Are we on the brinkof a major transformation of clinical method?

Ian R. McWhinney, MD, FRCP, FCFP, FRCGP

The traditional clinical method, which hasserved medicine well for over 100 years, had itsorigins in the integration of physical examina-tion with morbid anatomy in early 19th-centuryFrance. Now this method is showing signs offailing to meet some contemporary needs. Inparticular, there is no means for understandingthe inner experience of patients. Previous mod-els of a transformed method have not grappledwith the problem of validation. Data on theinner experience of patients are not open toempiric validation in the same way as clinicaldata. The process of understanding the meaningof an illness is not, therefore, scientific in theconventional sense. There are, none the less,rigorous methods for validating the results ofthis form of inquiry, notably those of phenome-nology. A transformed method should aim tounderstand the meaning of an illness for thepatient as well as provide a clinical diagnosis.The transformation will require a change in theepistemology of medicine and an educationalprocess that encourages reflection and growth ofself-knowledge.

Depuis plus de 100 ans la medecine s'est bientrouvee de la mdthode anatomo-clinique nee enFrance dans la premibre partie du 19e siecle.Mais il y a des raisons de croire qu'elle nerepond plus d certains besoins contemporains,notamment celui de connaltre la maniere dont lemalade vit sa maladie. Les nouvelles mdthodesqui ont etd proposdes n'ont pas ete validees, carle vecu intime du malade n'est pas susceptibled'une verification empirique de la meme faconque l'observation clinique. La comprehension dela maladie telle que ressentie par le malade n'a

Dr. McWhinney is professor and chairman of the Department ofFamily Medicine at the University of Western Ontario, London.

Reprint requests to: Dr. Ian R. McWhinney, Department ofFamily Medicine, Kresge Building, University of Western Ontar-io, London, Ont. N6A 5C1

rien de scientifique au sens habituel de ceterme. Neanmoins il existe dans ce domaine desmoyens rigoureux, tels ceux de la phdnomdnolo-gie, de valider les observations. Toute nouvellemethode en medecine doit avoir pour but decomprendre le vdcu du malade tout autant qued'arriver a un diagnostic. A cette fin il faudratransformer l'epistemologie de la medecine etinitier ses praticiens a la reflexion et a laconnaissance de soi.

Mt X ethod is central to any scholarly or pro-fessional discipline. Be it history or ar-cheology, physics or neurology, mastery

of the discipline requires mastery of a method,techniques for gathering information and rules forclassifying information and validating evidence.Implicit in the method are assumptions about theobjectives of the method and the information thatis relevant.

A discipline's method is not static. It evolvesunder the influence of changes in knowledge and,in the case of applied disciplines, in objectives. Forover 100 years medicine has been served by aclinical method (I will call it the traditional meth-od) that has proved extraordinarily effective inmeeting certain objectives. However, there is nowmounting evidence that this method is not ade-quately meeting the needs of the late 20th century.

The traditional clinical method

Origins

The traditional method originated in France atthe turn of the 19th century. Up to that time,medicine lacked a clinical method and a nosologythat were universally accepted as useful. Syden-ham, it is true, had demonstrated the predictivepower of a nosology based on observations of thenatural history of disease;1 however, the nosologiesof his 18th-century successors did not have thispower; they were "uncorrelated catalogues of clini-cal manifestations . . . lacking the prognostic or

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anatomic significance that would make the resultspractical or useful".

All this changed in early 19th-century France,when clinicians began to turn their attention to thephysical examination of the patient. New instru-ments such as the Laennec stethoscope revealed anew range of clinical information. At the sametime, clinicians began to examine the internalorgans after death and to correlate physical signswith postmortem appearances. According to Fou-cault,2 "the constitution of pathological anatomy atthe period when the clinicians were defining theirmethod is no mere coincidence: the balance ofexperience required that the gaze directed on theindividual and the language of description shouldrest upon the stable, visible, legible basis ofdeath". The result was a radically new classifica-tion of disease based on morbid anatomy, far morepowerful than the nosologies of the 18th century.

