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EDITORIALS: Moira Stewart Towards a global definition of patient centred care BMJ 2001; 322: 444-445 [Full text]

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Some have been patient centred for years

Rod MacQueen   (24 February 2001)

Towards a global definition of patient centred care

Liz Miller   (2 March 2001)

"Patient centred care requires learner centred education"

Shake Seigel   (3 March 2001)

Patient-centredness in Primary Care

David Heaney   (16 March 2001)

Deja Vu?

Phillip Hodson   (27 March 2001)

Some have been patient centred for years 24 February 2001
Rod MacQueen, Staff Specialist, alcohol and other drugs Population Health Unit, Liverpool Hospital and Mid Western Area Health Service Send response to journal: Re: Some have been patient centred for years	Editor, Stewart's summary of and enthusiasm for a patient centred approach is most welcome. I believe that one additional feature of this approach should be added - that it acknowledges the reality of patients accepting or rejecting our advice or treatment. Clinicians working in the field of alcohol and other drug (A&OD) problems, particularly those working in the harm reduction model, have known this for years. The work of W R Miller, for example, has shown that the more confrontational (ie, non empathic, non patient centred) the clinician, the poorer the outcome. Previously, poor outcomes were taken as a sign of the patient's denial or unwillingness to change - now most clinicians (A&OD, at least) accept that these problems usually represent therapist failure. The increasing evidence that it is not just those naughty alcohol and drug users, but indeed most humans, who do not always "comply" with our treatments, must surely make us more keen to enter our patients world and mind set as a clinical priority, at least if we wish to achieve good health outcomes. Stewart's point that some "may not prefer a patient centred approach" constitutes a false objection is most important, since any clinician who rigidly adheres to any model as taught is, by definition, model centred, not patient centred! Working in A&OD, we often meet people who are very sick, and who are occasionally dead by violence, overdose or organ failure over the ensuing days or weeks. With respect to outcomes, it is a discipline as serious as any other. But we do not delude ourselves that we can do much more than attempt to briefly enter another person's world and possibly help make some positive changes if they wish. I strongly suggest that all health training and undergraduate programs incorporate significant exposure to the management of A&OD problems, as a means to understand the person centred approach.
Towards a global definition of patient centred care 2 March 2001
Liz Miller, GP London Send response to journal: Re: Towards a global definition of patient centred care	Dear editor, Moira Stewart's plea for patient centered care (BMJ 2001;332;444-5), overlooks two issues. First, patients need health education so that they can appreciate the reasons behind health interventions. Without medical knowledge, these interventions are indistinguishable from the rituals of a charlatan. For example, unless a person understands the concept of atherosclerosis, expecting them to change their diet to lower their serum cholesterol means as much to them as asking them to carry a lucky rabbits foot. Second, a seven or ten minute consultation does not provide time to explore patients' concerns or even describe how to take a medicine properly. The nation needs educating about health. Either half the population needs to train as health professionals or some other way of distributing knowledge needs to be found. School might be a start, with less about Henry VIII's wives and more about the human body. For adults, the internet may be one answer. Working with people who have a basic understanding of how their body functions is easier than than starting from scratch. NHS Consultations are too short to be centred on anything, let alone the patient. Dissatisfaction is expressed by both sides - from the patient by their complaints and by the doctor with stress, depression and burnout. Lengthening the consultation, as well as allowing more members of the health care team to consult would be a start. Patient centred care needs proper foundations that require profound changes throughout society and the healthcare system. It cannot be tacked on as an additional extra to please politicians and sociologists. Yours sincerely Dr Liz Miller AKC, FRCSE, MRCGP Director www.med4u.co.uk 38 Harwood Rd Fulham SW6 4PH
"Patient centred care requires learner centred education" 3 March 2001
