Patient-centred interviewing and evidence-based patient counseling

Alan Bonsteel

One of Canadian family practices’ greatest contributions to the world is patient-centred interviewing, a practice that allows physicians to understand their patients’ experiences with their health conditions. As a US-born physician who is one of just a few Canadian family practice residency graduates for that country, I have a special perspective on the value of that contribution.

I graduated from an Ivy League medical school and completed a highly regarded internship in the United States; however, in all of the 5 years of my training, I never interviewed a single patient under the guidance of a teacher. My arrival at McGill University in Montreal, Que, in 1991 was therefore an epiphany. I received guidance during all my patient encounters. Family practice faculty members’ and clinical psychologists’ lessons included how to interact with patients. And many of my patient encounters were observed behind 1-way mirrors. This training was nothing short of a career- and life-changing experience.

At that time, I fell in love with Canada, and now, 20 years later, I have returned not only to teach, but also to serve as a conduit to the United States for the successful qualities of Canadian health care such as patient-centred interviewing and the universal, single-payer system.

In the intervening 20 years, our profession has been transformed by the concept of evidence-based medicine—that every treatment we give our patients should be supported by scientific studies. I firmly believe that patient-centred interviewing would easily pass that test.

Inspired study

In 2004 and 2005, my students and I conducted an informal study to test the effectiveness of various approaches to interacting with patients. This study was inspired by a man who also had a profound effect on my practice.

Following graduation from McGill University, my first job as an attending physician was a locum tenens in my home state of California—a work experience that turned out to be every bit as life changing as my training at McGill.

For a few weeks I replaced a family practitioner named Dr Zane Kime (now deceased). Kime remains the most accomplished family physician that I have ever known. He had an extraordinarily personal approach to patient care. He greeted patients, even the new ones, with a huge smile and a warm, 2-handed handshake; and at the end of the encounter, Kime gave almost every patient a big hug.

Kime had thought and studied a lot about how to motivate patients and get them to actually change their ways for the better. I learned so much from him, but one of the most effective things I learned was also astoundingly simple: the optimal way to sit with patients is to sit next to them rather than across from them. Not surprisingly, sitting next to a patient always sends the message, “Whatever tough issues you are facing, I am right here next to you as we deal with them.”

Kime gave every patient 100% of his attention. He had a photographic memory and remembered his patients’ names, as well as the names of their significant others, children, and even pets. With such extraordinary warmth and intimacy, he had his patients falling all over themselves to please him. They did whatever he asked them to do: stop smoking, sober up, exercise, diet, lose weight, whatever.

I still cannot do what he did, mainly because I do not have that kind of memory for the details of my patients’ lives. However, Kime shattered my previous limited view of how much we as physicians can truly change the lives of our patients. And now that I have been a teacher myself for the past 10 years, much of the behaviour I model for the students is based on Kime’s influence.

Various approaches

In the study inspired by Kime, a total of 156 patients were randomized to 3 groups and were weighed. For patients in the first group, the practitioner stood and faced the patient while asking him or her the following: “Can I get you to ramp up your diet and exercise?” The practitioner asked the patients in the other 2 groups the same question but with different physical approaches. For the second group, the practitioner sat next to the patient while asking the question; and for the third group, the practitioner not only sat next to the patient, but also put a hand on the patient’s shoulder. Upon patients’ return to the clinic, with random return dates but averaging approximately 3.5 weeks later for all 3 groups, they were reweighed.

The patients in the first group actually gained a tiny 0.1 kg. The patients in the second group, in which the practitioner sat next to them, lost about 0.45 kg, and those patients who also received a hand on the shoulder lost about 0.85 kg.

Our study was too flawed to be considered truly scientific, but it does raise the tantalizing possibility that we could prove the benefits of patient-centred interviewing in a truly scientific way and research further theories on the best approaches to interacting with patients, just as we test the effectiveness of drugs.