Family Practice Vol. 18, No. 5, 501-505
© Oxford University Press 2001
The consultation |
Knowing patients and knowledge about patients: evidence of modes of reasoning in the consultation?
Department of Community Health Sciences (General Practice), University of Edinburgh and
a School of Primary Care, University of Manchester; present address: Centre for Health Services Research, University of Newcastle upon Tyne, UK.
Fairhurst K and May C. Knowing patients and knowledge about patients: evidence of modes of reasoning in the consultation? Family Practice 2001; 18: 501–505.
Received 12 October 2000; Revised 2 March 2001; Accepted 4 May 2001.
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Abstract |
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Background. The idea that the patient is in some way known to the doctor is an important one in general practice. The thrust towards patient-centred medicine, the promotion of open and negotiative consultation skills and the development of a biopsychosocial model of primary care medicine all rely on the patient providing a history composed of more than a list of facts.
Objective. Our aim was to explore the nature and importance of doctors' knowledge about patients.
Methods. Fifteen GPs audio-recorded 25–30 consultations with consecutive consenting patients. They scored each consultation according to how satisfying they found it. Semi-structured interviews based on a selection of consultations were conducted to draw out the doctor's views on the factors that were important to their satisfaction. The interviews were transcribed verbatim. Qualitative analysis was inductive and iterative.
Results. Within doctors' narratives, we found accounts of two ways of ‘knowing' the patient. The first was a deductive mode of reasoning derived from facts about the patient. The facts that were known were specific to the context of the general practice consultation and led to biomedical and biographical knowledge. The second was an inductive mode of reasoning derived from a contextual interpretation of the facts about the patient which resulted in knowledge of their behaviour and cognitions. Both modes of reasoning gave the doctor knowledge of the patient and permitted action by the doctor in the consultation but led to different interpretations of the patient and different experiences of the consultation.
Conclusion. ‘Knowing the patient' is important to the way GPs attribute meaning to their work. Doctors were more likely to identify as ‘known' those patients with whom they adopted an inductive mode of reasoning. In addition, their experience of the consultation was more likely to be positive.
Keywords. Consultation, GPs, ‘knowing', knowledge.
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Introduction |
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TopAbstractIntroductionSubjects and methodsResultsConclusionReferences |
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This study concerns a concept that is central to understanding the general practice consultation, but which is largely neglected in debates about it. The idea that the patient is in some way ‘known' to the doctor is an important one in a professional discipline that has, through much of its recent history, placed great importance on the interpersonal relationship between doctor and patient and its operationalization within the consultation.
The consultation: analytic approaches
Consultation analyses of different kinds have been crucial to the professional project in general practice. Since the 1960s, a significant literature has grown up that explores the dimensions of doctor–patient interaction in the consultation. From the very beginning this has involved attempts to describe the business of the consultation, often using research methods that isolate particular kinds of activity (verbal and otherwise) within it. Indeed, the literature on the doctor–patient encounter in the consultation seems to fall into four main categories.
- Consideration of the doctor's work that interprets it from relatively abstract theoretical perspectives.1, 2
- Explorations of the doctor–patient encounter that emphasize power and knowledge relations in their social context.3–6
- The sociology and psychology of the clinical encounter in relation to specific disease states.7, 8
- Consideration of the consultation in relation to clinical skills and technical problems of practice.9–11
Although each of these approaches involves a very different interpretation of doctor–patient interaction, they are united by a recognition that the consultation is an encounter that relies on each participant being in some way ‘known' to the other. At an elevated level, the attribution of (and consent to) particular social identities is crucial to this. At a more mundane level, both doctor and patient tend to have relatively stable expectations about each other's behaviour in the consultation. One expectation that GPs have is that they can ‘know' their patients. The thrust towards person-centred medicine, open and negotiative consultation skills and the biopsychosocial model in primary care medicine all rely on the notion that the patient will provide a ‘history' composed of more than a brutal list of facts. Beyond this, British general practice is still run through with strong professional expectations about continuity of personal care12 and the potential for long-standing therapeutic relationships. However, what it means to ‘know' the patient depends on a good deal more than marshalling a particular set of facts. In fact, it derives from patterns of reasoning and interpretation. Here we explore those styles of reasoning about the patient as they are revealed through a qualitative study of GPs' perspectives on those factors that lead to their satisfaction with the consultation.
