Routine, Ceremony, or Drama: An Exploratory Field Study of the Primary Care Clinical Encounter William L. Miller, MD, MA Haafird, Connecticut

and thc hcad nursc identified thcmcs latcr clarified us-

Conclusions. Identifying a clinical cncountcr as a rou-

kcy informant review. Thc final rcsults wcrc compared with the litcraturc on physician-patient rclationships.

for futurc rcscarch, clinical practice, and teaching.

Aftcr completing family practicc rcsidcncy, a collcaguc

bc appropriate; thcn, aftcr following my intuition, I

O 1992 Appleton & Lange

ISSN 0094-3509

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alized cxpcctations of rcsidcncy to thc rcal~ticsof private practicc, this qucstion Icd to thc design and implcmcntation of an exploratory ficld study. This article is a rcport of what I learned abuut thc different kinds or typcs of clinical encounters recognized by thc two oldcr family physicians. Thc distinguishing features of cach type are charactcrizcd, and thc process by which cach type was idcntdied is dclincatcd. In summary, both a clinical cncountcr typology and its associated decision-making trce or taxonomy arc prcscntcd.

Methods Thc goal of thc rcscarch was to rcach a collaborativc undcrstanding of thc two oldcr, morc cxpcricnccd family physicians' pcrccptual schcmc for thc clinical cncountcr.1 Thc rcscarch objcctivcs wcrc to idcntie what was pcrccivcd as important, to dcscribc what was going on, and to cxplorc what possiblc pattcrns cxistcd with the hopc of discovering an implcmcntablc typology or dccision-making taxonomy or both. It was anticipated that the concepts discovcrcd would have rclcvancc and transfcrability, with contcxtual modifications, to other primary carc sitcs. Thcrc was no intcnt to gcncralizc to a population beyond the immcdiatc study sitc. Givcn thcsc goals and objcctivcs, qualitative or ficld methods rooted in naturalistic (constructivist) inquiry2 as a guiding paradigm wcrc sclcctcd as thc most appropriate research frarncwork. Thc ovcrall rcscarch dcsign was scqucntial in structure and iterative in proccss. Scmistructurcd kcy informant intcrvicws of thc two oldcr family physicians wcrc thc prcdominant initial modc of inquiry.3 Thcsc in-dcpth discussions wcrc dcsigncd to clicit and idcntify thc conccpts and factors used by thc two physicians in organizing and managing thcir paticnt cncountcrs. Thc following thrcc opcn-endcd qucstions, which wcrc dcrivcd directly from thc rcscarch qucstion, wcrc askcd: (1) how do you think about (plan, organizc) your day in the officc? (2) how d o you know what is going to happen in a givcn patient cncountcr? and (3) whcn d o you "think family"? Analysis of the information obtaincd during thcsc first intcrvicws indicatcd that both physicians wcrc scanning thcir paticnt schcdulcs cach morning and noting wherc they anticipated "problcms" or "bottlcnccks" and whcrc they cxpcctcd "snlooth sailing" and "breathing room" for malung telcphonc calls, sceing cmcrgcncy call-in patients, or catching up on paperwork. This information was then shared by thc physicians with the head nursc, who had the responsibility of screening all telephone calls and deciding who saw which call-in patients and whcn. Thc analysis also rcvcalcd that thc two 290

