J R Soc Med 2003;96:325-327
doi:10.1258/jrsm.96.7.325
© 2003 Royal Society of Medicine
Practical issues around putting the patient at the centre of care
Nick Dunn MA DM
Primary Medical Care, University of Southampton, Aldermoor Health Centre,
Aldermoor Close, Southampton SO16 5ST, UK
E-mail:
nick.dunn{at}soton.ac.uk
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INTRODUCTION
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Patient-centred care is the concept of 'informing and involving
patients,
responding quickly and effectively to patients' needs
and wishes, and ensuring
that patients are treated in a dignified
and supportive
manner'.
1 It is a
popular talking-point at
present, having been brought into the limelight by
the Bristol
inquiry,
2 but it is
not new. Balint in the 1950s was proposing
that doctors put more emphasis on
listening to what the patient
was trying to say behind the simple presenting
complaint.
3
Pendleton and colleagues in the 1980s were strong proponents
of the notion
that communication skills are the basis of fruitful
consultations
4—another
way of saying that the patient's
perspective is important. Indeed most medical
readers of this
article, if they became 'patients', would wish to be actively
involved in the management of their illness. Patients are increasingly
coming
to be seen as consumers of healthcare, with rights like
those of any other
consumer. As Richard Smith, editor of the
BMJ, has put it:'There is no
"truth" defined by experts. Rather
there are many opinions....
Doctors might hanker after a world
where their view is dominant. But that
world is disappearing
fast'.
5 Persuasive
evidence that patient-centred care helps
patients has been published—for
instance, reduction in
blood pressure was greater in patients who, during
visits to
the doctor, had been allowed to express their health concerns
without
interruptions;
6 and,
in patients with headache, improvement
was most likely in those enabled to
discuss their condition
in
full.
7 There is
also, admittedly, some evidence to the
contrary: patients randomized to
receive diabetes care from
workers trained in patient-centred care did worse
than the
comparison group in some clinical measures (though they were
more
satisfied with their
treatment).
8
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IF NOT PATIENT-CENTRED, WHAT ELSE?
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Doctor-centred care
In doctor-centred care the assumption is that the doctor knows
best, will
act in the patient's best interest, and should thus
dominate the relationship.
Another word for this model is medical
paternalism, and there are
circumstances in which it can be
defended. For example, in National Health
Service hospitals
patients do not, generally, have the chance to choose what
doctor
they see or who does their operation. The agenda is, in the
short term,
driven by doctors' needs, although the policy may
have long-term benefits for
patients as a whole. Another place
for paternalism is where the patient seems
to desire this approach,
and one might expect this to apply to older patients
who have
experienced doctor-controlled consultations through most of
their
lives. This could be wrong: in one study of older patients
with coronary heart
disease there was considerable dissatisfaction
with the lack of proper
communication.
9 The
personality of
the patient is probably more important than age: those with
a
'submissive' trait are most likely to favour paternalism.
Some general
practitioners say they keep patient-centred care
as a tool in their back
pocket, to be used in certain circumstances
with selected patients.
Public-health-centred care
Some doctor–patient interactions are driven by public health
considerations. A prime example is immunization. The MMR controversy is
generating considerable disquiet among some parents, and the patient-centred
approach would normally mean immediate acquiescence to a parent's refusal of
the triple vaccine. However, this would have implications for the public good,
and a doctor might see a duty to outline the facts of the case as presented by
the Department of
Health.10 More
subtle public health arguments enter into other types of healthcare. For
example, treatment of moderately raised blood pressure may usefully reduce the
burden of cardiovascular disease in the population overall, but for the
individual the benefits are much less obvious. Best evidence suggests that the
number needed to treat (NNT) in order to prevent one stroke in patients with
isolated systolic hypertension is about 55, and about the same for coronary
heart disease. NNT for prevention of one death is about
100.11 These may
not seem very favourable odds for the individual who, by accepting treatment,
becomes medicalized (a 'patient' condemned to lifelong medication, with a risk
of side-effects). The doctor is left with a dilemma as to how to manage the
patient in his/her best interest. A further difficulty with hypertension and
cardiovascular disease is relevant to this whole argument—presentation
and understanding of risk. This is not simply a matter of understanding
statistics.12 We
need to factor in the 'horror' associated with the risk, which is intensely
personal and difficult to quantify. Doctors must grapple with this, since
treatment decisions for doctor and patient depend on perception of risk. In
the case of hypertension, risk of cardiovascular disease depends on the
interrelation with numerous other risk factors
(Figure 1). How best to get
such complex information over to the patient, and thus enable a truly informed
choice, is a perplexing question.
