Patient-centred consultations and outcomes in primary care: a review of the literature
Introduction
A ‘patient-centred’ consulting style is increasingly advocated, particularly in primary care where complex undifferentiated problems, a high prevalence of psychosocial disorder and the long-term nature of the doctor–patient relationship all highlight the need for good communication [1], [2], [3], [4], [5]. However, despite general agreement on the importance of the broad construct of ‘patient-centredness’, there is less agreement about the exact definition of the term, optimal methods of measurement, or the magnitude of benefits associated with it in terms of patient outcomes like satisfaction, physical and emotional functioning.
‘Patient-centredness’ has been described in various ways in the literature. Some highlight single issues, such as ‘understanding the patient as a unique human being’ [6], or ‘[entering] the patient’s world, to see the illness through the patient’s eyes’ [2]. In contrast, Stewart et al. [7] describe multiple components of relevance: (i) exploring the disease and the illness experience; (ii) understanding the whole person; (iii) finding common ground regarding management; (iv) incorporating prevention and health promotion; (v) enhancing the doctor–patient relationship; and (vi) ‘being realistic’ about personal limitations and resources. Although there is some common ground, variation in definitions highlight the need for a clear conceptual framework. The present authors have attempted to provide a preliminary framework, describing five distinct dimensions of ‘patient-centred’ care [8]:
- (1)
The biopsychosocial perspective—a perspective on illness that includes consideration of social and psychological (as well as biomedical) factors.
- (2)
The ‘patient-as-person’—understanding the personal meaning of the illness for each individual patient.
- (3)
Sharing power and responsibility—sensitivity to patients’ preferences for information and shared decision-making and responding appropriately to these.
- (4)
The therapeutic alliance—developing common therapeutic goals and enhancing the personal bond between doctor and patient.
- (5)
The ‘doctor-as-person’—awareness of the influence of the personal qualities and subjectivity of the doctor on the practise of medicine.
Investigators have used a variety of methods for measuring patient-centredness including doctor and patient questionnaires and process measures of audio- or videotaped consultations. In respect of the latter, patient-centred consulting has been variously operationalised using checklists (to indicate the presence of certain skills), rating scales (to measure the quality or quantity of particular behaviours) or verbal coding schemes (to calculate frequencies or proportions of specific ‘utterances’) [8]. The exact content of different measures varies, reflecting the lack of clarity surrounding the concept. Thus, empirical relationships between different measures of patient-centredness are not always high [9].
What is the relationship between patient-centred consulting and patient outcomes? At present, it is unclear what the optimum outcome measure should be for such studies. Although usually seen as the ‘gold standard’ indicator of effectiveness, health outcomes may not be sensitive to the more interpersonal (as opposed to clinical) aspects of medical consultations. Process-referent measures, such as patient satisfaction, may be more sensitive indicators of the impact of doctors’ communication style.
In a recent editorial, Stewart claims ‘evidence of tangible benefit’ from patient-centred communication in terms of improved satisfaction, adherence and health outcomes [10]. In support, she draws on an earlier comprehensive review of ‘effective physician-patient communication and health outcomes’ in which 16 out of 21 included studies reported improvement in various patient-level outcomes such as distress, functioning, physiologic measures (e.g. blood pressure) and health service utilisation [11]. However, the reviewed studies covered a wide variety of clinical settings and patient populations and, importantly, none measured aspects of doctor–patient communication explicitly defined as ‘patient-centred’ by the respective investigators, a limitation highlighted by Graugaard and Finset [12]:
Evidence of the effectiveness of the patient-centred model … has mostly been derived from studies that have not specifically been designed to evaluate this model but that, nevertheless, have been interpreted as supporting one or a number of its elements.
If ‘patient-centredness’ is a specific model of care that can be taught and assessed, and not merely a diffuse concept that subsumes the myriad ways in which doctors communicate effectively with patients, benefits need to be demonstrated using studies that explicitly relate patient-centred consulting behaviour to outcome, preferably studies conducted within similar clinical contexts.
The present review sought to examine the following issues:
- (a)
How has patient-centred consulting been defined and measured in studies that explore relationships with patient outcomes?
- (b)
What outcome measures have been used to examine the effects of patient-centred consulting?
- (c)
Are patient-centred consultations associated with improved outcomes in primary care?
Section snippets
The search strategy
Relevant empirical literature was identified from searches of computerised databases (Medline and PsychInfo) using both UK and US spellings of the term ‘patient-centred(ness)’. Searches were restricted to English language (non-nursing) journals published between 1969 and 2000. Studies were included in the review if they (1) utilised a quantitative measure of a construct termed ‘patient-centred(ness)’ (however, defined by the investigators), (2) included at least one measure of consultation
Results
Eight published studies met the inclusion criteria for the review [18], [19], [20], [21], [22], [23], [24], [25]. One further study recently undertaken by the present authors [26] was also included. Table 1, Table 2 present data on process and outcome measures used in the studies. Data on internal and external validity can be found in Table 3, Table 4, respectively.
Discussion and conclusion
Primary care studies examining the relationship between consultation patient-centredness (as defined and operationalised by the respective investigators) and patient outcomes were identified for this review. An alternative approach would have been to define ‘patient-centredness’ a priori, then search for all studies measuring aspects of doctor–patient communication that met that definition. While the latter approach may have had advantages theoretically, it was not taken for two reasons. First,
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