Towards a global definition of patient centred care
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7284.444 (Published 24 February 2001) Cite this as: BMJ 2001;322:444
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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)
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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).
Competing interests: No competing interests