Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Seeing Your Patients Through New Perspectives


We can enhance our patient care if we incorporate the perspectives of life story and behavior.

How much do I as a physician really need to know about my patient? This question reminds me of experiences I had as a medical student.


“Did you get everything you needed about her whole life history?” my senior resident muttered sarcastically as I emerged from interviewing a patient.


I was a third year medical student on a surgery clerkship, and I had just spent a half-hour with a 52-year-old woman in breast clinic because of an abnormal mammogram. She told me a lot about herself, her various medical issues, and her trepidation about today’s visit.  As I reported a brief synopsis to my resident and attending, I felt sheepish for slowing down their clinic.


Many students struggle with the tension between listening to their patients and efficiently sticking to the information expected by their clinical supervisors. In my work and teaching, I’ve felt that I need to give students permission to invest the time in the patients they see.


Understanding Your Patient


One way I do this is by using a framework from Systematic Psychiatric Evaluation, by Margaret Chisolm and Constantine Lyketsos.  In this framework, Drs. Chisolm and Lyketsos stress the need to think about four perspectives when seeking to understand a patient: life story, dimensional, behavioral, and disease.


Medical training often encourages us to narrow our lens to the fourth perspective, disease, merely asking, “what is the disease?” However, these other dimensions can help clinicians and students to pursue the equally difficult and critical question: “Who is this patient, and why is she here?”


Making Space for Life Story


When we give space for the perspective of life story, we provide context to the visit. This is a larger concept than “social history,” which is often crammed in a visit between asking about allergies and whether anyone else in the family has had cancer.


At a minimum, I want to know what the patient does for a living and who they live with. I’ve started using Google Earth and the patient’s listed address to see put the patient in the context of their community.


By applying life story, we can go from a 52-year-old F w/ abnormal mammogram, to knowing that our patient is a civil engineer with two teenagers at home, who is worried about the cost of her co-pay for today’s visit. The perspective of Dimensions prompts us to get curious and use powers of observation when interacting with a patient. We now have a better sense after talking with her if she’ll be able to follow up on recommended care. We can see if she demonstrates trust or mistrust of the advice that we may provide.


Incorporating Patients’ Behavior


Every visit contains elements of the third perspective: behavior. If my patient with the abnormal mammogram smokes cigarettes, how do I address that at today’s visit? If we think that she will need to be taking aromatase inhibitor long-term or need to follow a certain post-surgical plan to avoid lymphedema in her arm, we need to understand what we can do to set her up for success. We can only do that if we put in the time.


We Need to Know Enough


In answer to my question about how much a physician needs to know about a patient, I now give this answer: “enough.” In applying these perspectives, such as a bit of our patient’s life story and behavior, we can more effectively address the question of treating and preventing the fourth perspective: disease. The medical student who walks out of the exam room with this information is already far down the road to clinical excellence.