The analysis offered herein takes as its starting point the doctor's view of his or her medical work in the specific form it takes within consultations. It takes account of the diversity of work that is done in this context and therefore does not restrict itself to consideration of work with patients with specific diseases but examines the work done by practitioners with patients who have presented to them with various needs and expectations.
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Subjects and methods |
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To examine the way in which GPs obtain satisfaction from consultations, a qualitative study was carried out involving indirect observation of consultations and semi-structured interviews with 15 GPs.
The doctors were recruited into the study following a personal telephone call from one of us (KF). The sample was purposive and, by design, diverse. Seven of the doctors were female; eight were male. They had been practising as GPs for between 2 and 22 years, and their ages ranged from 30 to 55 years. One doctor worked single-handedly, the rest worked in group practices with between three and nine doctors. Fourteen of the 15 doctors were partners in the practices in which they worked. The practices were in areas ranging from high socioeconomic disadvantage to affluence.
The participants were invited to audio-tape record between 25 and 30 consultations with consecutive consenting patients. They were asked to score each consultation according to how satisfying they found it on a scale of 0 to 10, where 0 was maximally dissatisfying and 10 maximally satisfying. The audio-tape recordings were reviewed and notes were made on the content of the two most satisfying, the two least satisfying and two other consultations chosen at random for each participant. These consultations formed the basis of a semi-structured interview conducted with each participant within 1 week of the completion of audio-recording. The purpose of the interviews was to clarify the details of the individual consultations and to draw out and discuss the doctors' views on the factors and issues that were important in contributing to their satisfaction with the encounter. The interviews themselves were audiotape recorded and transcribed verbatim.
The interpretation of qualitative data was governed by the broad precepts of constant comparative analysis.13 The interview transcripts were analysed iteratively (jointly by KF and CRM) to identify recurring themes within the data and recognizing patterned ways of accounting for the experience of consulting. The following discussion focuses on one major theme that emerged from the data: that of doctors knowing their patients.
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Results |
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Knowing the patient
The doctors who were interviewed talked about their knowledge of the patient in the majority of the consultations that were examined. This knowledge seemed to be crucial to the way in which the doctor experienced the consultation. It was clear that in the majority of consultations, the doctor had a priori knowledge about the patient and that this knowledge took a very specific form shaped by the context within which it was acquired, i.e. the general practice consultation. Knowledge about the patient was generally related as biomedical knowledge or biographical knowledge including what McKeganey refers to as ‘ethnographic' knowledge.14
However, the perception of ‘knowing' the patient is not necessarily predicated on this knowledge. A lot can be known about a patient without the doctor feeling that he ‘knows' that patient and, conversely, patients about whom little is known can be considered as ‘known'. Thus a distinction emerged between what was known about the patient and knowing the patient as a person. Furthermore, in terms of the doctor's experience of consultations, the facts that are known about patients seem less important than the way in which the facts become known to them or the way in which doctors get to know about individual patients.
The remainder of this paper explores the ways in which doctors get to know about their patients and the different types of knowledge that result. The impact of these processes and this knowledge upon the conduct of the consultation and upon the doctors' experience of the consultation will be discussed.
Deductive and inductive knowledge about the patient
Within doctors' narratives about the experience of the consultation, accounts of two ways of ‘knowing' the patient were apparent.
- Knowledge of the patient that is founded upon a deductive approach, i.e. the doctor formulates a hypothesis about the patient based upon initial factual evidence of different kinds, and then seeks to confirm or refute this by a line of questioning that obtains further information from the patient.
- Knowledge of the patient that arises from an inductive approach to the patient's own account. In this case, despite a priori factual knowledge, the doctor does not hypothesize about the patient but allows an interpretation of the patient to emerge within their interaction.
A deductive mode of reasoning about the patient results in the doctor focusing on factual or objective information, either directly from the patient or from medical records. Whilst this information is often provided willingly by the patient, it is not divulged spontaneously. The patient grants the doctor access to this information because it is requested and believes it to be important to the conduct of the consultation. As a result, the doctor gains a set of unilaterally worked up facts—medically oriented knowledge about the patient—but their interpretation is not necessarily shared with or by the patient. For example, this doctor is talking about a patient whom he sees very frequently with self-limiting physical symptoms.