English physicians, who had displayed littleenthusiasm for the botanical classifications of the18th century, became so convinced by the Frenchclinicopathologists that, according to Crookshank,3"to interpret in terms of specific diseases [became]almost the only duty of the diagnostician".

This change was not merely an advance inmedical knowledge; it was a change in the waysick people were perceived. "It meant that therelation between the visible and the invisible ...changed its structure, revealing through gaze andlanguage what had previously been below andbeyond their domain."2 The change involved "areorganization of the elements that make up thepathological phenomenon (a grammar of signs hasreplaced a botany of symptoms), a definition of alinear series of morbid events (as opposed to thetable of nosological species), a welding of thedisease on to the organism".2

This transformation was the beginning of themodern era in medicine. Certain social changeswere necessary for it to become possible: "areorganization of the hospital field, a new defini-tion of the status of the patient in society, and theestablishment of a certain relationship betweenpublic assistance and medical experience, betweenhelp and knowledge".2 The reorganization of hos-pitals and medical schools in the wake of theFrench Revolution prepared the ground for "amutation in medical knowledge".2

The emergence of the clinical method weknow today has been described by Tait,4 whostudied the archives of the clinical records of St.Bartholomew's Hospital in London, England. Inthe early 19th century, case notes were an unstruc-tured account of the patient's complaints and thephysician's superficial observations. By the 1820sthe stethoscope was being used, and notes onphysical signs in the chest began to appear. Thefirst part of the record to gain a regular structure,around 1850, was the postmortem report. By 1880there had emerged a more structured method forrecording the results of history-taking and physicalexamination that resembled the modern form.

Thus, the process that had begun in late 18th-cen-tury France culminated a century later in a fullydefined clinical method.

Advances in investigative technology havegreatly increased the precision of the method, andadvances in microbiology, physiology and bio-chemistry have increased the method's power tomake causal inferences. The method's aim, howev-er, is still to interpret symptoms and signs in termsof physical pathologic findings. This is both itsgreatest strength and its severest limitation.

The strength of the method lies in two of itsfeatures. First, it tells clinicians precisely what theyhave to do to get the required results: "Take thepatient's history and conduct the examination andinvestigation in the prescribed way, and you willeither arrive at the pathological diagnosis or beable to exclude organic disease." No clinical meth-od has done this before. Second, it provides precisecriteria for validation. The pathologist tells theclinicians whether they are right or wrong. Thegreat powers of inference and prediction conferredby the method not only led to its dominance inmedical thought but also paved the way for thegreat advances of technologic medicine in thiscentury.

Limitations

The traditional method is strictly objective. Itsaim is to diagnose a disease rather than to under-stand a patient. It does not aim, in any systematicway, to understand the meaning of the illness forthe patient or to place it in the context of thepatient's biography or culture. Subjective matters,such as feelings and relationships, are excludedfrom consideration; the physician is encouraged tobe objective and detached. The objectivity of thetraditional method fits well with its 19th-centuryorigins; it is, indeed, a product of the EuropeanEnlightenment.

Paradoxically, it is the successes of medicaltechnology that have exposed so vividly the limita-tions of the traditional method. Concentration onthe technical aspects of care has diverted us fromthe patient's inner world, an aspect of illness themethod does not routinely force on our attention.The complexities and discomforts of modem thera-peutics have made it even more important for us tounderstand the patient's experience. Our neglect inthis area may explain the remarkable increase inthe number of articles written by patients abouttheir illnesses. Many of these articles have beencritical of the care the patients received.5 Articleswritten by physicians or their relatives are ofspecial interest, for they often identify very vividlythe defects of the method. A recent example isSacks' description of his experience after a moun-taineering accident.6 Sacks, a neurologist, conclud-ed that the classic neurologic method is not ade-quate for understanding the experiences of pa-tients.

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One poignant example of this genre is theaccount by a physician of his experience withslowly progressive macular degeneration:7

Through all of these years, and despite many contactswith skilled and experienced professionals, no ophthal-mologist has at any time suggested any devices thatmight be of assistance to me. No ophthalmologist hasmentioned any of the many ways in which I could stemthe deterioration in the quality of my life. Fortunately, Ihave discovered a number of means whereby I havehelped myself, and the purpose of this essay is to callthe attention of the ophthalmological world to some ofthese devices and, courteously but firmly, to complain ofwhat appears to be the ophthalmologists' attitude: "Weare interested in vision but have little interest in blind-ness."

