In The Birth of the Clinic, Foucault describes the “clinical gaze,” which is when the physician perceives the patient as a body experiencing symptoms, instead of as a person experiencing illness. Even in the era of the biopsyschosocial model, the physician’s perspective is largely through a biomedical lens where biology and behavior cause disease.
In contrast, what I hear from patients is that health and illness are not merely the end results of individual biology and behavior. What people believe and experience when they are ill is usually something far more complex, deeply interconnected with their daily lives. And research shows the way people think about health influences whether they are receptive to health information, willing to change health behaviors or take medications, and even whether or not their health improves. But how are physicians, who are able to spend less and less time with patients, supposed to expand their clinical gaze to include the patient’s health beliefs and perspectives?
Psychiatrist and anthropologist Arthur Kleinman’s theory of explanatory models (EMs) proposes that individuals and groups can have vastly different notions of health and disease. Kleinman proposed that instead of simply asking patients, “Where does it hurt,” the physicians should focus on eliciting the patient’s answers to “Why,” “When,” “How,” and “What Next.”
Kleinman suggests the following questions to learn how your patient sees his or her illness:
1. What do you think caused your problem?
2. Why do you think it started when it did?
3. What do you think your sickness does to you?
4. How severe is your sickness? Do you think it will last a long time,
or will it be better soon in your opinion?
5. What are the chief problems your sickness has caused for you?
6. What do you fear most about your sickness?
7. What kind of treatment do you think you should receive?
8. What are the most important results you hope to get from treatment?
I began incorporating the EM questions into the medical interview when I was an internal medicine resident at Bellevue Hospital in New York City. Initially, I did it to allay my own frustrations when I realized that many of my patients did not follow through with the plan I thought we had agreed on. I also thought it would help me to understand the beliefs of my immigrant patients, especially when I was dealing with unexplained symptoms.
Eventually I simplified my approach down to two questions that I use whenever I see a new patient: “How is your health,” followed by, “How do you know?” These questions unlocked the patient and gave me a flood of information on how they see themselves, their bodies, and their health. Depending on the answers to these questions and the reason for the visit, I can then use the EM questions to further explore the patient’s beliefs.
In many medical schools, the EM questions are taught during cultural competency training, and students are encouraged to use them when dealing with patients from other cultures or with unexplained medical symptoms. But it is increasingly clear that asking about the patient’s explanatory model should be used with all patients, and in routine clinical encounters–because the vast majority of patients are not from the culture of biomedicine.
In a national study, patients reported that shared decision-making occurred least often in routine primary care situations, such as being started on blood pressure or lipid lowering medicines. That’s a problem. Routine clinical encounters are often the times when patients are being asked to make major lifestyle changes, including taking a medication every day. Physicians are frequently frustrated by patients’ “non-compliance” with prescribed diet, exercise, and medication. To be sure, the causes of non-adherence are complex. But one important reason may be that the patient’s way of explaining his illness to himself is at odds with that of the physician. Research shows that a patient’s explanatory model is not simply going to disappear because the patient has had a clinical encounter. These ways of perceiving one’s life and health are deeply ingrained and meaningful. They reflect a person’s lived experiences, contexts, and identities.
I find that eliciting a patient’s explanatory model is helpful with most patients and in common clinical situations, including sore throats, high blood pressure, high cholesterol, and back pain. Why? Because understanding a patient’s explanatory models gives me critical insight into what is most important to the patient, what the patient believes about health and illness, and what they think will help them get better.
I cannot effectively counsel a patient with high blood pressure to change her diet or take medication unless I understand her way of explaining her hypertension and how she thinks her blood pressure should be treated. Once I understand that, we can discuss her issues in a language that we both understand. If the goal is really to improve health care quality and outcomes, clinical care must be guided by a meeting of the doctor’s expertise and what matters most to the patient. And it works.
A recent clinical trial showed that a DVD-based intervention that utilized real patients’ stories and that incorporated patients’ health beliefs improved African-American patients’ blood pressure, even when it was previously uncontrolled.