View larger version (45K):
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Figure 1. Risk of mortality (expressed per 10 000 person years on the y axis) from
coronary heart disease and stroke in relation to various risk factors in
persons recruited to the Multiple Risk Factor Intervention Trial (MRFIT)
(Ref. 13)
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Clinical quality assurance
Some would argue that a system to guarantee high clinical quality is the
most important part of any doctor–patient
interaction.14 In
some circumstances (e.g. acute shock or serious road traffic accident), most
patients would surely wish the healthcare worker to take over and act in what
is perceived to be their best interest, as rapidly as possible. In most
interactions, however, decisions are less urgent and the patient's and
doctor's perspectives should go hand in hand.
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WHAT ARE THE BARRIERS TO PATIENT-CENTRED CARE?
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There are three important barriers to patient-centred care.
Time
The average consultation in general practice lasts 7–8 minutes. In
hospital, it is often not much longer. According to Gask and
Usherwood,15 the
main tasks in a medical consultation are to build a relationship, collect
data, and agree a management plan. The prominence of each of these elements in
an individual consultation will vary, and it is not necessarily desirable to
cover all aspects in one session. However, pressure on health services is such
that multiple consultations to cover all the ground may not be feasible (the
same doctor may not be available next time, there may be no appointment free
at the desired interval, and so on). The time taken to gather data and agree a
management plan will depend on the baseline knowledge of the patient, his or
her level of intelligence, the doctor's and the patient's ability to
communicate effectively, and the complexity of the patient's problems. Many
general practice consultations are multifaceted, with social as well as
medical issues to be tackled. It is difficult to see how these facts of life
can be reconciled with a patient-centred but time-limited approach.
Motivation
I believe that most doctors would wish to pursue a patient-centred agenda
as far as possible. It accords with underlying motives for becoming a doctor
such as altruism and beneficence. However, pressures of work may make the
paternalistic approach seem more attractive. To lay down the law is usually
easier and quicker: 'this is the ideal pill/operation for you, and you will be
better in two weeks'—end of consultation. Even if, at the beginning of a
surgery or clinic, we recognize the potential fallibility of such an approach
and make a conscious effort to avoid it, 2 hours later the resolution may have
slipped. Tiredness is a debilitating state, both for patient and for
doctor.
Wisdom
'Zeal without knowledge is fire without light'—proverb. 'Knowledge
comes, but wisdom lingers'—Tennyson.
Management of medical problems requires knowledge and wisdom on the part of
both patient and doctor. The doctor is expected to have medical expertise, but
the patient is the person with direct experience of the disease and how it
relates to his or her social circumstances and values. Patient-centred care
demands a marriage of these two sides of knowledge, and the acquisition of
wisdom as a result. Some patients have considerable medical knowledge as a
result of their personal experiences and reading, but they are not necessarily
wise about management. Equally, there are doctors who have very little
knowledge about diseases but try to appear wise about them, and doctors who
have ample theoretical knowledge but too little experience to have gained
wisdom. Such mismatches demand intellectual honesty from both parties, and
often agreement to seek help elsewhere. Most patients, however, are
ill-informed about their illness, and easy-to-understand and up-to-date
information will help them towards more fruitful discussion with their
doctors. The internet may be one answer, though it is full of conflicting
information and not all patients are computer literate. Such information can
also be supplied, at the cost of some effort, from doctors' surgeries and
hospitals.