This example should not be taken as a criti-cism of the ophthalmologists; they were onlyapplying the traditional method, according towhich macular degeneration is relevant and theexperience of blindness is not.

The traditional method is not designed toreach an understanding of the meaning of theillness for the patient, nor is it equipped to dealwith the moral and spiritual problems experiencedby patients. There may indeed be some resistanceto the idea that a clinical method should takeaccount of moral and spiritual questions. Are thesenot outside the physician's domain? The answer tothis question is to be found in the experience ofillness and suffering.

The profoundly disturbing effect of illnessmay lead a person to seriously examine his or herwhole life. This is almost bound to raise suchmoral and spiritual questions as What are theimportant things in my life? How have I fulfilledmy responsibilities to my spouse, my children, myparents? How will this illness change my ability tofulfil my responsibilities? Has lack of responsibilitycontributed to my present illness and my family'ssuffering? What is the purpose of my life andwork? What has motivated my working life? HaveI been faithful to my true vocation?

Healing in its deepest sense - the restorationof wholeness - requires answers to these ques-tions. Healing is not the same as treating or curing.It is something that happens to a whole person;that is why we can be cured without being healedand vice versa. A person who remains in spiritualanguish even after physical recovery cannot besaid to be healed. Frankl8 observed that even whencure is not possible, suffering can be borne morereadily if its meaning is understood.

How, then, can physicians be healers unlessthey try to understand these aspects of a patient'sillness? To ask this is not to place the physician inthe role of priest. Spiritual questions are notnecessarily religious. If there are religious ques-tions or a need for absolution the physician has noplace. There is, however, some common groundbetween medicine and religion. Attentive listeningis therapeutic; the confessional is also a means ofhealing the spirit. Physicians are not uniquely

qualified to listen to the sufferings of others, but,because of their closeness to suffering, their calls todo so are more frequent and urgent than those ofmost people.

Criticism of our clinical method is also to befound in the literature on doctor-patient communi-cation.9 All too frequently we do not listen to ourpatients, perceive their needs or understand theirsufferings. Is it unfair to blame all this on ourmethod rather than on ourselves? Although clinicalmethod is a tool, it is unlike a scalpel, a drug or anendoscope. Physicians' personalities and their per-ceptions of themselves and their tasks enter deeplyinto clinical method. Changing the-tool, therefore,requires changing the person. If we are on thebrink of a transformation of clinical method we arealso on the brink of a change in the way physiciansthink and feel.

Influence ofpsychiatry and behavioural science

Since the purpose of psychiatry is to under-stand aspects of human behaviour, we mightexpect that a transformed clinical method wouldemerge from the integration of psychiatry andclinical medicine. So far, this has not happened.Psychiatry itself has been influenced by the tradi-tional method, in that it has developed its ownnosology of mental illness. This has doubtless beennecessary, but it has focused attention on behav-ioural abnormalities rather than on the normalbehaviour of sick people and on generalizationrather than on an understanding of the individualpatient. Psychiatry and behavioural science havetried to become as objective as possible, followingthe trend toward what James10 called "medicalmaterialism" or "nothing butness", explainingaway man's moral and spiritual experiences as"nothing but" psychologic mechanisms.

There have been several exceptions to thesegeneralizations. Psychiatry and clinical medicinehave come together at some points in the last fewdecades to evolve different clinical methods. Theeffect of these confluences, however, has beeneither temporary or limited in range. None of themhas yet transformed the clinical method taught bythe medical schools.

In the 1950s and 1960s Donovan, a gynecolo-gist with training in psychiatry, wrote a series ofarticles on the doctor-patient relationship andsome psychosomatic aspects of gynecology.11 Histhesis was that the question-answer method ofinterviewing, so characteristic of the traditionalclinical method, biased the selection of informationfrom the patient. Donovan used an open-ended,patient-centred method, which gave him a verydifferent perspective on the patient's experience.Using this method with patients believed to havemenopausal symptoms, Donovan found no evi-dence of a clear-cut menopausal syndrome. Hefound instead that in many of the women thesymptoms were only one aspect of personal prob-lems that were often of many years' standing. The

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inadequacy of the clinical method used to assessthese patients had resulted, in his view, in asuperficial and inadequate diagnosis of the illness.Donovan's work does not appear to have had anyinfluence on gynecology; his papers have beencited more often in the literature on behaviouralscience than in that on medicine.