Shake Seigel, GP and Chairman Association Course Organisers Alrewas Surgery, Staffordshire, DE13 7AS Send response to journal: Re: "Patient centred care requires learner centred education"	Dear editor, I wish to respond to the editorial by Moira Stewart in the BMJ, 24th February; 322,444-445. The issue of "patient centred care" is in my opinion a central plank for the practice of medicine and is thus important for all doctors to consider. I believe it therefore to be an essential concept for all involved in medical education as well. When reading Moira Stewart's editorial one could easily substitute the words "patient centred" for "learner centred" and "doctor" for "facilitator" and retain the impact of the article. I would entirely agree that a better understanding of the patient centredness could lead to medicine being practised by doctors who are better able to explore their patients' worlds, thereby enhancing health outcomes and effectiveness of practice. I believe that learner centred education is the way to prepare doctors for this. The parallels are in my opinion compellingly close. The findings of Little et al which stress the appreciation by patients who seek to be understood in a whole person way, and to build a therapeutic relationship with their carer, who is able to address their concerns and find common ground on which to agree future plans, are I believe, akin to desirable elements of an effective facilitator: learner relationship. After all "doctor” also means "teacher". In my experience of 25 years in medical education and medical practice in South Africa and the UK I would echo the sentiment that the term "is becoming widely used, but poorly understood" for medical education as well as in medical practice. Additionally I feel the phrase "learner centred" is becoming widely used, but poorly understood in medical education. I believe that by practising one the other is enhanced and thus a symbiosis exists between the two phrases, which represents a deep value system for medicine. This could be summarised as "do unto others as you wish to be done to". I believe that a learner centred approach in medical education prepares doctors for patient centred care. It can further enhance the impact of an educational experience which "walks its talk", or practises the principles of patient centredness in education too. This can represent the transfer of values and beliefs into the learner's world mirroring the whole person approach of patient centred medicine. The common misunderstanding that all decisions must be shared with the patient (or learner) is again a common error in education. The skill of learner centred facilitation lies in the ability to know when and how to involve the learner. John Heron describes three modes of hierarchy, co- operation or autonomy in which a facilitator can operate. He also describes six dimensions of facilitation, namely planning, meaning, confronting, feelings, structuring and valuing, in an attempt to broaden the view of potential arenas in which human interactions occur. At any one time an interaction could have all these elements present and be in keeping with a humanistic approach. For example a doctor could plan to see a patient in their clinic for the purposes of carrying out an investigation (hierarchical), in discussing the purpose of the investigation there will be a sharing of understanding (co-operation) and possibly a discussion about the pros and cons of proceeding (co-operation or autonomy). The feelings aroused in the patient can be acknowledged and their own beliefs respected by the doctor (autonomy). Ultimately the patient will make sense of their situation for themselves, (autonomy). Heron's approach to facilitation provides a practical way of bridging medical practice and medical education. Dr Shake Seigel, general practitioner and medical educator Chairman, Association of Course Organisers. Alrewas Surgery , Staffs, DE13 7AS bitty_shake@compuserve.com REFS: 1. Stewart M, Towards a global definition of patient centred care. BMJ 2001; 322:444-445 2. Little P, Everitt H, Williamson I, Warner G, Moore m, Gould C, et al. Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ 2001;322:468-472 3. Heron J., (1989) The Facilitators' Handbook; London, Kogan Page.
Patient-centredness in Primary Care 16 March 2001
David Heaney, research fellow University of Edinburgh Department of Community Health Sciences Send response to journal: Re: Patient-centredness in Primary Care	Dear Sir Patient-centredness is widely regarded as one of the defining concepts of good consultation practice in Primary Care, and the articles by Stewart and Little add to our understanding of where current thinking stands (1,2) . Stewart's attempt at an international definition will be welcomed by clinicians, teachers and researchers alike. Stewart's leader asks whether doctors practice patient-centred care and whether patients benefit from it, and answering those questions present significant academic challenges, particularly as not all patients want to be equally involved in the processes of making decisions about their care (3). Most attempts to measure patient-centred practice have relied on assessing video-recordings of consultations, a process of uncertain reliability, far from universal appropriateness, and unrealistic as a way of assessing quality on a large scale. Similarly, although both Stewart and Little quote papers reporting outcome benefits from patient- centred care, most