Research on patient-centred care “feeds the soul”

Your research training and PhD were in epidemiology. How did you choose family medicine as your main field of research?

As a new university graduate contemplating my career, I chose epidemiology rather than medicine having in mind to study the intersection of the biological, psychological, and social factors of health. After I arrived at Western University from Halifax, Nova Scotia, my thesis supervisor, the late and great Dr Carol Buck, said, “You talk just like this new faculty member leading Family Medicine, Ian McWhinney. I will introduce you.” Dr McWhinney altered my thinking from studies of populations to studies of family medicine, integrating considerations of patients’ biological, psychological, and social factors. I wanted to work shoulder to shoulder with practising family physicians. This career in research was the perfect combination of a monastic life, suited to an introvert, and a collaborative life working with colleagues, practitioners, patients, and policy-makers.

Your most-cited work addresses issues related to patient-centred care. What drew you to that research theme?

My interest in all factors in health and illness (psychological, social, and physical) dovetailed with Dr McWhinney’s interest in patients’ multifaceted reasons for seeking care (discomforts, anxieties, and signals to problems of living). I was a graduate student in the 1970s with Drs Buck and McWhinney as my supervisors. We conducted studies of patients’ reasons for seeking care and family physicians’ knowledge and responses to those reasons; the higher the proportion of reasons that were known to the physician, the better the patient outcomes. Next, in my postdoctoral work, I wanted to find out how family physicians succeeded in learning more about their patients, by audiotaping visits. So, in 1981 to 1982—when Dr McWhinney invited Dr Joseph Levenstein [(a family physician from South Africa)] to be a visiting professor at Western to share his views of the importance of patients’ feelings, fears, and expectations—I knew a lot about coding conversations and helped create new measures of the emerging concepts that came to be called the patient-centred clinical method. Seven years [after completing my] PhD, I started a decades-long collaborative research program on outcomes of patient-centred care.

Successful careers usually reflect a combination of good fortune and good planning. What role did each of these play in your research life?

There did not seem, looking back, to have been much planning. My mentors and I responded to opportunities. We forged ahead and made a career that had never been conceived of before: that is, a basic scientist in a department of family medicine. The building blocks were external funding opportunities. [During] my 39-year career, all but 6 years were funded from sources external to the department.

How has mentorship shaped your career?

Ideas are co-created in an atmosphere of creativity and openness. The Department of Family Medicine at Western was a hotbed of ideas either brought in by frequent visitors from abroad or locally engendered by groups of thinkers. This atmosphere was fostered by Dr McWhinney. His key piece of advice for me, as a nonclinician, was to immerse myself in family practice. He arranged for me to view family physicians in their daily work. Dr Carol Buck imbued me with a knowledge of rigorous methods and with an approach to writing grants. [The late] Dr Brian Hennen, [a former chair of the Department of Family Medicine at Western], demonstrated assertive and strategic leadership and modelled unstinting and infectious energy.

What would you identify as the most satisfying of your research endeavours?

The work that feeds the soul is on the patient-centred clinical method. As a patient having experienced the patient-centred approach, and its antithesis, I can attest to its value and impact on health and healing. We developed a wholly original research program that stretched over 4 decades to measure patient-centredness, to assess its impact on patient-reported outcomes and costs of care, to test its impact on doctors and patients in large trials (1 of these was an Ontario-Quebec collaboration of which I am particularly proud), and to illuminate the patient’s experience of such care, all providing a rich seam of information and insight to help practitioners and teachers.³

Other passions of mine were unravelling the mystery of symptoms and co-creating an undisputed jewel, a program called TUTOR-PHC [(Transdisciplinary Understanding and Training on Research–Primary Health Care)], to pass on soft and hard research skills to the next generation of researchers.

Research has its ups and downs. Have there been times when you have felt discouraged?

Research is hard work that requires an inner strength to persist with the single-minded focus that produces grant applications and papers. While it was discouraging always to be applying for salary support, it was a blessing in disguise. These funding agencies have extremely high standards, far higher than the standards of the university. This propelled me to a higher level.

In an atmosphere of basic biomedical research at a faculty of medicine, it took advocacy in my role as the Family Medicine Director of Research to make clear that, among the medical disciplines, family medicine is unique [not only] in its clinical approach, but also in its research endeavours with a broad reach (clinical, health services, population research) and methods (quantitative, measures development, and qualitative), having implications for the appropriate faculty complement in the research branch of the department.

What has it been like to be a nonclinician and a woman in a field of research dominated by clinically trained male physicians?

I was the first female faculty person in Western’s Department of Family Medicine in 1978. I felt fortunate to have a job at all, so things like how I was welcomed were immaterial. The chair of the department, Dr McWhinney, was truly gender-blind and always made me feel welcome.

How have you managed the balance between your professional and personal life?

Nothing is more important than family life. We have 2 children and 2 grandchildren and we prioritize for them time, attention, and love. Just as when things are hectic at work and I delegate, when things got hectic at home I delegated with strong oversight. I found it important to compartmentalize. Also, when high school sports demanded weekends away for tournaments, I moved to reduced responsibilities at work, taking Mondays to recover from the active weekend. Delegation in the workplace cannot be overemphasized; strong staff, well mentored, are worth their weight in gold.

It can be difficult to link specific studies to health care innovations, but have you seen your research influence practice and policy?

The most influential research programs answer an array of questions on a research topic and build connections with practitioners, educators, and policy-makers. The program on the patient-centred clinical method is an example. Those many studies are able to provide the relevant answers that practitioners, educators, and policy-makers need to incorporate patient-centredness into their world. For the practitioner: How do I do this? What good does it do my patients? How long will it take? For the educator: How do I justify this in the curriculum? How can patient-centredness be taught? And for the policy-maker: Does it improve health? Does it cost less? Research on the patient-centred clinical method has changed primary health care in Canada, the United Kingdom, Turkey, Japan, Singapore, Brazil, Nigeria, India, and elsewhere through Western’s masters and PhD programs in family medicine—we train the trainers. Connection with the CFPC led to patient-centredness being evaluated at the certification examination. The researcher team communicates results through teaching, advocating, volunteering, writing papers and books, giving presentations and keynote addresses, and mentoring future leaders in family medicine.

Finally, what would you like to say to aspiring primary health care researchers?

I think that primary care or family medicine is the most worthy field; it is the glue that helps hold society together through its contribution to health and healing. Within family medicine, I suggest to early researchers: Find your passion. Find generous and generative mentors. Focus. Work hard. Do not get distracted but rather stay the course. When the inevitable foul-ups occur, people will help you through them; you are not alone. Talk to kind and thoughtful colleagues and listen when they need you to.