In the 1950s Balint,12'l3 a psychoanalyst, beganto work with groups of general practitioners toexplore the doctor-patient relationship. The resultwas a series of insights that have had a lastingeffect on family practice. One of his aphorisms was"If you ask questions you will get answers, andnothing else"."3 Like Donovan, Balint was struckby the inadequacies of the traditional method forreaching any deep understanding of the patient'sillness. The need was to listen, not to ask ques-tions. Balint developed the concepts of attentivelistening and responding to a patient's "offers" asmeans of reaching an understanding of the illness.One of his most important contributions to clinicalmethod was his distinction between traditionaldiagnosis - the search for a pathologic sourceand overall diagnosis - the attempt to understandthe patient and the doctor-patient relationship.However, Balint's influence has yet to be felt inclinical disciplines other than family practice.

Engel,14 a psychiatrist and internist, uses sys-tems theory as a model for integrating biologic,psychologic and social data in the clinical process.Systems theory has its roots in engineering, cyber-netics, Gestalt psychology and operations research.The method of 19th-century science was to dealwith problems by "cutting them down to size",separating them from their surroundings and re-ducing them as far as possible to linear causalchains. Systems theory seeks to do the opposite:enlarge the problems until all their significantrelationships are included.

Each system in nature is both an organizedwhole and part of a larger whole. Systems areordered hierarchically: a person is a hierarchy ofsystems ranging from the cell to the organ andorgan system; a person is also the lowest unit of ahierarchy of social systems, from family to com-munity, subculture and culture. Each level of thehierarchy has its own rules and qualities. Thebiopsychosocial model requires the physician toconsider and integrate information from severallevels of hierarchy: the milieu interieur, the personand the interpersonal level. Although this modelhas been widely accepted conceptually, I know ofno evidence that it has been rigorously tested inpractice or widely adopted as a clinical method.The reason for this, I believe, is that the modellacks the two strengths of the traditional method: aprecise prescription for action and criteria forvalidation.

Engel is critical of the psychologic and socialjudgements arrived at by the biomedical method,claiming that the biopsychosocial method is morescientific. The biomedically trained physician, saysEngel, reaches judgements on interpersonal and

social aspects of patients' lives on the basis of"tradition, custom, prescribed rules, compassion,intuition, 'common sense' and sometimes highlypersonal self-reference. Such processes . . . remainoutside the realm of science and critical inquiry.Not so for the bio-psycho-socially oriented physi-cian, who recognizes that to best serve the patient,higher-system-level occurrences must be ap-proached with the same rigor and critical scrutinythat are applied to systems lower in the hierar-chy".14 But Engel does not go on to acknowledgethat the canons of rigour for reaching a clinicaldiagnosis are not the same as those for establishingthe meaning of the experience for the patient.There is no empirical test for patients' perceptionsof their illness, the quality of their relationships ortheir feelings of responsibility. These can only beascertained by a dialogue between doctor andpatient in which the meanings of words andactions are always being interpreted and reinter-preted. This method has its own rigour, differentfrom that of empirical science.

The transformed clinical method

The transformed clinical method will be pa-tient-centred rather than doctor-centred. The es-sence of the patient-centred method is that physi-cians try to enter the patient's world and to see theillness through the patient's eyes. In the traditionaldoctor-centred method physicians try to bring thepatient's illness into their own world and tointerpret the illness in terms of their own patholog-ical frame of reference. The transformed methodwill, of course, include this process, but it will nolonger have the dominance it now enjoys.

The physician using the patient-centred meth-od invites and encourages openness by the patient.The aim in every case is to understand the pa-tient's expectations, feelings and fears. Very oftenthese feelings are not made explicit but are ex-pressed in the form of subtle cues, which will bepicked up only if the physician is attentive.