oldcr family physicians distinguished between typcs of visits, typcs of paticnts, and typcs of problcrns. The ncxt cyclc of key informant intcrvicws includcd the hcad nursc and focused on cliciting the attributes that charactcrizcd thc various typcs of visits, paticnts, and problcms. An cthnoscicncc-typc intcnicw stratcgy4.5 was used sincc thc aim was to establish thc informants' taxonomic~.Categoly qucstions (cg, "What clsc distinguishcs thc 'difficult' visit?"), contrast qucstions (cg, "What is thc diffcrcncc bctwccn visits that arc 'schcdulc bustcrs' and those that arc 'always thc sarnc'?"), and special incident questions (cg, "Arc thcrc any cxccptions to your mlcs about whcn to convcnc thc family?") prcdominatcd in thcsc intcrvicws. Hccausc I was a mcmbcr of the practicc (an insider), I had continuous acccss to all of thc physicians and staff (actors) and could obscrvc most of thc activitics and cncountcrs that took place. As a result, during thc samc timc framc as thc kcy informant intcrvicws with my collcagucs, a scrics of bricf, informal, unstructured intcrviews6 wcrc conductcd with thc samc two physicians and thc hcad nursc. Thcsc "convcrsations" wcrc either planncd or spontancous. Thc planncd intcrvicws occurrcd in thc morning and at noon whcn thc two oldcr family physicians rcvicwcd their schcdulcs. Category, contrast, and spccial incident qucstions (described abovc) wcrc the major focus. Thc hcad nursc was askcd similar qucstions throughout thc day as shc was making schcdulc decisions for call-in paticnts. Thc spontancous questioning happcncd whcncvcr onc of thc two physicians and I wcrc waiting togcthcr bctwccn paticnt visits. During thcsc rnomcnts, the qucstions ccntcrcd on the prcvious and upcoming clinical cncountcrs. Bccausc thcy wcrc obtaincd closcr to thc timc of actual dccisionmaking and collcctcd ovcr timc, thcsc data wcrc a uscful crcdibility check on thc information obtaincd from thc kcy informant intcrvicws and on my evolving undcrstanding. Several additional Iccy informant intcrvicws with thc same pcrsons werc conducted as furthcr undcrstanding of thc rcscarch qucstion dcvclopcd. All thc data wcrc rccordcd in thc form of ficld notcs. Thc intemicws wcrc not tapcd. Most of thc ficld notcs wcrc jottcd immediately following thc intcrvicw. Prcliminary analysis occurred concurrent with data c o l l c c t i ~ n . ~ I rcvicwcd my ficld notcs wecldy, and any ncw analytic constructs or morc refined questions wcrc discusscd at thc ncxt intcrvicw scssion. As a rcsult, the developing undcrstanding was both my own and that of the rescarch participants. Wc wcrc not seclcing thc "true" or "real" way to managc clinical cncountcrs; wc wcrc starching for a pragmatic, jointly created way to make our family practicc bctter. The style of analysis I cmployed is often rcfcrred to as he~n:ttic.~ .- The Journal of Family Practice, Vol. 34, No. 3, 1992

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The initial informant intcrvicws occurred during the first 2 wccks of the study period, and analysis of thcsc interview notes took 2 additional wccks. The ncxt scrics of key informant intcrvicws and the concurrent unstructurcd interviews were conducted over 3 months, after which an initial typology of encounters and a related decision-making taxonomy were constructed. During the ncxt phasc of the research, I implcmentcd the typology and taxonomy. Over the ncxt 4 months, as a self-reflective participant-observer (cmphasis on participant),g I bcgan to employ and modify the typology and taxonomy as I managed and organized my daily cncountcrs. All modifications were reviewed with

phases of this exploratory rcscarch were the literature review and the writing of thc manuscript. The literature review was delayed until after the field research was completed in an attempt to minimize theoretical bias during the discovery phasc of the study.

T a b l e 1. Clinical E n c o u n t e r T y p o l o g y Encounter

Type Routine

"Simple" "Easy" "Bread and butter"

Drama

"Complicated" C r ~ s time ~ s in chronic "Difficult" disease '‘Trouble" Bad news "Long-playing record" Family discord Chronic fatigue Low back pain Temper tantrums

Maintenance

"Always the same"

Well-child care

"Friendly"

Prenatal care

ceremony

Minor acute infection Minor trauma Reassurance Driver's examination Insurance physical examina-

DRAMAS

Clinical Encounter Typology

news visit." These visits were part of a connected scrics of

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Rcfcrrcd to as "simple," "easy," "just another cold," or "our bread and butter" (Table I), routine cncountcrs wcre visits for relatively simple, single, straightforward "body problems" for which the physicians bclicved they had readily available solutions. What distinguished thcsc cncountcrs was the rapid use of a presumed mutually acceptable biomedical protocol applied in prescriptive fashion to an everyday primary care problem; thcsc clinical cncountcrs involved the habitual performance of an ordinary, established procedure. Examples of routincs included patients presenting with minor acute infections or minor trauma, uncomplicated requests for a driver's examination or insurance physical, or a need for rcassur-

"you thesc "complicated" encounters when [referring to the two younger, less experienced family a drama out of physicians] arc always trying to every visit." Dramas were those clinical encounters occurring over timc and involving conflict(s) or intense cmotion or both. Dramas were theatrical, as performance, setting, and audience wcrc important characteristics. Dramas always required multiple visits and flexibility and usually involved the family. Gcnograms wcrc helpful; stories were told; and poetic license was in order. Examplcs cncountercd included the new diagnosis of hypcrtcnsion, the prcscntation of chronic fatigue o r chronic low back

therapeutic denouement. Learning t o recognize a drama

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Clinical Encounters

early hclpcd rcducc thc "by the way" statcmcnts at the end of visits and taught mc thc valuc of multiple visits over timc. I no Iongcr nccdcd to "solvc the problem" during onc cncountcr.

