The anthropologist involved in fieldwork establishes relationships with the local people by participating in the local life and using methods such as in-depth interviews,5 focus group discussions6 and participant observation.7 Knowledge is generated in the interaction between the anthropologist and the local people, and in order to gain access to this knowledge the anthropologist uses reflexivity, which implies being aware of how anthropologist and informants construct the social world in which they take part. Informants are people who take part in the study by participating in the study, thereby providing the anthropologist with information regarding the object of study.
Regarding knowledge production, there are similarities between the relationship of the anthropologist and informants on the one hand and the GP and patients on the other. Working as a GP implies on the one hand acquiring knowledge of the patients' perspective on illness and their understanding of the social world in which they participate and on the other hand communicating treatment and solutions to the patient. A common understanding between GP and patient is negotiated in the communication and interaction in the consultation. At this point, we believe that the GP can benefit from the anthropological notion of reflexivity as an analytical contribution to a patient-centred approach in the consultation in general practice.
The notion of reflexivity
According to Marcus, reflexivity involves having "a self-conscious account regarding the condition of knowledge production as it is being produced".8 Reflexivity moves the observational eye of the anthropologist with her personal ‘I’, and implies being aware of both object and subject as well as her own positioning in the particular context. It implies being aware of how the interaction between anthropologist and informant or between GP and patient influences the information that is exchanged in the interaction. According to Good et al., all clinical practice has an interpretive dimension.9 We believe that this interpretive dimension is analogous to some extent to the interpretation of data constructed during fieldwork. In this light, the interpretive process of knowledge production in general practice should include the influence of the GP's own perspective and interests on the encounter with the patients. This is the role of reflexivity.
If the GP uses reflexivity as a strategy in the consultation, knowledge production should include an analysis of (i) the encounter between GP and patient and (ii) the influence of the GP's experiences on the interpretation made. GPs need to be aware of not only what the patient says and does but also what is not said and done. GPs need to be aware of what they themselves say and do as well as what they do not say and do. Finally, GPs also need to be aware of the encounter with the patients as a frame of reference of the spoken and unspoken, the action and non-action. Knowledge production in both fieldwork and the consultation implies reflecting upon the relationships and contexts in which knowledge is generated.
Observation and reflexivity
When the sociologist Goffman conducted fieldwork in a psychiatric hospital,10 he used participant observation by being admitted to the hospital as a patient in order to gain knowledge of psychiatric patients' social world. He followed the same routines as the patients, gaining access to their perspective of the social world by sharing experiences with them and by making the routines of the patients his own routines.
In any fieldwork, there are limits as to the extent of participation. An anthropologist studying the role of doctors in hospitals cannot perform any task related to working as a doctor. For instance, when the doctor performs a gastroscopy the anthropologist will have to observe rather than participate. However, observation along with reflexivity is a way of gaining access to local perspectives. When Kleinman did fieldwork in Taiwan, his role was observational rather than participatory.1 Ohnuki-Tierney, too, used observations rather than participation and describes how her observations of advertisements by hospitals or pharmaceutical companies at train stations also became a part of the analysis of Japanese health consciousness.4 Working as a GP, it may not be possible to participate in the sense of making the routines of the patient's social world the GP's routines. Being a GP is in many respects an observational role; however, it is still a role that calls for reflexivity.
The consultation process in itself calls for reflexivity. Initially the focus is on the patient. The patient tells the story and the GP listens and observes. Then the GP begins asking questions and examines the patient in order to focus on the problem the patient has presented. Finally, the GP and the patient negotiate about finding a common understanding of the problem. The GP uses experience from former cases with the patient and other patients as well as his/her personal experiences in general.
As an illustration, we will present a case of a consultation between a young woman and her GP. The case is taken from a pilot study carried out in general practice by the first author (CB) in the spring of 1999. The purpose of the study was to obtain knowledge on women's strategies concerning how to handle stress, and the methods used were in-depth interviews and participant observation.