Expectations, feelings and fears are specific foreach patient. The meaning of an illness for apatient reflects a unique situation and experienceof life. Understanding a person in this way requiresthat the physician get rid of preconceptions andprejudgements, including those derived from theo-ries and schemata of human behaviour. Theories ofhuman behaviour come from the physician'sworld, not the patient's. As the enquiry proceeds, atheoretical frame of reference may help both thephysician and the patient understand aspects ofthe illness, but it is not a substitute for knowingthe patient as an individual. Understanding pa-tients in this way also requires in the physiciancertain qualities not usually emphasized in medicaleducation: self-knowledge, moral awareness, a re-flective habit of mind and a capacity for empathyand attentive listening. The following vignetteillustrates the need for such qualities.

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patient's lack of cooperation, anger and certain

A 19-year-old girl dislocated her right patellaplaying baseball. At the orthopedic service of alarge general hospital an arthrotomy was per-formed, with soft tissue stabilization of the patella.

The orthopedic clinic doctor felt that herresponse to surgical treatment was unsatisfactory.Postoperatively she did not do her quadricepsexercises as instructed, but when the doctor chal-lenged her she became hostile, and their relation-ship deteriorated.

The patient continued to have pain, discom-fort and loss of function in her knee. In addition,she complained of profound fatigue and needed 18hours of sleep each day. She experienced tremor,fainting spells, palpitations, episodes of tachycar-dia, upper abdominal discomfort, nausea, vomit-ing, episodic diarrhea and excessive perspiration.The staff at the orthopedic clinic advised her thatthese symptoms were not postsurgical complica-tions and suggested that she consult her familyphysician.

After a physical examination and some labora-tory investigations the family physician concludedthat the patient's symptoms were manifestations ofanxiety. The patient was encouraged to return onseveral occasions, and over the next few weeks, inresponse to the physician's active listening, shetalked about her life. She had been raised in anevangelical atmosphere, and the strictness of herupbringing had influenced her relationships withpeers and friends and her sexuality and how it wasexpressed. She was the youngest child, and cons-tant competition with her very athletic brothershad caused her to excel in sports. She recognizedthat she had compensated for her poor academicachievement and social skills by investing all hertime and aspirations in athletic activities and thatshe had become immensely competitive.

Over several weeks the patient developedinsight into her problems and gradually recoveredfrom her injury. She was able to recognize that theone area of her life in which she had invested allher hopes and expectations of self-actualizationhad been destroyed. She also recognized that herresponse to this had been profound anxiety, withperiods of depression and withdrawal.

This patient's illness can be interpreted atmore than one level. At the most superficial levelits meaning in anatomic and functional terms is notdifficult to define. To the patient, however, theillness had another meaning. Her athletic pursuitswere her way of dealing with doubts about herattractiveness and of compensating for her pooracademic performance. At one blow the injurydestroyed the basis of her self-respect and createda need for reassessment of her life. Understand-ably, this reassessment did not occur immediately.The injury was followed by a reaction to her loss.The personal meaning of the illness was thereforeconveyed to the physician indirectly, through the

physiologic symptoms.What did this illness require of the physician?

First, he had to be able to identify the patient'sbehaviour and her symptoms as cues to herfeelings. This required enough self-knowledge torespond to the patient's anger not with anger butwith the question Why is this patient angry anduncooperative? The physician had to have theanalytic skill to exclude an organic basis for thepatient's symptoms and the ability to think interms of a complex web rather than a single causalchain of relationships. The injury triggered a lifecrisis that delayed recovery from the injury. Thephysician became part of the web, both as arecipient of the patient's anger and, later, as atherapist. Finally, he had to have the empathy andattentiveness to help the patient work through herproblems.

Testing the new method

The need for empathy and attentiveness hasbeen recognized in medical education. One re-sponse has been to introduce the teaching ofcommunication skills. To judge the effectiveness ofthese skills we must look to their impact on theclinical method as it is practised at the very centreof medicine, on the wards and in the clinics. Ibelieve the impact here has been minimal. Anobserver could test this by recording how oftenstudents and residents are asked questions likeWhat are the patient's feelings about the illness?What does it mean to him? What are his fears?What are his expectations?

