By Eve Purdy (@purdy_eve)
I realized during one of my master’s courses that anthropology is at the core of one of the most ubiquitous teaching tools used in clinical skills. The FIFE model is taught to first and second year medical students as a way to explore illness from the patient perspective. Medical students are taught to ask about the patients’ feelings, ideas, fears, and expectations. In standardized exams, these questions often just make it to the standardized patient under the buzzer and in a rapid fire fashion from the flustered examinee. Furthermore, FIFE is often the butt of the recurring joke during medical school variety shows. As with many lessons taught in the early years of medical school, the genuine importance of understanding the patient’s perspective as central to a therapeutic encounter is sometimes lost amongst other important facts to be learned.
So where does FIFE come from? The model itself was put forward by Brown, Weston, and Stewart in a book well worth reading, “Patient-centered medicine: transforming the clinical method” in the 1990s. Understanding the patient’s experience with illness is just one part of their larger framework for teaching and practicing patient centered medicine. The FIFE aspect of the model was informed by a number of perspectives including anthropology, specifically the work of physician-anthropologist Arthur Kleinman. I came across Kleinman’s work independently during a course last semester and immediately appreciated the pedigree.
In an article published in Annals of Internal Medicine in 1978 Kleinman introduced the physician to the idea that there are different explanatory models, or clinical realities, for patients and physicians in a given encounter and for given illnesses and diseases. Each of us has our own orientation towards an illness experience. For patients, this orientation may be affected by ethnicity, age, gender, occupation, family situation or any other number and combination of a near infinite number of variables. Kleinman suggested that in order to successfully heal illness, not just identify and cure disease, physicians must do a better job of understanding patients’ explanatory models. He identified questions that physicians might use to understand the clinical realities of their patients – the types of questions that anthropologists would employ while gaining deeper understanding. Once the physician understands the patient’s model she can compare it to her own and the path forward can be negotiated collaboratively based on a shared understanding. The questions Kleinman suggested overlap in many ways with the FIFE model and the remainder of his framework is in keeping with the patient-centered approach suggested decades later. He was ahead of his time.
Situating the focus on FIFE during the early years of medical school is likely meant to signpost the importance of creating overlap in clinical realities to early medical learners. I worry, however, that an algorithmic checklist – as it is often interpreted by early learners – has the capacity to do the opposite. Does it foster a genuine curiosity in the realities patients bring to the table or does it trivialize them? It depends. It depends on how the model is introduced, how it is employed in curriculum and assessment, how it interacts with the hidden curriculum, and how students interpret their experience with it. The FIFE construct does truly have ability to be beneficial but more so if the model is revisited once students are engrossed in those complicated realities. In the same way that re-visiting cardiac physiology after seeing a patient with an inferior STEMI can enrich one’s understanding of the clinical condition. I have experienced little re-visitation of explicit communication training on non-critical patient communication situations (ie. not end of life discussions, disclosure of error, resuscitations, communication with other specialists etc.) since being in the hospital in clerkship and residency. I find myself learning by trial and error, by picking up on phrases I overhear staff and senior residents using, and occasionally getting it all gloriously wrong. Don’t mistake me, these are valuable learning opportunities that I will continue to capitalize on. However, the opportunity for reflection on, and growth of, my approach has been most profound after rare prompting, even if just subtly by an astute educator. I encourage teachers to reflect on how they negotiate overlap between their own clinical realities and that of their patients. Consider sharing that process and its importance with your learners. Explore with your advanced learners basic, not just critical, patient communication practices. Please come back to the complicated, beautiful, messiness of patients’ clinical realities in the later years of training. Our thirst for this skillset, understanding of its importance for success as physicians, and ability to incorporate suggestions given our experiences, is likely greater than it was in our early years of medical school.
We can also expand Kleinman’s ideas beyond the patient-physician interaction to the physician-physician interaction or to the physician-allied health interaction. Though not part of his model, I know that each physician is also uniquely oriented. For the physician, orientation may be affected by training, specialty, gender, recent cases, fatigue, case load and again a near infinite number of other variables. When physicians initially speak with each other they may not have a shared clinical reality. I venture that this is likely a cause of conflict during consults and may result in dissatisfying interactions. Sharing our clinical reality, genuinely seeking to understand that of our colleagues, and negotiating overlap might be as important as the same process that Kleinman suggested we undertake with our patients.
Finally, master clinical educators seem to adopt Kleinman’s model naturally. The best teachers that I have had identify how I understand a clinical situation, share with me how they view the same situation, then identify the gaps in my practice to get me from A to B. They create overlap in their expertise and mine. By employing the same approach that Kleinman suggests, our realities begin to overlap. The humblest of educators will occasionally learn from me too! Eventually, through many years of training, the overlap becomes near complete. Reading and incorporating the frameworks of anthropologists might be of interest to budding educators.
At the end of the day, in their works, Kleinman, Brown, Weston, and Stewart were not only teaching us about how to be more effective physicians but also about some of the basic principles of applied anthropology!
Stewart, M, JB Brown, WW Weston, IR McWhinney, CL McWilliam, TR Freeman. Patient Centered Medicine: Transforming the Clinical Method. Sage Publications, Thousand Oaks, California, 1995. Rosenberg, EE, M Lussier & C Beaudoin. Lessons for clinicians from physician-patient communication literature. Arch Fam Med, 6:279-283
Kleinman, A., Eisenberg Leon., & Good, B. 1978. Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine; 88: 251-258.