INTRODUCTION
Consultation frameworks usually address only generic skills and largely ignore the extent to which the clinician is able to establish a human connection, to understand what an illness means to their patient, and to help them navigate through it, particularly in the face of uncertainty. In order to support whole-person care, we have developed a model that sees biomedical and humanistic approaches as complementary and where hermeneutics, the finding and creation of meaning by both patient and doctor, plays a key role. We now explore how this model can work in practice.
THE HERMENEUTIC WINDOW
In a previous article,1 we proposed a new model of the GP consultation represented as a two-by-two table with four related domains (Figure 1).
Figure 1. Four Domain Model.
Window 1 consists of clinical skills, such as history taking and physical examination, underpinned by knowledge, including current guidelines. Window 2 directly above this, evidence-based practice, represents the application of these skills to a specific patient in a specific context. Communication skills (Window 3) then go beyond basic history taking to include person-centred consulting.
The hermeneutic window (Window 4) is where assumptions, meanings, and roles are interpreted in a way particular to the patient, doctor, and circumstances, and to the moment. 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 in its widest sense. This is where validation of a patient’s experience (‘doctor as witness’)2 is important and where a GP may uncover a web of meanings,3 trigger a new insight (Heron’s ‘catalytic intervention’),4 or may help a patient to move on from a fixed set of ideas about their symptoms (a ‘stuck narrative’).5 Central to this is a view of individuals as having both agency and creative capacity.6
WORKING IN THE HERMENEUTIC WINDOW
There are different techniques and personal stances that enable a hermeneutic approach (Figure 2). Whichever of these are used, connection between the clinician and the patient is essential, so that the clinician is attuned to the patient’s behaviour and speech, and notices discontinuities or other signals which might suggest that there is something else that needs exploration. It requires the doctor to have the emotional and moral awareness to ask, ‘What might be going on here? How can I inquire into it in a way that not only permits the emergence of something important, but also allows for reticence or withdrawal if that feels unsafe?’ Markers of such a stance include the patient feeling ‘listened to’ and the clinician noticing connection and coherence within the consultation. This level of moral and interpretive engagement may involve an element of personal risk. It may entail, for example, stepping away from guidelines or using oneself in a therapeutic way. Our model describes and thereby seeks to legitimise such approaches. Dispositions that encourage a hermeneutic stance include kindness, curiosity, self-awareness (including awareness of bias and power), compassion, and the willingness to challenge both oneself and the patient, as well as questioning existing practice.
Figure 2. What enables a hermeneutic stance?
CASE STUDY: MRS P
Dr L has a longstanding relationship with Mrs P, whom he supported 5 years ago when she ended an emotionally abusive relationship with her controlling husband. Now she has developed type 2 diabetes at the age of 49. She has a BMI of 38 and hypertension. Dr L asks about her understanding of diabetes and her concerns. She tells him that she has done some reading about diabetes and realises that she should lose weight and exercise. She is worried that it might affect her job as a bus driver and is pleased to be reassured about that. Dr L gives lifestyle advice and prescribes metformin.
There is a lot to cover when a patient is diagnosed with diabetes. The initial consultations with Mrs P are mainly in the domains of clinical and communication skills. Dr L has acknowledged her concern about her job and recommended an evidence-based treatment plan. So far, he has focused more on the disease than on the patient and what it means to her.
A year later, Mrs P’s diabetes remains poorly controlled. She has seen a dietician and a diabetes specialist nurse but has put on weight. Dr L asks how she might explain what is going on. She says she is pretty good during the day when she is at work, but feels lonely in the evenings and often binges on chocolate biscuits. Dr L senses she is low spirited and gently asks, ‘How much is this getting to you?’ Mrs P cries and goes on, ‘I feel so useless. My ex used to call me pathetic and I think he was right.’ It becomes clear that she still has mental scars from the abusive relationship with her ex-husband. She and Dr L talk about issues of control — by her husband and in relation to her diabetes. Dr L points out that she was strong enough to divorce her husband and reminds her that she is a key worker, holding down an important job. Subsequently, this appears to have been a turning point. Mrs P’s diabetes starts to improve, she decides to see a counsellor, and over time she re-establishes contact with her grown-up children.
Although care and respect for patient autonomy are qualities that a GP will bring to most consultations, the extent to which they are used to find and create meaning varies with each patient or encounter. Dr L’s intuition that there is something else underlying Mrs P’s binge eating leads to a tentative enquiry. This is followed by new insights for both doctor and patient into possible links between her previous relationship and her relationship with food. The resulting change in perspective gives Mrs P cause to value and look after herself better. This outcome is a direct result of the GP positioning himself as a witness to a difficult moment in Mrs P’s life and his willingness to take emotional risks and be generous at a human level. Some of these themes are summarised in Figure 2.
REMOTE CONSULTATIONS
The move towards remote consulting as a result of COVID-19 has brought new challenges. Although certain cues are lost and it is harder to establish relationships and maintain connection, we have found it is still possible to maintain a hermeneutic stance during a telephone or video consultation, through sensitive enquiry and use of oneself. However, as we move out of the pandemic, we will need to consider carefully how we decide which patients should be seen in person. The need for a clinical examination should be only one of several considerations. Finding meaning is just as important in a general practice consultation. When this appears to be constrained by a patient’s capacity or willingness to articulate the effect that their symptoms are having, or by our own ability to maintain focused attention, this might be a good reason for a face-to-face encounter.
IN CONCLUSION
Adopting a hermeneutic stance is integral to high-quality care. It is particularly important where there is complexity and uncertainty. Doing so creates meaning both for patients and for clinicians, and is at the heart of general practice.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2021
