Fluent Essays

Need both sections answered but i first need to see how you will answer this first question so we can make a bid to do the whole paper.This is the question am talking about  a) What is the philosophical position used in this article 1 Course Name: Research Methods for Health Sciences Course Code: HSC 4003 Case Analysis 15% Deadline: to be determined – at 4:00 pm Title Mark Weight Written Assessment (Case Analysis) 15% Description of the written assignment: Choose one article from three that are available on BBL to answer the following questions. You will need to ensure a thorough reading so you would be able to answer all questions. Options: Study 1: Providing education on evidence-based practice improved knowledge but did not change behaviour: a before and after study. Study 2: Clinician–patient relationships after two decades of a paradigm of patient- centered care Write the title of the paper you would like to use in answering this assignment: __________________________________________________________________ • Answer the following questions: Section 1: a) What is the philosophical position used in this article? (2 marks) _________________________________________________________________________ _________________________________________________________________________ b) Why do you think the researcher/s adopted this philosophical position? Make sure you discuss the ontological and epistemological stances in your answer. (4 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ c) What is the methodology used in this article? (2 marks) 2 _________________________________________________________________________ _________________________________________________________________________ d) Why do you think the researcher/s adopted this methodology? Make sure you discuss the suitability of this methodology for the research aim/s. (4 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ e) What is the data collection method used in this article? (2 marks) _________________________________________________________________________ _________________________________________________________________________ f) Why do you think the researcher/s adopted this method? Make sure you discuss the suitability of the collection method for the research aim/s. (2 marks) _________________________________________________________________________ _________________________________________________________________________ g) How suitable is the sample of this study to achieve the aim/s? Justify your answer (2 marks) _________________________________________________________________________ _________________________________________________________________________ After answering questions a to g, move to section 2. Section 2: Based on your reading and answers in section 1, propose a new aim for the study so it would have an opposing philosophy and methodology. 3 a) Change the article objective so it would have an opposing philosophy and methodology. For example, if you had a quantitative article, then change the objective to be qualitative. (2 marks) _________________________________________________________________________ _________________________________________________________________________ b) Why do you think the objective you wrote has an opposing philosophical position and methodology to the original one? (5 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ c) What design would you choose to achieve the new proposed objective? And why? (5 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ d) What data collection method would you choose to achieve the new proposed objective? And why? (5 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 4 e) What data collection method would you choose to achieve the new proposed objective? And why? (5 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ f) What should be the characteristics of the new study sample? And why? (5 marks) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=yjhm20 International Journal of Healthcare Management ISSN: 2047-9700 (Print) 2047-9719 (Online) Journal homepage: https://www.tandfonline.com/loi/yjhm20 Clinician–patient relationships after two decades of a paradigm of patient-centered care Riaz Akseer, Maureen Connolly, Jarold Cosby, Gail Frost, Rajwin Raja Kanagarajah & Swee-Hua Erin Lim To cite this article: Riaz Akseer, Maureen Connolly, Jarold Cosby, Gail Frost, Rajwin Raja Kanagarajah & Swee-Hua Erin Lim (2020): Clinician–patient relationships after two decades of a paradigm of patient-centered care, International Journal of Healthcare Management, DOI: 10.1080/20479700.2020.1713535 To link to this article: https://doi.org/10.1080/20479700.2020.1713535 Published online: 23 Jan 2020. Submit your article to this journal View related articles View Crossmark data https://www.tandfonline.com/action/journalInformation?journalCode=yjhm20 https://www.tandfonline.com/loi/yjhm20 https://www.tandfonline.com/action/showCitFormats?doi=10.1080/20479700.2020.1713535 https://doi.org/10.1080/20479700.2020.1713535 https://www.tandfonline.com/action/authorSubmission?journalCode=yjhm20&show=instructions https://www.tandfonline.com/action/authorSubmission?journalCode=yjhm20&show=instructions https://www.tandfonline.com/doi/mlt/10.1080/20479700.2020.1713535 https://www.tandfonline.com/doi/mlt/10.1080/20479700.2020.1713535 http://crossmark.crossref.org/dialog/?doi=10.1080/20479700.2020.1713535&domain=pdf&date_stamp=2020-01-23 