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THE WAY FORWARD?
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Though we should be striving towards patient-centred care, we
must accept
that patient–doctor interactions are driven
by forces of different
kinds. Sometimes the doctor will take
control with the patient's implicit
consent; sometimes public
health considerations weigh heavily. Whatever the
circumstances
the priority is high clinical quality, backed by regulatory
systems. Much of patient-centred care is to do with communication
with
patients—a skill that can be taught, and now prominent
in
medical-student education. Those of us who finished formal
training some years
ago need to be self-critical and hone our
skills. To become more effective in
communicating the concept
of risk is a particular challenge. For doctors also,
patient-centred
care demands humility, for if the patient is at the centre it
follows that we must be at the periphery. Another big obstacle
to
implementation of patient-centred care is the present working
of the National
Health Service. There is too little time to
treat patients as the most
important part of the system. The
emphasis is on throughput, not input, and
this has the effect
of putting quality of interaction second to quantity. More
time
per patient requires more healthcare workers on the ground,
and the
solution to that is political, not medical.
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REFERENCES
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- Coulter A. After Bristol: putting patients at the centre.
BMJ 2002; 324: 648
-51[Free Full Text]
- Bristol Royal Infirmary Inquiry. Learning from Bristol:
the Report of the Public Inquiry into Children's Heart Surgery at the Bristol
Royal Infirmary 1984–1995. London: Stationery Office, 2001
[www.bristol-inquiry.org.uk]
- Balint M. The Doctor, his Patient and the
Illness. London: Tavistock Publications, 1957
- Pendleton D, Schofield T, Tate P, Havelock P. The
Consultation: an Approach to Teaching and Learning. Oxford:
Oxford University Press, 1984
- Smith R. The discomfort of patient power [Editorial].
BMJ 2002; 324: 497
-8[Free Full Text]
- Orth JE, Stiles WB, Sherwitz L, et al. Patient exposition
and provider explanation in routine interviews and hypertensive patients'
blood pressure control. Health Psychol 1987; 6: 29
-42[Medline]
- Headache Study Group of University of Western Ontario. Predictors
of outcome in headache patients presenting to family physicians—a one
year prospective study. Headache J 1986; 26: 285
-94
- Kinmonth AL, Woodcock A, Griffin S, et al. Randomised
controlled trial of patient centred care of diabetes in general practice:
impact on current wellbeing and future disease risk. The Diabetes Care from
Diagnosis Research Team. BMJ 1998; 317: 1202
-8[Abstract/Free Full Text]
- Kennelly C, Bowling A. Suffering in deference: a focus group study
of older cardiac patients' preferences for treatment and perceptions of risk.
Qual Health Care 2001; 10(suppl 1): 123
-8[Free Full Text]
- Kmietowicz Z. Government launches intensive media campaign on MMR.
BMJ 2002; 324: 383[Free Full Text]
- Staessen JA, Gasowski J, Wang JG, et al. Risks of
untreated and treated isolated systolic hypertension in the elderly:
meta-analysis of outcome trials. Lancet 2000; 355: 865
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- Ashworth J. Science, Policy and Risk.
London: Royal Society, 1997
- Stamler J, Wentworth D, Neaton JD for the MRFIT research group.
Relationship between serum cholesterol and risk of premature death from
coronary heart disease: continuous and graded. Findings in 356 222 primary
cases of the Multiple Risk Factor Intervention Trial (MRFIT).
JAMA 1986; 256: 2823
-8[Abstract/Free Full Text]
- Pickering WG. Clinical quality should be put at the centre of care
[Letter]. BMJ 2002; 324: 1398[Free Full Text]
- Gask L, Usherwood T. ABC of psychological medicine: the
consultation. BMJ 2002; 324: 1567
-9[Free Full Text]
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INTRODUCTION
IF NOT PATIENT-CENTRED, WHAT...