"I don't mind holding on and I don't mind having superficially dysfunctional consultations with people if I can continue with them long enough to work it out. And that has helped with her, it has worked with her a little. There have been a few consultations when having seen her for 2 years I am able to talk to her about her bereavements, her turning forty and her inability to have children which are her big problems. and that has possibly helped a little." GP1
Similarly, this doctor about a middle-aged man with ongoing low mood:"So it's trying to find out what goes on in their life, and again another advantage of being in general practice, particularly in a fairly tight community like this, is you can understand a lot about where they live, who they live with and who they interact with, both in terms of their family, extended family and friends . . ." GP11
In both instances, the GP talks about ‘facts' in the context of the patient's life, and about the interpretative function through which he attributes meaning to the facts constructed in history taking. The interpretation is his own and it is not clear how this relates to the patient's interpretation. As a result, the doctor has unilateral knowledge of the patient within the specific context in which he is presenting, and here this is characterized in terms of an absence of connection.
"Well it would be interesting to know what he thought actually, because he's definitely the kind of bloke that you know he seems to leave the room quite happy but you've no idea what he's thinking, certainly not on my wavelength." GP7
An inductive mode of reasoning in the consultation involves a jointly produced account of the patient's ill-health and the doctor's response. Here, the patient voluntarily admits the doctor into the inter-subjective construction of information perceived to be relevant to her ill-health.
"That was the third one (consultation) that she'd been to and the first two consultations she just sat and cried for the first sort of five minutes and been in such an almost hysterical state that she'd been barely able to get her words out and she'd had these dreadful social problems—they'd moved down from X, they'd been kicked out of their house and discovered they'd bought a car which turned out to be stolen property and they got arrested and held by the police and it was just a whole string of disasters and the first time she came to see me . . . I mean I just felt like weeping when she finished telling me the story herself. I just thought you know how bad is it going to get for this girl, she was just a mess and there was a lot of ignorance about the hepatitis C business . . ." GP8
The doctor has few preconceived ideas about what information is needed or relevant but allows the salient issues to emerge from the interaction. Furthermore, the meaning of these issues is constructed jointly by both doctor and patient. Thus, the doctor gains a ‘voluntary' knowledge of the patient which allows a shared understanding of the patient and the doctor–patient relationship to develop.
When doctors felt they knew a patient in this way, they often described a ‘connection' or ‘rapport' between themselves and the patient. This was associated with an ease of interaction which facilitated therapeutic aspects of their relationship. As this doctor says about a patient:"I feel that we connect. We've met on quite a few occasions and I feel easy talking to her and I'd like to think she's found it reasonably easy to talk to me. She's had some psychological difficulties related to her physical problems and I've sort of, I hope, helped her with that and drawn some of that out of her which I think maybe she wouldn't have talked to some of the other doctors she didn't know so well." GP6
Consultations in which doctors perceived a ‘connection' between themselves and the patient were by and large among the most satisfying.
Impact on consultation: the concept of meaningful knowledge
In any consultation, some knowledge of the patient is obligatory for the doctor to be able to proceed with his work. Reasoning of either of the types described above can give rise to this obligatory knowledge, but each results in different interpretations of the patient. Deductive reasoning tends to lead to an interpretation of the patient as a case, whereas inductive reasoning is more likely to result in knowing the patient as an ‘actor' in a social interaction. These different interpretations influence the subsequent course of the consultation and underpin the actions that are taken.
When a deductive mode of reasoning is foremost with a patient, the action that is taken is determined primarily by a reading of the facts of the case. Consequently, it is difficult for the doctor to predict the outcome of the consultation in the patient's ‘world'. This doctor is talking about a patient who presented with a possible small haemoptysis"And you always like when you've had a consultation to have an idea what the patient will be thinking of as they go home and when they get home what they will tell their family, and I have absolutely no idea what that lady thought. Maybe I didn't use any of the right words or whatever, I don't know, I think I maybe tried to but I have no idea. And when she came back again I really had very little idea of what she was thinking. And we rely on feedback, of course we do, to let us know if we're doing OK." GP2
When an inductive mode of reasoning is pre-eminent with an individual patient, the facts the doctor knows about the patient are understood within the context of the patient's life, making meaningful action possible. Here, an interpretation of factual knowledge within the patient's world permits the doctor to act in partnership with the patient to individualize the therapeutic intervention.
"Even with a fellow like that who had certainly had a depressive illness and he's probably passed that now, his major problems lie in his confidence about his own self and finding a direction. He's going through a kind of midlife crisis, because he's this age, he's single, he's wanted a wife, he's wanted children, and he feels he's well passed all of that stuff now. So you're trying to find ways of him coping with that bit of life that he's in at the moment, which aren't hard psychology—behavioural cognitive stuff—but neither are they about taking tablets and this will make you better. So it's trying to find ways that suit him as an individual to get better." GP11
Furthermore, the consequences of the consultation in the patient's world become easier to predict, and this insight contributes to the doctor's positive feelings about the consultation.