http://crossmark.crossref.org/dialog/?doi=10.1080/20479700.2020.1713535&domain=pdf&date_stamp=2020-01-23 REVIEW Clinician–patient relationships after two decades of a paradigm of patient- centered care Riaz Akseera, Maureen Connollyb, Jarold Cosbyb, Gail Frostb, Rajwin Raja Kanagarajahc and Swee-Hua Erin Lim a,c aHealth Sciences Division, Abu Dhabi Women’s College, Higher Colleges of Technology Abu Dhabi, United Arab Emirates; bDepartment of Kinesiology at Faculty of Applied Health Sciences, Brock University, St. Catharines, Canada; cPerdana University-Royal College of Surgeons in Ireland, Perdana University, Selangor, Malaysia ABSTRACT Background: Despite well-known advancements in medicine, there is rather little known about the effects of patient-centered care on clinician-patient encounters. The aim of this narrative study is to explore interactive competencies in diagnostic and therapeutic encounters and intake protocols from the perspectives of physicians, nurses and medical receptionists. Methods: Three data sets including 13 participant interviews, policy documents and a website were used. Further triangulated analyses, including N-Vivo, manifest and latent, Mishler’s narrative elements and Charon’s narrative themes, in recursive, overlapping, comparative and intersected analysis strategies were employed. Results: A common factor affecting physicians’ relationships with their clients was limitation of time. For almost all nurse participants in the study establishing therapeutic relationships meant being compassionate and empathetic. The goals of intake protocols for the medical receptionists were about being empathetic, listening attentively, developing rapport, and being polite to patients. Conclusion: Patient-centeredness has emerged as a discourse practice, with nebulous enactment of its premises in most clinical settings. The healing power of effective communication is well-known but the scientific affirmation of it is scarce. More research has to be undertaken to better define and understand the role of good narration in terms of outcomes with regards to diseases and illnesses. ARTICLE HISTORY Received 6 March 2019 Accepted 29 October 2019 KEYWORDS Patient-centered care; clinician-patient relationships; narrative medicine; narrative inquiry; physician-patient relationships Introduction The concept of ‘patient-centeredness’ was introduced by Balint [1] over five decades ago and it gained its popularity in healthcare in the late 90s [2]. He believed that illness was as much a psychosocial condition as a biological one and encouraged physicians to look beyond the physical manifestations and focus on the social and psychological aspects of a patient as well. Literature review Over the past few decades, a vast quantity of literature has emerged, supporting patient-centered health care delivery. However, despite being the most frequently discussed topic in medical practice [2,3], it may not be entirely responsive to patients’ needs as its develop- ment has been mainly physician-driven with limited patient input [2,4]. Communication is believed to be central to the delivery of patient-centered care [3]. Despite recent advancements in patient care, such as patient-centeredness [5,6] and evidence-based medi- cine and practice [7] in the medical field, there is rather little known about the effects of communication on the particulars of physician-patient encounters [8]. The emphasis in clinical encounters is mostly on treatment and diagnosis [9] and less on communication compe- tencies for medical professionals. In addition, medical training is primarily concerned with developing techni- cal and scientific skills that help clinicians in diagnos- ing diseases [10,11]. Medicalized approaches believe that changes in human bodies are changes in chemical, hormonal, electrical, or neurological and mechanical functions, leading to an approach that is atomistic and primarily concerned with human organisms [10,12,13]. Application of a checklist protocol by clin- icians supersedes patients’ experiences of illness and their agenda [14]. This promotes the dominance of a biomedical explanation of a patient’s experience of ill- ness rather than a patient’s real-life experience [10,15,16]. With growing challenges and emerging chronic ill- nesses, and emphasis on improved quality of services for patients, healthcare professionals are expected to deliver the best possible services for their patients [17]. Therefore, there is a need for focusing on the impor- © 2020 Informa UK Limited, trading as Taylor & Francis Group CONTACT Riaz Akseer [email protected] Health Sciences Division, Abu Dhabi Women’s College, Higher Colleges of Technology 41012, Abu Dhabi, United Arab Emirates INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT https://doi.org/10.1080/20479700.2020.1713535 http://crossmark.crossref.org/dialog/?doi=10.1080/20479700.2020.1713535&domain=pdf&date_stamp=2020-01-22 http://orcid.org/0000-0001-5177-0257 mailto:[email protected] http://www.tandfonline.com tance of interaction between clinician and patient rather than solely on the diagnosis and treatment of disease, because comprehending the illness experience is as important, if not more important, than making sense of the pathophysiology behind it [18,19]. The preference of medical practitioners is to focus mostly on biomedical explanations of the human body [6,8,10]. The assumptions in a biomedical model undermine a patient’s lived experience of illness and, thus, result