of these have in truth been of disappointingly modest extent and derived from studies using rather contrived designs. We have started our attempt to study the epidemiology of quality of interpersonal care from the 'outcome' rather than 'process' standpoint. We have used 'enablement', capturing as it does improved understanding of illness and feeling of ability to cope following consultations - probably the main aims of patient-centred care. Enablement is significantly associated with longer consultations and greater personal continuity of care (as measured by patients saying they know their doctor well). These process or contextual variables explain 35% of variance between doctors' mean enablement scores (based on 100 unselected adult consultations). Doctors who enable more of their patients and enable them better, are those who offer their patients more time and greater continuity (4). At this stage we believe that mean consultation length, personal continuity and enablement can be combined to provide a useable proxy for measuring patient-centredness at consultations (CQI) (5). We believe that this provides a basis for further researches. These include understanding the epidemiology of patient-centredness (and better interpersonal care); finding ways of measuring the contribution of personal attributes of doctors; producing more evidence on the relationship between interpersonal and biomedical care and improved health outcomes; and planning educational and structural interventions to help doctors and practices improve performance. Stewart's work on patient-centredness has made a notable contribution to better consulting. However, the future depends on finding new ways of quantifying the concepts involved. We believe the approach described above can contribute to this process. 1 Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S. Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ 2001;322:468- 472. 2 Stewart M. Towards a global definition of patient centred care. BMJ 2001;322:444-5. 3 McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ 2000; 321: 867-871. 4 Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross-sectional survey. BMJ 1999;319:736-743. 5 Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK. Developing a 'consultation quality index' (CQI) for use in general practice. Family Practice 2000;17:455-461. John GR Howie Professor David J Heaney Research Fellow Margaret Maxwell Research Fellow Jeremy J Walker Research Fellow University of Edinburgh, Department of Community Health Sciences - General Practice, 20 West Richmond Street, Edinburgh, EH8 9DX George K Freeman Professor of General Practice Imperial College School of Medicine, Department of Primary Health Care and General Practice, Centre for Primary Care and Social Medicine, ICSM Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London W6 8RP Correspondence to: John Howie (EMAIL: John.Howie@ed.ac.uk)
Deja Vu? 27 March 2001
Phillip Hodson, psychotherapist in private practice North London Send response to journal: Re: Deja Vu?	Dear Sir, Your current issue (Volume 322 – February 24th) carries a heart- warming report plus editorial on the necessity of something called ‘the patient-centred approach’ to medicine’. As a practising psychotherapist with over 25 years experience can I say how much I welcome this change? Patients obviously benefit from being regarded as people and not faulty body parts. But I have a slight sense of déjà vu. Reading your two articles is a bit like reading a Person-Centred Counselling textbook which Carl Rogers first penned 50 years ago (1). I really think you should acknowledge the central contribution of counselling and psychotherapy to this new ‘holistic’ or ‘emotionally joined-up’ medical thinking. Therapists are today a major force in the surgeries. Half the primary care practices in England now offer some form of counselling to patients. Between 1992 and 1998, the provision of counselling in Primary Care has grown from 31% to 51% of all GP practices. Problems of a psychosocial nature comprise the second largest presenting symptom-cluster in primary care(2). A 1996 Mori Opinion Poll showed that 86% of patients would prefer a talking treatment to taking pills. The recent King Study of depression in Primary Care concluded that the most effective treatment for the majority of depressions is COUNSELLING - as you reported only last December. The approach was also cost effective. In the light of all this perhaps you could accept that that the new ‘patient-centred approach’ marks the moment when doctors started to adapt ideas from the ‘person-centred approach’ pioneered by psychotherapy? Perhaps we could get a book by Carl Rogers onto the medical curriculum? Yours truly, Phillip Hodson, Fellow of the British Association for Counselling & Psychotherapy [phillip@philliphodson.co.uk] -------------------------------- (1) Rogers, C.R. – ‘Client-Centred Therapy’ – London, Constable 1951 (2) (Mellor-Clark Report: “Counselling in Primary Care in the Context of the NHS Quality Agenda”, BACP Publications, Rugby – ISBN 0-946181-81-0).