Finding meaning in the consultation: introducing the hermeneutic window

WHOLE-PERSON CARE

Iona Heath reminds us that ‘clinicians must see and hear each patient in the fullness of his or her humanity in order to minimise fear, to locate hope (however limited), to explain symptoms and diagnoses in language that makes sense to the particular patient, to witness courage and endurance, and to accompany suffering’.¹

In an interview recorded before his death in 2011,² Dr Kieran Sweeney, a retired GP and Professor of Primary Care, poignantly described what was missing in the outwardly faultless chain of encounters that culminated in his diagnosis of mesothelioma. Although there were no delays at any stage, he didn’t feel that there was enough in the way of human connection or consideration given to what the diagnosis meant for him and for his family, and this absence made a difference to his ability to come to terms with his disease. Yet, if his trajectory were audited, it could reasonably be concluded that everything was done correctly, from the initial referral through to the eventual diagnosis. Earlier in his career, he and other colleagues had written about ‘personal significance’ as an important dimension of the patient encounter.³

Commonly used consultation frameworks fail to capture the humanity inherent within any meaningful encounter between a patient and a clinician adequately; rather we tend to analyse the consultation from a transactional point of view and, in doing so, do not capture the subtleties of communication that add huge value to patients and to clinicians themselves. Doctors who practise with empathy have been shown to have lower rates of burnout.⁴

As an aid to promoting the values and skills we have described, we propose a model that includes a hermeneutic dimension. The term hermeneutics, derived from the Greek word ‘ hermeneuo’ which means ‘translate’ or ‘interpret’, originally pertained to the interpretation of classical texts. Here we take hermeneutics to signify an approach that seeks to help doctor and patient find and create meaning in a context-specific manner; the perspectives of both are brought together during any consultation, thereby generating new understanding. In this sense, there is a close relation between hermeneutics and narrative practice.⁵

There is much that has been written on how we can promote a hermeneutic approach^6–8 In broad terms, we would suggest that important attributes include curiosity; awareness of the multiple influences on both patient and practitioner; ability to challenge a narrative when it is ‘stuck’; and compassion. Supervisors may wish to encourage trainees to consider multiple possible interpretations of a patient’s story and how each might influence their own management choices.

INTRODUCING THE HERMENEUTIC WINDOW MODEL

We propose a model to describe the skills and attributes that contribute to whole-person care. It is represented as a two-by-two table with four separate but related domains (Figure 1). The first column is labelled biomedical and is supported by the natural sciences, whereas the second column is labelled humanistic and has its foundation within the social sciences. Window 1 consists of clinical skills, such as history taking and physical examination of different systems, underpinned by knowledge, including an awareness of current guidelines.

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Figure 1.

The hermeneutic window model.

The second window directly above this, evidence-based practice, represents the application of such knowledge and skills to a specific patient in a specific context, rather than being based on a population in a clinical trial. This usually entails an increase in complexity and is frequently also accompanied by an increase in uncertainty because the ‘right’ answer for an individual patient may not be certain, even in the face of clear evidence from the scientific literature.

Within the humanistic column, communication skills in window 3 go beyond basic history taking to include some of the skills of person-centred consulting, for example, eliciting a patient’s ideas and concerns about their symptoms and using patient expectations as a basis for negotiating a shared management plan.

Finally, we reach the hermeneutic window of window 4 where assumptions, meanings, and roles are interpreted in a way that is particular to the individual. This is often the area of greatest complexity and uncertainty, where questions about what it means to be a healthcare professional are asked and relationships with individual patients are examined. It entails reflective practice and the exploration of values and beliefs. What are the assumptions, biases, and judgements that are informing clinical decision making? What are the external influences on the consultation, for example, performance incentive schemes, external quality regulators, fear of litigation, and time pressures? This is where validation of a patient’s experience (Heath’s ‘doctor as witness’)⁹ is important and where a GP may uncover a web of meanings,¹⁰ trigger a new insight (Heron’s ‘catalytic intervention’),¹¹ or may help a patient to move on from a stuck autobiographical narrative.¹² Central to this is a view of individuals as having both agency and creative capacity.⁶ A hermeneutic gaze can be equally powerful in supporting, challenging, and transforming both clinicians and patients during the consultation and beyond (Figure 2).

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Figure 2.

Case study. Mrs T is a 52-year-old woman who is a frequent attender at the practice. In the last year she has presented with multiple symptoms including lower back pain, tennis elbow, and low abdominal pain. This time she attends with a headache, which the GP diagnoses as a migraine.

IMPLICATIONS

The model we propose encourages us to notice the particularities of each encounter we have with our patients and to recognise when there are deviations from usual patterns. It prompts us to examine our values, challenge our assumptions, and to practise with empathy. It should make us ask not just the generic question: ‘What sort of a doctor am I?’ but also the more specific: ‘What is my role with this particular patient at this time?’ Entering the hermeneutic window requires both an investment of time and a willingness to navigate uncertainty. By identifying and legitimising the skills included in the hermeneutic window, we hope to preserve the whole-person care that is central to general practice. This may become even more pertinent if we do move away from traditional models of care.

SUMMARY

Hermeneutic approaches involve the interpretation of meaning, roles, and values, and are particularly important when dealing with complexity or uncertainty. They are an essential complement to the biomedical model, influencing and framing many discussions between practitioners and patients. A four-domain model emphasises the importance of the hermeneutic window in providing whole-person care.