in challenges and variations in opinion between physician and patient in clinical practice [6,8,10,13,20]. Further, there is increased tension and dissatisfaction from patients with chronic conditions about lack of recognition of their felt experience due to clinicians’ reliance largely on biomedical interven- tions [14,15,21]. Recent studies have shown that patients with lower education levels feel disconnected and excluded when doctors are too technical and don’t treat them as partners in managing their health [22]. Patients do not possess the medical knowledge of clinicians and thus view illnesses not just as a bio- logical malady but as something intertwined with many other facets of their lives [23]. Hence, when clin- icians are indifferent towards patients’ suspicions and presumptions, conflict occurs and this inevitably com- promises care. The patient-centered clinical method allows phys- icians to listen to a patient’s stories and explore a patient’s experience of illness. Physicians enter the patient’s world and grasp the uniqueness of the patient’s experience of illness, and understanding of what illness means for them (i.e. emotions, feelings, beliefs, expectations, goals and barriers) in order to effectively provide diagnosis and treatment, leading to better clinical outcomes [6,24,25]. Patient-centeredness as an approach strongly supports individualistically oriented Western cultural views where patients actively participate in a diagnostic interview, establish a mutually respectful working relationship with their physician and participate in joint decision-making, all of which can be adopted if the interactions are indeed reciprocal and mutual. This approach does not seem to be equally effective in communicating with patients from non-Western cultures. Studies such as the one by Kim, Smith and Yueguo [26] support a decision- making process based on a patient’s preference as a preferred method for physician interaction with patients from non-Western cultures. The role of a physician is not limited to diagnosis, treatment or procedures but is also more ethically and organizationally complex [27]. The increasing size of general practice requires the involvement of nurses, health visitors, and other parties involved in provision of primary care. Therefore, provision of individual patient care requires attending to good interpersonal and communication skills among all members involved in the patient’s care. The goal of improving patient outcomes is not limited to physicians but includes a large group of healthcare workers, such as nurses, tech- nicians, and particularly the medical receptionists. Patients’ care involves more than physicians’ compe- tency in everyday encounters. Patients’ care can be affected by conflict between physicians and medical receptionists [28]. The importance of the medical recep- tionist role in patient care was reported in several studies [29,30], however, despite medical receptionists’ key role in general practice as the first point of contact for patients, there is limited literature detailing the extent to which they are undertaking and influencing direct patient care activities in healthcare settings. The research problem that the study addressed included a lack of empirical literature on the phys- icians’, nurses’, and medical receptionists’ encounters with patients. For example, research on optimal methods of conducting diagnostic interviews is very limited and there is little research on developing rap- port and empathy in clinical encounters [31]. Similarly, the impact of rapport and empathy on the outcome of the diagnostic interview has not been studied exten- sively. Further, the impact of structured and unstruc- tured approaches to interviewing in clinical discourse is not adequately explored [31]. To our knowledge, the perceptions and experiences of medical reception- ists in clinical encounters have not been explored to date. Including medical receptionists’ perceptions and experiences in clinical encounters will help clinicians make more informed decisions about particular inter- actions in their everyday practice. Given the somewhat atomized discipline-specific character of investigations into patient-centeredness, a study that used a combinatory approach and explored intersecting and overlapping narratives addressed a gap in the integrated examination of prac- titioners and patients. Methods A narrative inquiry method was used to explore the experiences of the study participants. Multiple sources of data including interviews (5 physicians, 4 nurses and 4 medical receptionists), policy documents, and a web- site were used. Open, axial and selective coding were used to analyze the transcripts. Open coding was used to label and summarize data into meaningful units. Each participant’s account was examined for similarities and differences. Axial coding helped to con- nect different open codes into clusters and categories and included situations and phenomena in discovering the relationships between different statements. Selec- tive coding was then used to confirm the relationships between different categories [32]. Mishler’s [33] narra- tive strategies were deployed in ‘retelling’ the narrative elements and in the construction of a composite, con- solidated narrative. Policy documents regarding intake 2 R. AKSEER ET AL. protocols and diagnostic interviews, and standards of practice/curricula applicable to practitioners in Ontario, Canada were