Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7167.1202 (Published 31 October 1998) Cite this as: BMJ 1998;317:1202All rapid responses
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Dear Sir,
Professor Kinmonth and her colleagues report [1], with the elegance
of methodology and discussion customary from that quarter, a randomised
controlled trial of patient-centred care of diabetes. One group of health
professionals (intervention group) received training in "patient-centred
care", the other (comparison group) did not. Subsequently, scores on
quality of communication with patients favoured the former, but scores on
patient knowledge about their disease favoured the latter. Crudely put,
it is as if patients assigned to the intervention group were - relatively
- happy but ignorant.
Sadly, the straightforward paradox of saying, in effect, "he
communicates well but tells you nothing" is all but lost in the way the
word "communication" is used in medical education these days. Indeed,
Kinmonth et al gloss this vexed term, in a manner many medical educators
would find unexceptionable, as "the ability to tell the doctor or nurse
personal or troubling things and feeling understood": as if the transfer
of information from professional to patient was something else.
Where does this content-free definition come from?
Perhaps the problem is that the whole communication skills movement
arose from a perception that medicine (if not nursing) had insufficient
empathy, so that the result, the common,lazy identification of empathy
with patient-centredenss, and of both with communication, has its own
historical logic. But we cannot propogate a view of communication that
suggests - in Oprah's ghastly jargon - that just to be there is enough.
We need a more grown-up and integrated view of what is at stake. Put
simply, health professionals have expertise: if they didn't, patients
wouldn't visit them. It is hardly patient-centred to act as if things
were otherwise, nor rational to deny that it is knowledge people seek to
communicate.
Yours sincerely
John Skelton
Senior Lecturer in Communication Skills
[1]Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ on
behalf of the Diabetes Care from Diagnosis Research Team. Randomised
controlled trial of patient centred care of diabetes in general practice:
impact on current wellbeing and future disease risk. BMJ 1998;317:1202-
1208.
Competing interests: No competing interests
EDITOR - Professor Anne Louise Kinmouth and her colleagues are to be
congratulated on completing such an excellent study. It has important
implications for general practice as the authors suggest that
practitioners who concentrate on being patient centred might be at risk
of losing the focus on disease management. One of the findings that
supports this conclusion is that patients in the intervention group
gained weight.
In the discussion, it was suggested that this difference between the
two groups could not be accounted for by small differences in prescribing
rates of hypoglycaemic agents (50% in the intervention group and 46% in
the comparison group). There were, however, larger differences between
the groups in the type of hypoglycaemic agent prescribed. In the
intervention group, 47% were prescribed a sulphonylurea and 11% a
biguanide. In the comparison group the figures were 40% and 15%
respectively. Given that sulphoylureas tend to cause weight gain and
biguanides promote weight loss, might not some of the difference in
weight be accounted for by this difference in prescribing?
Christopher Hand
Competing interests: No competing interests
Trial did not measure patient-centredness
Kinmonth et al should not claim that their study "shows the power of
a consultation to affect patients' health and well being"(1). They robustly
-evaluated some of the outcomes of training health professionals in
patient-centred clinical method, but failed to measure the patient-
centredness of general practitioners' or nurses' consulting behaviour.
Consequently, we have no idea whether training actually resulted in
clinicians providing more patient-centred care. The study provides, at
best, circumstantial evidence about the influence of patient-centred
clinical method on clinical outcomes.
Before we can accurately investigate the effects of patient-centred
care, we need reliable instruments for measuring the relevant aspects of
doctor: patient communication(2). Although a number of communication coding
systems exist(3), few have been validated adequately for their intended
uses(3). One of these research tools was designed to measure clinicians'
patient-centredness(4) and there is some evidence for its reliability(4) and
validity(5). Further development of this research instrument will inform us
of its strengths and weaknesses for measuring clinicians' patient-
centredness in routine primary care consultations. This would enable
those investigating the effects of patient-centred care to use it to
monitor doctor: patient communication appropriately. Although this is
methodologically challenging and likely to be costly, it could ultimately
lead to trials providing more relevant information. If Kinmonth et al had
used this approach, they would, perhaps, have produced hard evidence to
relate their unexpected findings to clinicians' consulting behaviours.
Yours faithfully,
Tim Coleman,
Clinical Lecturer
References
1 Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ.
Randomised controlled trial of patient centred care of diabetes in general
practice: impact on current wellbeing and future disease risk. BMJ
1998;317:1202-1208.
2 Inui TS, Carter WB. Problems and prospects for health services
research on provider-patient communication. Medical Care 1985;23:521-538.
3 Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient
communication: a review of the literature. Social Science & Medicine
1995;40:903-918.
4 Henbest RJ, Stewart MA. Patient-centredness in the consultation.
1: A method for measurement. Family Practice 1989;6:249-253.
5 Henbest RJ, Stewart M. Patient-centredness in the consultation. 2:
Does it really make a difference? Family Practice 1990;7:28-33.
Competing interests: No competing interests