Knowing patients and knowledge about patients: evidence of modes of reasoning in the consultation?

Background. The idea that the patient is in some way known to the doctor is an important one in general practice. The thrust towards patient-centred m edicine, the promotion of open and negotiative consultation skills and the development of a biopsychosocial model of primary care medicine all rely on the patient providing a history composed of more than a list of facts. Objective. Our aim was to explore the nature and importance of doctors' kno wledge about patients. Methods. Fifteen GPs audio-recorded 25-30 consultations with consecutive co nsenting patients. They scored each consultation according to how satisfyin g they found it. Semi-structured interviews based on a selection of consult ations were conducted to draw out the doctor's views on the factors that we re important to their satisfaction. The interviews were transcribed verbati m. Qualitative analysis was inductive and iterative. Results. Within doctors' narratives, we found accounts of two ways of 'know ing' the patient. The first was a deductive mode of reasoning derived from facts about the patient. The facts that were known were specific to the con text of the general practice consultation and led to biomedical and biograp hical knowledge. The second was an inductive mode of reasoning derived from a contextual interpretation of the facts about the patient which resulted in knowledge of their behaviour and cognitions. Both modes of reasoning gav e the doctor knowledge of the patient and permitted action by the doctor in the consultation but led to different interpretations of the patient and d ifferent experiences of the consultation. Conclusion. 'Knowing the patient' is important to the way GPs attribute mea ning to their work. Doctors were more likely to identify as 'known' those p atients with whom they adopted an inductive mode of reasoning. In addition, their experience of the consultation was more likely to be positive.