The case of Sarah and her GP (male)
Initially, the patient Sarah introduces her problem as pain in the chest. She makes no suggestions herself as to what is the matter and simply expresses worries of what might be the cause of the pain in her chest. Sarah's ex-boyfriend, Tom, has been harrassing her by phone since their break up. She has continued answering his calls fearing what he might do to himself. Recently, she has met a new man, and is afraid of losing him because of Tom. The GP listens to her. Then he asks Sarah to show him where the pain is situated. On palpating the chest and auscultating the lungs and heart, the GP finds no objective signs of disease, and concludes that there is nothing unusual to notice. He then asks whether he could examine Sarah's breasts "just in case". During the examination Sarah says: "Do you think it could be because of Tom?" The GP stops the examination and says: "Yes, it is very likely." "Yes," Sarah says, "I thought it might be." The GP finishes the examination, shakes his head as a sign of not finding any signs of tumours. Sarah is relieved now knowing that what she actually thought was the matter, the harassment by her ex-boyfriend, actually caused the pain she felt in her chest. When Sarah has left, the GP tells CB that patients with emotional problems related to relationships often have chest pain (not that emotional problems are always the reason for chest pain).
The contribution of reflexivity to knowledge production
Working as a GP requires being able to approach problems from different positions. The GP seeks to understand the values and norms of the patient as well as the patient's perceptions of the situation in order to understand her illness. At the same time, the GP must distance himself from the patient and look objectively at signs. There are similarities between the role of the GP and the role of the anthropologist11 in the sense that both anthropologist and GP seek to gain access to respectively the informants' or the patients' perspectives of the social world. An important experience as an anthropologist doing fieldwork is the experience of becoming your own informant. By taking part in the local life, the anthropologist makes her own experiences while at the same time she observes herself. She, thereby, generates knowledge through personal experience. In other words, she uses reflexivity in analysing her experiences as well as her encounter with the informants. In the case of Sarah, the GP could become his own informant if he himself had had experiences with chest pain, and if he is conscious about these experiences and uses them in relation to Sarah.
When CB did fieldwork in a Danish hospital studying patient–professional communication, she experienced becoming her own informant while carrying out participant observation. "Participating in the work of the nurses required among other things serving lunch for the patients. While I was performing this task with a nurse one day, a patient requested a glass of water when we were leaving the room. It seemed that the nurse pretended not to hear the request, and I wondered why and what to do. I decided to get a glass of water for the woman. When I returned to the patient, she began talking to me, telling me long, interesting and insightful stories of her life. I could not get out of the room again. When I finally could leave it was to experience that the nurse in the meantime had bathed several patients while I had been stuck with the storytelling patient".12 From this episode, CB learned by personal experience about priorities and compromises of patient care.
The anthropologist becoming her own informant requires reflexivity in the sense of being conscious of the meaning of oneself in the production of knowledge as well as relying on experience as a valid source of understanding. Aspects of reflexivity and experience are also present in the case of Sarah and her GP. The GP's thoughts about the relationship between chest pain and emotional problems represents reflexivity of the GP himself in the encounter with Sarah as well as his encounters with patients with similar chest pain. He relates Sarah's problem to his frame of reference and experiences in general.
In the following, we will elaborate further how the GP consciously can use reflexivity as a strategy in the production of knowledge in the consultation. This will be described in relation to (i) empathy, (ii) personal experience and (iii) self-knowledge.
Empathy
GPs spend a lot of the time in general practice simply watching and listening. At different levels, these activities demand different kinds of involvement in order to gain access to patients' experiences with illness. McWhinney13 describes different levels of involvement, making it clear that the feelings entering into the patient–professional relationship are of many kinds, some of them helpful and some of them harmful to healing. For instance, the feeling of helplessness can make the GP afraid to recognize the suffering of his patients, openness to patients can make the GP fear what questions they may ask.
The notion of empathy indicates involvement in the sense of the professionals' abilities to identify themselves with the patients' situation. Through empathy, the GP seeks to understand the patient's perspective of illness. However, empathy represents a dilemma for the medical profession in general14—the tension between professional distance and involvement. The clinical function of empathy is examined by Good et al. who emphasize that empathic understanding is not sufficient for the professional to detach herself from the ego which the professional as an analyst uses in the interpretation of knowledge production.9 Anthropologists have in the last few years suggested a replacement of empathy by resonance because ‘resonance' explicitly recognizes the use of personal experiences as a basis for your understanding.14 In other words, being able to identify oneself with the patient's situation requires reliance on personal experience. The anthropologist Barth argues that "through participating in the experience, we come to recognize the efforts of attention that are required in [handling a particular situation]".15 Thus, through resonance, we can come to share some of the associations and connotations, which are generated by the people, in whose experience we seek to participate15. Resonance can bridge the gap between illness and disease as well as between lay and professional perceptions of illness.