CEREMONIES Thc first visit in a drama was oftcn unplanncd (by thc physician) and schcdulcd as a bricf visit. Thcsc opcning sccncs of a drama wcrc callcd "schcdulc bustcrs" o r "hiddcn timc bombs," and thc physician's goal was t o "buy timc" and allow thc drama to "gct started." Thc physicians claimcd to accomplish this by following four steps. They suggcstcd that (1) thc paticnt must Icnow

T a b l e 2. Physicians' Q u e s t i o n s t o D e t e r m i n e T a x o n o m i c

Categories --

Taxonomic Categories

Questions for physicians to ask patients What bnngs you here today? What worries you the most about (that)? Whac d o you hope I can d o for that? Have you ever had t h ~ slurid of problctn before? D o you know anyone else. . . ? Have you read o r heard about. . . ? for physicians to ask thclnselvcs What is my past experience w ~ t hthis patienr? H o w does the parienc appear?

What IS 111). "gut feeling"? Is chc parienr a "srraighc talker"?

Presenting concern Reason for coming Pacicnt rcquesc Shared experience Shared experience Shared cxperiencc Shared expcricncc The ~nitial examination Intuition Corn~nunicacionstylc I

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Both "schcdulc bustcrs" (transition ccrcmonics) and

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cope" (problcm of living), (6) "they madc me" (sanctioning), and (7) "can't take it anymore," "thc pain, the pain" (intolerable pain). Thc rcason for coming was clicitcd by aslung why thc paticnt came with thc particular prcscnting concern at this timc and "What worries [or frightens] you the most about [that]?" Six patient requests wcre also rccognizcd by thc physicians: (1) "fricnd," "hand-holder" (psychosocial assistance), (2) "magical comfort" (therapeutic listening), (3) "tell me what it is," "a labcl" (medical information), (4) "what to do" (gcncral health advicc), (5) "bread and butter," "fix it" (biomedical treatment), and (6) "complctcd form" (bureaucratic fultillmcnt). These cxpcctations wcrc idcntificd b\; asking, "nThat d o you hope I can d o for that?" or " H O can ~ I help you?" The first five of thcsc paticnt requests arc consisten; with thosc proposed by Likc and Zyzanslu." While eliciting the paticnt's story, the physicians were "eyeballing thcm," doing an initial ex-anzination. They were noting thc patient's appcarancc, cxprcssivcncss, and demeanor, and evaluating how closely it fit the story being told. "Gut fccling" or intuition rcfcrrcd to thc physician's sixth scnsc dcvclopcd from past cxpcricnccs with the paticnt ("all thosc past times together") both as a paticnt and as a fellow citizen in the community. (All physicians in this study livcd near the office.) This sixth scnsc also derived from past cxpcricnccs with othcr patients who shared similar characteristics with thc paticnt of immcdiate conccrn. This intuition, often bascd on shared ex-penence, was the primary mcans by which the two older family physicians clairncd to cnact the biopsychosocial modcl. Finally, the physicians madc a determination as to the paticnt's communication style. They simply wantcd to know "how straight the paticnt tallts." In othcr words, is what the paticnt says what the paticnt mcans? This is similar to McWhinncy's distinction between direct and indirect communication.13 On the basis of thc casily obtained information discussed abovc, the type of clinical cncountcr was dctcrmincd. If the prcscnting conccrn was simplc, singlc, and rcccnt (within the last 2 weeks), and if thc actual rcason for coming was anything othcr than siclc-role legitimation or a problem of living, and if thc paticnt's cxpcctation was a "labcl," "what t o do," "complctcd form," or "fix it," if all of thcsc parts of thc story fit with thc physician's initial cxamination and intuition, and if the paticnt was a "straight talkcr," thcn the cncountcr was probably a routinc. If, on the other hand, thcrc was a new diagnosis of chronic disease, or thcrc was 110 rcadily idcntifiablc discasc, or the patient's visit was triggcrcd by a problcm of --