The ineffectiveness of attempts to reform ourclinical method is attributable, I believe, to thesame two defects that have blunted the impact ofthe biopsychosocial model - the lack of both aclear injunction and validation criteria. How canthese needs be met? Just as the traditional clinicalmethod brings simplicity to the complexity ofclinical information by reducing it to items such aspresenting complaint and history of present condi-tion, so the new method must simplify and reducethe data on the personal meaning of illness.Levenstein and colleagues"5 have done this byasking physicians to focus on three items: thepatient's expectations, feelings and fears.

Clinical method can be validated by bothprocess and outcome measures. Validation of theprocess of the traditional method is usually doneby audit of the medical record. However, this hasthe serious drawback of giving the observer only asecond-hand account of the interaction betweendoctor and patient. For validation of a method thatincludes the exploration of a patient's inner experi-ence, audit of the record is very unlikely to besufficient. In the videotape and audiotape, howev-er, we have the means to lay open to criticalobservers all the subtleties of an interaction. Brownand Stewart and their associates'6-18 have shown

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Case vignette

how explicit criteria can be used to measure the"patient-centredness" of an interaction.

The ultimate test of a method is its outcome.To measure the accuracy of a clinical diagnosis theclinician can go to the pathologist. What is theequivalent for testing the accuracy of the diagnosisof the patient's inner experience? Going to thepatient. The patient can tell us whether the physi-cian has acknowledged and understood his or herexpectations and feelings. Moreover, once we havevalid operational criteria for measuring patient-centredness we can examine the already provenassociation between patient-centredness and thepatient's recovery.19'20

The nature of the transformation

I regard this clinical method as transformedrather than additive for two reasons: first, itrequires a radical change in the physician's charac-ter and perception, and, second, it requires achange in the epistemology of medicine. Keen2'has described the method thus.

Mature awareness is possible only when I have digestedand compensated for the biases and prejudices that arethe residue of my personal history. Awareness of whatpresents itself to me involves a double movement ofattention, silencing the familiar and welcoming thestrange. Each time I approach a strange object, person orevent, I have a tendency to let my present needs, pastexperience or expectations for the future determine whatI will see. If I am to appreciate the uniqueness of anydatum, I must be sufficiently aware of my preconceivedideas and characteristic emotional distortions to bracketthem long enough to welcome strangeness and noveltyinto my perceptual world. This discipline of bracketing,compensating, or silencing requires sophisticated self-knowledge and courageous honesty.

Although medicine does not make its episte-mology explicit, an examination of the medicalschool curriculum leaves one in little doubt thatmedical knowledge is defined as that which isverifiable empirically by the scientific method. Inthis, medicine has embraced the positivism thathas dominated Western thought since the Enlight-enment. The transformation of clinical methodrequires the medical profession to acknowledgethat the scientific method is only one of severalroutes to knowledge.

The perennial philosophy - the distilled wis-dom of the great philosophic and religious _tradi-tions - recognizes three paths to knowledge: thesensory, the mental and the transcendent. All ofthem require rigorous discipline if they are to leadto truth. What we need is a re-examination of whatFoucault2 would call our "episteme", a redefinitionof what medical knowledge is and how it can beobtained. Why should a knowledge of blindness -and a patient's experience of blindness - not be asimportant to a physician as a knowledge of vision?

If I am correct, there are far-reaching implica-tions for medical education. If physicians are to

change in the way I have suggested, their educa-tion will have to encourage reflection, personaldevelopment and the growth of self-knowledge.The current environment of the medical school,with its information overload, frenzied activity andcompetitive ethos, in many ways discourages per-sonal development of this kind. Medical scientistssometimes make reference to "the frontiers ofknowledge". I think they have in mind a frontierthat is "out there". The newest and most challeng-ing frontier may be within us.

I thank Dr. John Johnstone, Jr., for his valued criticism ofearly drafts of this article, Drs. Gayle Stevens, MichaelBrennan, Bruce Squires and the late Ronald Christie fortheir suggestions and criticisms, and Dr. Eric McCrackenfor the case vignette.

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