The next time you are with a patient, in even the most routine clinical encounter, try expanding your clinical gaze by investigating the patient’s explanatory model. Not only will it bring you closer to your patients, but the information you learn will help guide you to better care and a healthier patient.
Dr. Namratha Kandula, a Public Voices fellow with The OpEd Project, is a general internist and Assistant Professor at Northwestern University’s Feinberg School of Medicine. Her research on the social and cultural determinants of health has appeared in the American Journal of Public Health.
Well said Dr. Namratha! The way that you have explained is unique in its kind.
A useful acronym to teach patients is SAFE, so they can talk to their doctor safely !
S = Story. The patient tells his story ( preferably ,in chronologic order)
A= Assessment. ( what does he think is wrong with him ?)
F = Fears. What is he scared his illness might mean ?
E= Expectations ( what does he want from you ?)
Dr Aniruddha Malpani, MD
HELP – Health Education Library for People
Bombay 400 034
Helping patients to talk to doctors !
Information Therapy is the Best Prescription – http://www.informationtherapy.in !
Putting Patients First Conferences at http://www.patientpower.in
Read over 20 health books free at http://www.helpforhealth.org
Read my blog about improving the doctor-patient
relationship at http://doctorandpatient.blogspot.com/
Check out the Healthwise Knowledgebase at http://www.healthlibrary.com/healthwise !
With the remarkable technology now available to facilitate the diagnosis and treatment of patients, medical educators have devoted less time to the fine points of EM or “bedside medicine”—the taking of a thorough history and performance of a good physical exam. Many students are coming out of medical school deficient in this area. By learning to ask these questions and listening for the answers a doctor can often learn more than tests can ever tell.
Thanks Shiv. While I do not have metrics on % of adherent patients, I do have metrics on my efficiency. A lot of residents, students, and other docs say that they do not have time to use the EM. But since my practice keeps track of time from check-in to check-out for each MD, I can say that I am one o fthe most time-efficient in my practice. Using the EM approach makes me more efficient- and I don’t think patients feel rushed because the time we do spend together is largely focused on their perspective/stories, not just mine.
Dr. Kandula, thank you for a great article. It’s great to see an academic concept such as EM being applied. I’d love to hear more about how it has affected your outcomes, e.g. percent of complying patients. Too many powerful concepts are trapped in academic papers and not being applied broadly. For example, one of the initiatives I launched at Hopkins (www.thepatientpromise.org) took the observation that physicians who practice what they preach are more likely to counsel their patients to adopt healthier lifestyle behaviors. However, as you write eloquently above, we not only need to do /more/ counseling, but /smarter/ counseling.
Dr. Kandula’s message is absolutely central to the future of healthcare.
Today it seems visionary, as practice style has become virtually rush-rush industrial. She asks, “…how are physicians, who are able to spend less and less time with patients, supposed to expand their clinical gaze to include the patient’s health beliefs and perspectives?”
Arthur Kleiman’s “Explanatory Models” come from his work in illness narratives. He’s shown that we treat patients far more effectively when we’re familiar with the stories they tell about getting sick and navigating through their sickness. The questions he suggests generate much of this information, and Dr. Kandula’s abbreviation of them–necessitated by time constraints–are also useful. Nothing, though, is as effective as simply spending the time getting to know patients intimately, a practice and skill that’s tragically atrophied over the past two generations.
How can we get back on track? The only strategy that will work over the long run is for patients and physicians to insist on restoring their previous closeness and trust. That will mean resisting the pressures of the medical-industrial complex, and enacting more humane preferences. Do we have the courage to do that?
Jeff Kane MD
Dr. Kane- you are absolutely correct. Medical education should include field work that allows students to gain critical skills and experience in narratives, ethnography, and observation. Recent study found that residents spend on average, 8 minutes with an inpatient. http://nyti.ms/19nXqsf
Nothing can replace the time a smart doctor spends with a patient.