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Thc Jonrnal of Farn~lyPract~cc,Vol 34, No 3, 1992

living or sick-role Icgitimation, or the paticnt's request was for psychosocial assistancc, or if in thc casc of any of thc abovc, thc cxamination or "gut fccling" did not match, or if the paticnt was not communicating directly, thcn thc cncountcr was most likely a drama. New dramas in a limited timc slot wcrc transition ccrcmonics. All othcr encounters, espccially thosc with frequent attendcrs, wcrc generally maintcnancc ccrcmonics. Two cascs of irritablc bowcl syndromc illustrate this dccision-maklng taxonomy. T w o CASE HISTORIES A.G. was a 24-ycar-old, single, third-year graduatc student with known, wcll-controlled irritablc bowcl syndrome who prcscntcd bccausc of hcr conccrn about 1 wcck of persistent runny diarrhca, nausea: and crampy abdominal pain. The symptoms wcrc not rclicvcd by hcr usual trcatmcnts. She was "scared" that this might be an ulcer, was a "straight talkcr," and wantcd to know "what it is." The physician's "gut fccling," bascd on past cxpcricncc with this paticnt, and a bricf cxamination revealing a hcalthy-appearing, anxious young woman with normal vital signs and n o wcight change, wcrc consistent with her prcscnting issues. Her conccrns wcrc simplc, single, and rcccnt. This was a routinc cncountcr, and the biomedical modcl was invoked. Furthcr bricf history rcvcalcd a viral illncss 2 wccl
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Miller

tcrrninated family thcrapy prcmaturcly. Thc drama was tcmporarily ovcr. Six months after terminating family thcrapy, B.H. rcturncd complaining of incrcascd abdominal pain and

often cvokcs a shamanic imagc of thc physician and thus a stylc of intcraction that can be dcscribcd as parental; thc relationship is bound by covcnant.2Vhis stylc should not bc confuscd with paternalism. In rcccnt years, thc

formed, and thc firidings of good health wcrc cmpha-

otcnt parent," and "pcrsccutor-victim" arc avoidcd,24 and

ticiit."".6 Dramas, on the othcr hand, ncccssitatc thc usc of cvcr-changing modcls of thc physician-paticnt rclationship, accordiiig to thc physicians intcrvicwcd in this

A scarch of the litcraturc rcvcalcd that othcr rc-

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wcrc cvidcnt.

tincs, rituals, and dramas. Routincs rcfcr to common

sponds closcly to what thc literature suggcsts arc uscful and appropriate occasions for convcning thc family.l9 Dramas include perplexing diagnostic problems, poor treatmcnt adhcrcncc, failurc to rcspond to trcatmcnt, emotionally charged encounters, and new chronic diagnoses. Thcsc may be timcs for expanding thc contcxt and for involving faniilics in carc. Koutincs may not be thc timc to involvc the family or to d o gcnograms. Onc of the original rcscarch concerns was to dctcr-

offcrs both hopcs and warnings. M'c arc rcmindcd that thc clinical cncountcr is a ritual space whcrc the ordinary world of the physician mccts the extraordinary, intcnsificd cxpcricncc of the paticnt.30 Wc arc warncd about thc risks of cxccssivc routinization31 and the role of rit~ralas a reinforcer of cultural norms and bclicfs." La KarrS3 cloqucntly dcscribcs how ccrcmonics can bc a hypnotic substitutc for reality such that wc see only our rcflcctcd cxpcctations and risk being cxploitativc of our

contractual or mutuality sqlcs for routincs.22 Ccrcmony

carcful with ritual .

01-risk -

the paticnt bci~lgtransformed -

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into our imagc and not t o onc of his or her own crcation. VCThilcstudying the rulcs and ritual proccss in rny prac-

field rcscarchcr is oftcn trappcd. T h c use of pilc-sort tcchniqucs" could also increasc objcctivity. Finally, in-

Discussion

Do other family practice and primary care settings confirm thcsc findings? What is thc frcqucncy of thc thrcc

scientific intcrcicws. Thcsc rcsults wcrc thcn implc-

This rcscarch cvolvcd o u t of dilcrnmas and conflicts

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pants' chcchng39 greatly strcngthcns the liltclihood that

discussed in this articlc. The pcdagogical implications of

)

rcadcr can cvaluatc thc context of the rcportcd findings.40

whclm family practicc physicians. The typology of clini-

standing my clinical practicc is now sharcd with my

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The Journal of Familv Practice, Vol. 34, No. 3, 1992

Clinical E n c o u n t e r s

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seeing a colick!~i n f a n t and a bcleagucrcd p a r e n t , a s k , "Is this a r o u t i n c , a c c r c m o n y , a d r a i n a . . . or s o m c t h i i l g clsd"

Acknowledgments I want to thank my colleagues lCim Yanoshik and Bcnj~nirnC r ~ b t r e e for their ~nsrghtfulcornments and suggestions, and to express special thanks to my research collaborators and former partners in practice.