Personal experience
Sacks, a neurologist, published an account of his experiences as a patient after having broken a leg during a holiday in Norway.16 Having neurological problems with the broken leg, Sacks faced some of the same situations that his patients faced. He experienced similar worries to those of his patients, asking the doctor some of the same questions his own patients usually asked him. Having had personal experiences with being a patient, Sacks used his experiences in order to understand his patients' feelings of helplessness and lack of autonomy in the encounter with himself as a neurologist. This understanding could not have been attained through empathy, but by reflecting upon his personal experiences as a patient: "Now I knew, for I had experienced myself. And now I could truly begin to understand my patients, the many hundreds of patients with profound disturbances of body-image and body-ego, whom I saw over the years".16 According to Sacks, this knowing can only be obtained by personal experience.
The production of knowledge through experience cannot be generated without reflexivity, which is confirmed by Thomas' call for technological devices that would allow doctors in training to experience patienthood.17. Thomas believes that every doctor should experience the loss of control of the body and the feeling of being personally mortal. Accounts of doctors experiencing patienthood such as those of Sacks and Thomas are often characterized by a transformation of their self, which influences their future practice of medicine. The transformation is based on their experiences as patients along with their encounter with other patients and patient communities. Being a good doctor does not necessarily imply having experienced patienthood. We believe that the GP can use her experiences from general practice, from listening to patients' illness stories and other doctor's stories of patients' illness along with her personal experiences with colds, headaches, flu or illness that most people have experienced.
However, it is not an easy assignment for GPs to attend to their patients' experience. The GP cannot see a headache or anxiety, but the patient can describe it and the GP can use personal experience to understand what the patient feels. To a great extent the GP shares the bodily, existential conditions with the patients. With experiences from personal life and clinical work, the GP can offer the patient grounds for understanding that are much wider than those of lay people.13 In problem-based learning, we see how easy it is for medical students and professionals in roleplay to take the role of the patient. Not only does the knowledge of physiology and anatomy constitute the basis of the GP's approach to the patient, but also personal experience of general practice. This point is what Rudebeck defines as bodily empathy,18 and it can be illustrated in the consultation with Sarah. The GP has had previous experience with Sarah and other patients, and through these experiences and as a human being he also knows that chest pain can be caused by emotional problems.
Self-knowledge
Personal experience is related to self-knowledge, and these notions point toward reciprocity in the doctor–patient relationship. Gaining access to knowledge through experience expresses an anthropological reliance on experience, and an affirmation of experience as a valid source of understanding.7 Experience can be used as a strategy to attain self-knowledge. By involving yourself in the lives of others, you share understanding with others through personal experience, and thereby through self-knowledge. However, sharing understanding with others through experience goes both ways. Patients also share understanding with the GP through experience. This is what happens with Sarah and her GP. Their negotiation of the problem through physical examination, through Sarah's reasoning related to her ex-boyfriend and through the GP's knowledge and experiences leads to sharing a common understanding of Sarah's chest pain. Not only are patients different from each other, GP's are also different, and however obvious that seems, we tend to look upon doctors as all being of the same kind. However, GPs' backgrounds and personalities create the basis for their being in the social world, and their personal experiences and attitudes constitute the grounds for understanding each patient.
Reflexivity—a patient-centred approach
At the heart of the GP's listening and watching lies interaction and, in order to gain access to knowledge, GPs trade shared understandings with their patients. GPs use experience to further observation by experimenting on themselves. It takes time to learn the problems facing their patients in everyday life. Understanding the patients requires a realization of what skill patients' lives demand of them. In this sense, reflexivity can bridge the gap between the patient's and the GP's understanding of the patient's health. As humans, we only understand each other by investing our own experience in the process of understanding.14 When the GP cannot observe a headache, the GP has to relate to his/her own experiences with headaches in order to understand, as well as to his own experiences with patients and life in general. As part of humanity, GPs share some of the same experiences as their patients. By being reflective about these issues, the GP can get closer to the patient's perspective.