"The other thing that made me feel good about that consultation was the fact that I knew this guy was feeling good himself, and I knew that he was going out feeling that he trusted me, that he had a good doctor who was doing as much as he could for him and he was getting everything he would expect from a GP and I knew that having been to see me would have had a good effect on him and that he would go home thinking ‘Right I feel happier'." GP1
The doctor's own subjectivity is highlighted in consultations with patients in whom inductive reasoning is paramount. The doctor's action may deviate from what might be expected after an objective appraisal of the facts of the case and based on information from diagnostic technologies. Their interactions with the patient and experiences allow them to exercise discretion about what should be done or not done. As this doctor says:"I think probably when I was younger I used to fret about that and wonder ‘gosh am I doing the right thing, am I going to harm someone' but I think what I do now is I tend to let things drift a little bit and in that drifting period sound out the patient as to what they would feel about changes . . . and then you know that the patient's with you." GP7
"I think despite the fact that we might not have done the right thing with her, I don't know that that probably mattered all that much because she's the type of patient . . . if they like you it makes you feel better and I think she probably likes me and I know she appreciates what I do and respects me." GP10
Deductive and inductive knowledge are not mutually exclusive. Doctors are able to have, and often do have, both types of knowledge about patients, and indeed each type of knowledge can complement the other. For example, this doctor says:"She's just brilliant. She is just an amazing woman. The first letter in her case notes volume one says ‘This blond vivacious and attractive woman presented to me.' That's the same woman and if you read through what's happened to her in her life, she's had an abusive relationship, her mother was killed by a roadsweeper, her husband had alcohol problems and was abusive and violent, her son was handicapped. And if you go through the catalogue of her life you know where she's coming from and it all makes sense when you see what's happened to her. But if you saw her as a one off you'd think she was a very mentally dull poor soul. But I think you have a rare insight into somebody's life and I completely understand why this lady's how she is. She's been to see somebody at the pain clinic nine times, nine separate referrals in the last 15 years for pain because she has a lot to gain by being ill." GP2
The way in which doctors understand a patient is instrumental in their evaluation of the moral status of the patient. This moral judgement seems to be an important factor in the calculation the doctor makes about the effort involved in working with a patient and the potential reward.
"I'm very controlled about that . . . I must make some judgements about the extent to which I think these people are helpable or actually want to change in some meaningful way, if they do I'll work with them, if they don't I'll freeze them out, probably politely but nevertheless freeze them out." GP12
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Conclusion |
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TopAbstractIntroductionSubjects and methodsResultsConclusionReferences |
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The objective of this study was to understand better the sources of professional satisfaction with the consultation at a time when, as we have observed previously,15 interest in this topic focuses almost entirely on patients' views. The limits of the present study are clear, and it is important to note that we are drawing a set of inferences (second order constructs) from a body of qualitative data that was organized around experiences of the consultation, rather than patterns of reasoning within it. Nevertheless, the concept of knowing a patient is clearly important in the way GPs attribute meaning in their work. It is also potentially important conceptually because of how it might relate to the issue of continuity of care. The relationship is unlikely to be a straightforward one especially as more than one definition of continuity of care exists. However, in the context of general practice, personal continuity is usually privileged. This is generally regarded as occurring when the same doctor delivers care to one patient over an extended period of time. The assumption follows that care is then delivered in the context of an ongoing doctor–patient relationship and, in consequence, takes account of the patient's personal and social context. Reasoning of either of the types described here can lead to knowledge of this context; however, sensitivity to the unique meaning of this context in individual patients is much more likely to result from inductive reasoning. Furthermore, if inductive reasoning about a patient occurs, discontinuity of care need not necessarily be a barrier to achieving this sensitivity.
In conclusion, when doctors perceive they have discerned the authentic nature of patients as human beings they denote these patients as ‘known'. This feeling is most likely to materialize out of an inter-subjective construction of the doctor–patient relationship and allows doctors to get away from the need to objectify patients in biological, psychological or biographical terms.
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Acknowledgments |
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This paper was presented at the 2000 Annual Scientific Meeting of the Association of University Departments of General Practice. We thank the participants, in particular Professor Chris Dowrick, for their contribution and helpful comments.
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Notes |
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present address: Centre for Health Services Research, University of Newcastle upon Tyne, UK.
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References |
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