References

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1. Reason l', cd. Human inqu~ryin actlon: dcvclopmcnrs in new paradigm research. London: Sdge Publicat~ons,1988. 2. ICuzel AJ. Naturalistic rnilurry: an appropriate model for family mcdrcinc. Farn Mcd 1986; 18:369-74. 3. Ellen l i p . Ethnograpli~cresearch. a gulde to general conduct. New York: Acadcniic Press, 1984. 4 Spradlcy JP. The cthnograpllic Intenllew. New York: Holt, Rrnchart & Wlnrtoii, 1979. 5 Gladwin CH Ethnograph~cdecrslon tree modcllng. Ncwbury I'ark, Calif: Sagc Publicarior~s,1989. Bcvcrly Hills, Cal~f:Sagc Pub6 . Douglas J1) Crcarivc rnten~~ewirig. lications, 1985. 7 . Agar hIH. Speaking of ethnography. Beverly Hrlls. Cal~f.Sagc Publications, 1986. 8. Moustakas C. Heuristic research: desrgn, methodolog;\., and appllcatlons. Ncu,bur)' l'ark, Calif: Sage Puhl~cat~ons, 1990. 9. Spradlcy J P . Parricrpanr observatron. New York: Holt. R~nehart, cYr Winston, 1980. s : approach to the integration 10. McWhinney 1R. Beyond d ~ a g n o s ~an ofbelia\~~oral scicncc and clinical medic~nc.New Engl J Mcd 1972; 287:3847. 11. Zola IR. l'atliways t o the doctor: from pcrsoll to patlcnt. Soc Sci Mcd 1973, 7:677-89. 12. Like li, Zyzanski SJ. l'ntienr satisfact~onw ~ t hthe clirlical cncountcr: social psychological determ~nants.Soc Sci Med 1987; 24: 35 1-7. 13. McWlirnney IK. A textbook of fam~lymedicine. New Yol-k: Oxford Unrvcrsity Press, 1989 14. Stuan M R , Licbcrman JA 111. The fifteen minutc Ilour: applied psychotherapy for the prrmary care pliys~cian.New York: Praegcr Scientific, 1986. 15. Weston WW, Brown JR, Stewart MA. Patient-ceritercd Intenleuing, part 1: ~uidcrstandingpatlents' cxpcrrences. Can Fam Pli\:s~cian 1990; 35: 147-51. 16. Brown JB, Weston WW, Stewart MA. Patrelit ccntcred ~ n t c n i c w ing, part 2: iindrng cornmon ground. Can Farn l'liysician 1990; 35:153-7. 17. Stewart MA, Brown JB, Weston W.Patient-ccntct-cd intcnicwIng, part 3: Five provocative questions. Can Farn Physician 1990; 35:159-61. 18. Coulehan JL. Adjustment, the hands and healing. Cult hled l'syclilaty 1985; 9:353-82. 19. Schnndt Dl> W11ei IS a I~rlpfulto coiivc~icthe family? J Fan1 Pract 1983; 16:967-73.

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20. Szasz TS, Hollender M H . h contribution to the philosopliy of medicine. Arch Intern Mrd 1955; 113:585-92. 21. QuillTE. Partnerships in patient care: a c o n t r ~ c t u ~pproacli. ~l Ann Intern Mcd 1983; 98:228-34. 22. Tuckett D, Boulton M , Olson C, Willia~nsA, hlectings bcnvecn experts: an approach to rliaring ideas in medical con5ultarions. London: Tavistock Publications, 1985. 23. Vcatcli RM. Modcls for ctliical nicdic~ncin a rcvolut~onaryagr. Hastings Cent Rep 1972; 2(3):5-7. 24. Twernlow SW, Gabbard G O . Iatrogenic disease or doctor-patlent collusion? Am Fan1 Physrcran 1981; 24: 129-34. 25. Strull U'M, Lo B, Charles G. D o patlcnrs want to panic~patein medical dccls~onmakrng? JAMA 1984; 2 5 2 : 2 9 9 0 4 . 26. LeBaron S? Reyher J, Stack JM. Paternal~sticvs egalitarian physician stylcs: rlic trcatmenr of patlents in crisis. J Fam Pract 1985; 21:56162. 27. h4arlilker M Commu~ilcarionIn general practice. In: l'cndleton D, Hasler J, eds. Doctor-patient c o m m u n ~ c ~ r i oLondon: n. Academic Press, 1983:275-85. 28. Marlnkcr h i . 'Cl~nicalmethod' in reaching general practice. Brentwood. U1<: I
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