reviewed. The third source of information that was invaluable to this research was analysis of documents available on the website called Communication and Cultural Competency (CCC) by the Royal College of Physicians and Surgeons of Ontario [27]. For the purpose of reviewing the website on communication and cultural competency as well as human resource documents, the features suggested by Mishler [33] and Charon [34] as well as manifest and latent analysis allowed for a holistic lens on the experi- ences, ideas, and views that were offered. The three features suggested by Mishler [33] for nar- rative studies are as follows; first, the relationship between the order in which events happened and the order in which they are told in narration refers to the order of reference and temporal orders. In this stage, transcripts were read numerous times, considering par- ticipants’ interaction based on past, present, and future structure. Second, textual consistency and structure con- cerns the linguistic and narrative strategies on which the story is constructed. Third, is the importance of narra- tive with the broader place of the story within the greater society or culture. In the last two stages, participants’ experiences based on narrative and discourse elements and larger ‘master’ narratives were identified. Further, participants’ existential conditions in the environment with other people and their intentions, purposes, assumptions, and points of view were explored. Charon [35] uses the process metaphors of atten- tion, representation, and affiliation to allow for an analysis of typical encounters which illuminate and crystalize how various levels and types of narratives might be operating simultaneously and/or at odds with each other. Mishler [33] uses more formal tropes of language structures, order of reference or order of temporality and figure/ground against a larger cultural narrative to allow aspects of taken for granted retelling to be analyzed in more particular and unsparing fashion, most especially when specialized discourses are used and when power differentials are enacted, either consciously or otherwise. The comparative analysis (transcripts, policy document, and CCC web- site) disclosed important consistencies relating to narrative elements, educational standards, training programs, and technical and quantitative competencies expected of clinicians. The narrative frameworks offered by Charon [34,35] and Mishler [10,33] allowed for a more robust examination of how narrative struc- tures function in many levels of medical and clinical education and in clinical practice. The study is closely aligned to the overarching struc- tural approach and utilizes the particular application of narrative to medical contexts as proposed by Charon [34,35] and Mishler [33]. Narrative elements are pre- sent in the stories, documents, and websites. Induc- tively, Mishler [33] allows for an articulation not of an individual physician’s story or narrative account of an experience, but rather a superordinate template of the narrative elements operating within the inter- view accounts of clinical encounters, policy documents of physicians, nurses and medical receptionists, and the CCC website. Deliberately using Charon [34] allows the data sets to be recast in terms of narrative medicine themes that are present across types and levels of clini- cal encounters. Summary chart Summary chart details are given in Tables (1–3). Results The use of attention, representation, and affiliation was different among the three different data sets including transcripts, policy documents, and the CCC website. The physician participants’ narratives were mostly focused on learning about their patients’ situations through careful listening and observation. Attention in clinical encounters was mostly based on physicians’ understanding of patients’ conditions as well as simi- larities between clinical cases. Representation of patients’ conditions appeared to be in the language of medicine. Affiliation was Table 2. Data collection. Interviewing Human resource policy document Website Site Physicians The logistic and technical experience related to diagnostic encounters & staff members Communication & Cultural Competency (CCC) Ontario Nurses Medical receptionists Table 1. Sampling and site. Sampling strategy Number of participants Site Criterion 5 physicians Niagara Region Heterogeneous 4 nurses Niagara Region Purposeful 4 medical receptionists Niagara Region Table 3. Data analysis (Using NVivo10). Interviewing Human Resource Policy Document Website Open, axial and selective coding, within-case and cross-case analysis. Narrative features and structure based on Mishler [33] Charon [35]. Manifest and latent content analysis, as well as Mishler & Charon’s narrative structures. Manifest and latent content analysis. Mishler and Charon’s narrative structures. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3 expressed through the importance of passion and gain- ing patients’ trust in medical encounters. For most of the nurse participants, attention to patients’ conditions through attentive listening, and creating a nonjudgmental environment for patients was identified. Representation of patients’ condition was done based on reports developed by other nurses and healthcare professionals. Affiliation was expressed through advocacy and gaining patients’ trust; however, engagement in patient care meant relying on other healthcare professionals’ feedback and following expected policies, procedures, and protocols (Table 4). Attention in the medical receptionists’ narratives was expressed through careful listening and noticing patients’ verbal and nonverbal communication. Rep- resentation of patients’ conditions was often through creating notes using patients’ language. Documenting reflective notes of patients’ feelings were also included in patients’ reasons for the visit. Affiliation in medical receptionists’ narratives was through showing care for patients’ conditions and gaining their trust. On the CCC website, attention was apparent through emphasis on having good listening skills, the need for a change in routine clinical practice, and adding more open-ended questions. Representation on the CCC website includes the patient’s subjective experience in addition to objective data; however, representation is still based on physicians’ thoughts, feelings, and percep- tions of the patient’s condition. The CCC website rec- ommends including reflective notes in patients’ records. A composite narrative A patient enters the clinical setting and a cheerful, friendly medical receptionist greets him, and carefully attends to his spoken and unspoken expressions. The medical receptionist skillfully obtains the patient’s infor- mation and assists the patient in preparing an appropri- ately focused presentation of self and symptoms for the physician.Themedicalreceptionistalsoprovidessupport and reassurance while keeping reflective notes and being job-focused despite interruptions. The medical recep- tionist’s ability to use everyday language and be attentive, with in the moment focus, allows for the possibility of developing patient trust and rapport. The medical receptionist escorts the patient to phase two of the encounter, the consult with a nurse or nurse practitioner. This consult is a significant, nonjudgmen- tal encounter that transforms the patient’s experience of protocoled and standardized information gathering into a therapeutic event based on intense training and affiliation with other nurses and transfer of this professional commitment into an efficient, and under- appreciated, delivery and presentation of care. Following his preparation with the supporting char- acter (medical receptionist) and his therapeutically focused engagement with the unsung hero (nurse), the patient moves on to the main event, his encounter with the hero of the saga, the physician. The patient delivers an appropriately sanitized and reduced rendi- tion of his perceived medical reason for being there, and the physician performs good listening skills, trans- lating the patient’s complaints into technical medical shorthand for further reference, while noting previous and/or related experiences with some bearing or rel- evance for the patient of the moment. Following a timely and compassionate relaying of important infor- mation to the patient, the physician then returns the patient to the medical receptionist for a translation of the recently relayed information and instructions on the next steps (Figure 1). These narrative arcs (pictured above) have been extracted from the consolidated summary to demon- strate how these overlapping narrative tendencies oper- ate simultaneously within a typical clinic experience, described in the preceding consolidated narrative. This, albeit ‘tongue in cheek’, consolidation of narrative elements gleaned from the findings illustrates the dis- parity between temporal and referential order (patient and medical receptionist in a sequential story line, nurse and physician in an episodic, and referentially oriented story line) as well as the intriguing interdepen- dencies across the characters in the unfolding plot: a patient ought to be sick and miserable enough to call forth both the unsung hero and saga like protagonist but not so sick and miserable as to complicate an efficient therapeutic relationship or a timely and com- passionate diagnostic encounter. This composite also does not do justice to the many clinical encounters where trust, rapport, compassion, attentiveness, and time are authentically enacted by the medical professionals involved. It represents the Table 4. List of themes and subthemes from open, axial and selective coding. Main Themes Subthemes Challenges Time Dealing with upset patients and difficult clients Lack of resources Increased client expectations Patients’ visits (single versus multiple) Dealing with patients from diverse cultures Lack of adequate training Evidence-based versus Narrative Medicine Preferred method during interview Communication Skills The ups and downs of communication with patients Dealing with patients from diverse culture Accomplishments and interactive competencies Accomplishment during interview and intake protocol Hopes and desired changes Desired change Likes and dislikes Career choices Plans for further training Therapeutic Relationship Diagnostic Interview Preferred method during interview 4 R. AKSEER ET AL. narrative elements disclosed by the nine levels of analy- sis in the present study of five physicians, four nurses, and four medical receptionists. This composite also should not overshadow the interesting finding that patients-healthcare worker’s interactions and attempts at communication are actually relative and context- dependent and not single form. The interactions seem to depend on the type of settings and the goals of the encounter (e.g. emergency ward, clinic (family