University of Toronto Standardized Patient Program (SPP)

A roadmap to patient-centred communication

Canada is a leader in the development of physician-patient communication skills and patient-centred communication is the expected standard in every training program. Perhaps the most complete model is that from the University of Western Ontario: The Patient-centred clinical method (Stewart, M., et. al., 2003). Its six components are designed for primary care physicians but the principles apply to any physician act of communication. It is evidence-based, and most important, it makes clear that more than acquisition of communication skills is required.

Patient-centred care presupposes several changes in the mindset of the clinician. First, the hierarchical notion of the professional being in charge and the patient being passive does not hold here. To be patient-centered, the practitioner must be able to empower the patient, share the power in the relationship, and this means renouncing control which traditionally has been in the hands of the professional. This is the moral imperative of patient-centered practice. (Stewart, et. al, pp 5-6.)

How does one acquire such skills and, ultimately, attitudes? This system of teaching interviewing has been developed by the Standardized Patient Program (SPP) of the University of Toronto. It is used to help students at all levels understand the patient-centred method and to develop their language and communication skills.

It can be likened to a roadmap a physician might use to help navigate the landscape of the physician-patient conversation. Landscapes have features in common such as trees, meadows, perhaps a river, but each is also unique and there are many ways to navigate. We all view landscapes differently depending upon our previous experience. So it is with the physician-patient relationship. Depending upon the physician’s attitude and skills, they may use the roadmap effectively to get through the landscape of the conversation — or they may get lost. It is the physician’s obligation to see and understand the patient’s landscape, while noting important biomedical signposts.

The Observation Guide is also available as a PDF. You can consult the accompanying selected glossary.

Commentary on the Observation Guide

It might seem a bit overwhelming at first to work with the Observation Guide. Here are a few general points to consider:

  • Upon looking at the techniques, styles and attitudes, you might be thinking: “I already use many of these approaches in my current interviewing style.” It is really a question of how these approaches are used that determines whether an interview is more or less patient-centred. For example, you will note in every interview you see that the physician uses closed questions, but in the more physician-centred examples they tend to be more frequent, occur earlier in the interview and usually result in premature closure (making up one’s mind before sufficient information has been obtained). The physician ends up doing most of the talking rather than having a professional dialogue with the patient.
  • Sometimes people think that every item on a guide or checklist should be demonstrated in each interview. Not so. As in real life, every physician-patient encounter is unique and a good interviewer chooses words and actions at the appropriate time and in the appropriate way for the context.
  • When you start working with the Guide, you might want to focus on dissecting one item; for example, appropriate use of open- and closed-ended questions. As you become more familiar with the Guide, you will be able to observe more items simultaneously. Remember, the strength of this Guide is that it exposes many rich layers which reveal themselves over repeated observation. It is not necessary to take in everything at once and in fact, this approach can be a bit overwhelming.
  • It is also important to note that an interview is not necessarily patient-centred just because patient-centred techniques, styles and/or attitudes are arbitrarily used once or twice in an interview, in a disconnected manner and/or in an attempt to demonstrate an understanding. Such an approach often reveals itself as mechanical and “performed” as opposed to being authentically generated. A patient-centred approach means that all three levels are operating consistently and seamlessly, supporting and feeding into each other in an integrated manner throughout the interview. There is no one right way to do an interview. The Observation Guide allows for endless exploration and experimentation as you hone your patient-centred approach.


Next: The core interviews