Reflexivity is not restricted to the consultation itself, but can also be used when carrying out home visits or when the patient speaks to the secretary in the general practice. The GP's thoughts about the interaction with the patient in the consultation are the grounds for using reflexivity as a strategy in general practice.
Reflexivity as an approach to the encounter with patients in general practice can contribute to implementation of a patient-centred approach in general practice and allows the GP to gain access to additional information about the patient. The way in which the encounter with the patient in the consultation is located in the social world profoundly influences the success of the consultation. Even before the consultation, the patient has ideas about the GP and the consultation, thereby imposing her meanings in the situation.19 Both GP and patient position themselves in the consultation in order to give the other the right impression. The right impression is one way of influencing the outcome of the consultation, and patients may have their own reasons for providing the GP with the information that they give. Of course, both GPs and patients have strategies for their mutual encounter. For the GP, reflexivity could be one.
References
1 Kleinman A. Patients and Healers in the Context of Culture. Berkeley: University of California Press, 1980.
2 Lock M. East Asian Medicine in Urban Japan: Varieties of Medical Experience. Berkeley: University of California Press, 1980.
3 Scheper-Hughes N. Saints, Scholars and Schizophrenics: Mental Illness in Rural Ireland. Berkeley: University of California Press, 1979.
4 Ohnuki-Tierney E. Illness and Culture in Contemporary Japan. An Anthropological View. Cambridge: Cambridge University Press, 1984.
5 Kvale S. InterViews. An Introduction to Qualitative Research Interviewing. Thousand Oaks, CA: Sage, 1996.
6 Morgan D, Krueger RA. The Focus Group Kit. Thousand Oaks, CA: Sage Publications, 1998.
7 Spradely JP. Participant Observation. Holt, Rinehart and Winston, Inc. 1980.
8 Marcus GE. After the critique of ethnography: faith, hope, and charity, but the greatest of these is charity. In Borofsky R (ed.). Assessing Cultural Anthropology. New York: McGraw-Hill, 1994: 40–52.
9 Good BJ, Herrera H, Good M-J DelVecchio, Cooper J. Reflexivity, countertransference and clinical ethnography: a case from a psychiatric cultural consultation clinic. In Hahn RA, Gaines AD (eds). Physicians of Western Medicine. Dordrecht: Reidel, 1985: 193–221.
10 Goffman E. Asylums. New York: Doubleday, 1961.
11
Whitaker A. Qualitative methods in general practice research: experiences from the Oceanpoint Study. Fam Pract 1996; 13: 310–316.
12 Baarts C. Her er vi alle ens. Om lighed og forskellighed i kommunikation mellem patienter og behandlere, medicinsk afdeling, Sygehuset Øresund, Helsingør. [We are all alike here. Equality and difference in communication between patients and professionals in a medical department of a Danish hospital.] Københavns University, 1998 [in Danish].
13 McWhinney IR. A Textbook of Family Medicine. 2nd edn. New York: Oxford University Press, 1997.
14 Hastrup K. Patientens dilemma [The patient's dilemma]. Ugeskr Læger 1993; 155: 3149–3152 [in Danish].
15 Barth F. A personal view of present task and priorities in cultural and social anthropology. In Borofsky R (ed.). Assessing Cultural Anthropology. New York: McGraw-Hill, 1994: 349–360.
16 Sacks O. One Leg to Stand on. New York: Summit, 1984.
17 Thomas L. The Youngest Science. New York: Viking, 1983.
18 Rudebeck CE. Medicinens mänskliga språk. Kroppsempati förenar diagnostik och förståelse. Läkartidningen 1998; 95: 4500–4507 [in Swedish].[Medline]
19 Eisenthal S, Koopman C, Stoeckle JD. The nature of patients' requests for physicians' help. Acad Med 1990; 65: 401–405.[Web of Science][Medline]
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