physician), walk-in-clinic, hospital, home visit). Additionally, the ages, specialties, and backgrounds of the physician and nurse informants seemed to influ- ence how they provided information and how they described encounters that were based on diversity. The analyses have also yielded several further insights. One, that communication as Lanigan [36] claims is the goal, not the ground, and the presumptions of shared communication must be checked against the elements suggested by Charon: attention, representation, and affiliation and placed against the backdrop of cultural competency. Clinicians have responsibilities regarding cultural sensitivity and responsiveness that seemed largely unacknowledged in this study. Secondly, that ‘patient-centered care’ is an important concept that has achieved discourse status, but that has also, likely inadvertently, become reduced to that status, discourse as practice, without a concomi- tant enactment of practice of patient-centeredness. In this study, it is the medical receptionists who are enact- ing patient-centeredness in practice, and the nurses and physicians who are working at the level of discourse as practice. Clinicians with increasing time constraints will need to develop strategies for becoming ‘efficiently’ patient- centered. Third, there are numerous factors affecting how clinicians interact with patients and also affecting how possible changes can be made in these interactions. Figure 1. Narrative arcs: medical receptionists, nurses and physicians. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5 Discussion The results of this study articulate that the experiences of thestudyparticipantsinpatientencounterswerelinkedto their training and dominant biomedical cultural beliefs. Thefindingsindicateacloserelationshipbetweenthepar- ticipants’ personal beliefs, areas of practice, and their understanding of interactive competencies in patient encounters. In most of the participants’ cases, particularly physicians and nurses, the patient-centered practice is operating at the discourse level. A lack of balance between the objective and subjective evidence in participants’ encounters with patients may have resulted in an implicit paternalistic practice that was not patient-centered and likely not brought to critical self-awareness. These findings clearly demonstrate that the encounters were mostly based on clinicians’ understanding of patients’ conditions and, in four cases, also about taking a reduc- tionist approach based on a biomedical model as opposed to a patient-centered model supportive of embodiment. A conceptual diagram of participants’ experiences of patient encounters is presented in Figure 2. The purpose of this diagram is to give an overall picture of the present study’s participants’ experiences of patient encounters after two decades of a patient-centered paradigm. The diagram brings together the existing dominant themes from the literature and the findings from analyses of the participants’ accounts. This model can be used by individuals and organizations involved in patient care in designing initiatives focused on patient-centeredness and narrative medicine approaches. The conceptual diagrams assist in understanding the experiences and processes a clinical practitioner goes through in the movement toward patient-centered (embodied) and narrative medicine paradigms and away from a biomedical approach based on a medica- lized body and a paradigm of clinician control. Based on the participants’ accounts and encounters, two participants (Dr. Greg and Dr. Carly) are closer to practicing a patient-centered approach. In an emer- gency setting, Dr. Adrian takes an approach based on generalization but in his office setting, he adopts a mixed-method approach supportive of patient-cente- redness. Dr. Bob mostly and Dr. Jane partly adopt approaches based on biomedical models. Nurse Crystal respects and listens to the patients’ stories and Nurse Wendy also advocates for her clients. Nurses Barb and Paula are more supportive of generalized and stan- dardized approaches with all their clients. If clinicians were more aware of how they are enact- ing particular biomedical, embodied, blended, and nar- rative elements in their everyday clinical counters, perhaps these encounters might align more authenti- cally with the discourse of patient-centeredness. Figure 2. Participants’ experiences of patient encounters. 6 R. AKSEER ET AL. Unlike the physician and nurse participants of the study, the medical receptionists appeared to be more engaged in gaining patients’ trust by working colla- boratively and narratively in connecting with patients and establishing human relationships. Therefore, all the medical receptionists are located at the top of the fourth circle in the conceptual diagram. Training programs designed for physicians, nurses, and medical receptionists who are in search of adopting a morepatient-centeredandnarrativemedicineapproach would allow them to gain patients’ trust and might pro- duce more fruitful results in clinical encounters. Participants’ experiences of narrative medicine are shown in Figure 3. Participants closer to the center are taking a positivistic approach (i.e. Dr. Bob and Dr. Jane, Nurse Barb, and Nurse Paula). All the medical receptionists, however, are located closer to the edge of the diagram indicating the more positive and suppor- tive encounters based on patient-centered approaches. Conclusion While more traditional …