Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms

Becky A. Purkaple; James W. Mold; Sixia Chen

doi:10.1370/afm.1905

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Comments on "Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms"
Daisuke Kato

Published on: 28 November 2016
Goal oriented care: now more than ever!
Pauline R Boeckxstaens

Published on: 16 June 2016

Published on: (28 November 2016)
Page navigation anchor for Comments on "Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms"
Comments on "Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms"
Daisuke Kato, MD
Other Contributors:
The report by Dr. Becky Purkaple et al.(1) about encouraging patient-centered care is one of important ideas that we could like to implement in our medical service. We understand the authors' aim to observe physicians-patients' interactions and appreciate the authors' great effort to maintain objectivity. The report inspired us in the way to conduct such study, to improve physician-patient communication. Of that particu...
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The report by Dr. Becky Purkaple et al.(1) about encouraging patient-centered care is one of important ideas that we could like to implement in our medical service. We understand the authors' aim to observe physicians-patients' interactions and appreciate the authors' great effort to maintain objectivity. The report inspired us in the way to conduct such study, to improve physician-patient communication. Of that particular interest of our group, we would like to point out concerns about the study design.
First, we are concerned about how the authors selected the three-questions for the intervention group versus the one-question for the control group. As there were only two discussions of QOL (quality of life) as mentioned in the result (1), we were wondering whether the questionnaires were adequate enough to stimulate the discussion between patients and physicians.
Second, we don't find appropriate criteria to select patients. Though concealed randomization was done, we are worried about the equality of patients' characteristics of the two groups.(2) The authors should actually provide a baseline comparison of the patients to show similar characteristics.
The above two points might not be a problem whenever authors calculated sufficient sample size that might comprise as much as possible all independent variables in the analysis. For example, did the authors think for communication skills of the physicians that might hinder the expected outcome? Other factors might be duration of the consultation and patient's characteristics in the encounter. Concerning the above-mentioned comments, we are worried about the internal validity of this study.(3) To develop the study further, we would consider using two different groups of physicians and patients whose backgrounds and characteristics are equal.
1) Purkaple BA, Mold JW, Chen S. Encouraging Patient-Centered Care by Including Quality-of-Life Question on Pre-encounter forms. Ann Fam Med 2016; 14: 221-226.
2) Schulz, Kenneth F., Douglas G. Altman, and David Moher. "CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials." BMC medicine 8.1 (2010): 1.
3) Critical appraisal worksheet for Randomized Control Trial. Center for Evidence Based Medicine University of Oxford. Available at: http://www.cebm.net/critical-appraisal/ .
Competing interests: None declared
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Competing Interests: None declared.
Published on: (16 June 2016)
Page navigation anchor for Goal oriented care: now more than ever!
Goal oriented care: now more than ever!
Pauline R Boeckxstaens, MD PhD, Post-doc
Other Contributors:
Even though all healthcare eventually aims to improve the daily lives of patients, Purkaple[1] and colleagues observe that quality of life issues are only mentioned in 2 out of 64 encounters between patients and their family doctors. Their work even suggests that eliciting quality of life information in a pre-visit questionnaire reduces physician empathy. This is a worrying observation which may reflect that our current h...
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Even though all healthcare eventually aims to improve the daily lives of patients, Purkaple[1] and colleagues observe that quality of life issues are only mentioned in 2 out of 64 encounters between patients and their family doctors. Their work even suggests that eliciting quality of life information in a pre-visit questionnaire reduces physician empathy. This is a worrying observation which may reflect that our current health care system has been shaped so much to a disease-oriented approach that it has lost sight of the individual patient. Providers may actually feel uncomfortable to talk about what matters to patients instead of what's the matter with them.
The authors ground their work on the theoretical concept of Goal Oriented Care which was originally described by Mold and Blake[2] and more recently by Reuben and Tinetti[3]. In goal-oriented care, care is focused on the patient's individual health goals and on how well these goals are being met. The theoretical concept seems to be self-evident but - as Purkaple[1] and colleagues demonstrate - its implementation is not. The authors advocate for training of physicians and patients in order to create a more equal interaction in which both are expert; one in medicine and one in the desired outcomes of treatment. They recognize that training physicians may be more challenging given the fact that many components of the current health-care system primarily reinforce disease-oriented thinking and behavior. The reported quotes in the paper illustrate this. When quality of life issues are mentioned, physicians immediately mingle it with glycemic control. One of the main reasons for this observation could be that healthcare systems have increasingly been shaped by disease-oriented research and biomedical outcomes. So not only should providers be trained to re-align with their patients, research should also explicitly re-orient its focus to the individual patient. If we want to address the added value of goal-oriented care, we will need to increase insights on the process of how to help the patient to express their individual health-related goals and on how to integrate these individual goals into the design and the delivery of care. These processes may be hard to capture in a short intervention without any long-term assessment. Moreover, the concept of goal-oriented care is challenging outcome measurement. Although patient centered outcomes - such as the assessment of health related quality of life or functional status - gain increasing importance in research through the use of patient reported outcome measures, users should be aware that the adoption of these outcomes will not ensure patient-centeredness, unless they are considered within the context of the patients' individual values and preferences4. Patients may well set goals outside of the domains of HRQOL and functional status. This asks for the development of innovative tools which enable an individualized instead if a standardized approach to health outcome measurement. This will help reshaping our health systems to care for people instead of diseases.
1. Purkaple BA, Mold JW, Chen S. Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms. Ann Fam Med. 2016;14(3):221-226.
2. Mold JW, Blake GH, Becker LA. Goal-oriented medical care. Family medicine. 1991;23(1):46-51.
3. Reuben DB, Tinetti ME. Goal-oriented patient care--an alternative health outcomes paradigm. The New England journal of medicine. 2012;366(9):777-779.
4. Miller D, Steele Gray C, Kuluski K, Cott C. Patient-Centered Care and Patient-Reported Measures: Let's Look Before We Leap. Patient. 2015;8(4):293-299.
Competing interests: None declared
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Competing Interests: None declared.