Preferences of patients for patient centred approach to consultation in primary care: observational study
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7284.468 (Published 24 February 2001) Cite this as: BMJ 2001;322:468
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Dear Sir
Little et al's (1) study of patients’ preferences for patient focused care
assumes that responses to questionnaires on this sort of topic can be
taken at face value. The following hypothetical scenario illustrates the
questionable validity of such an assumption. Were I to conduct and submit
to the BMJ a questionnaire study of doctors’ preferences for providing a
patient focused approach, I might ask parallel questions to those devised
by Little et al. For instance, asking the doctors: ‘Do you want to….
 clearly explain what the problem is to patients
 discuss and agree with the patient on treatment
 give advice on how to reduce the risk of future illness
It would be likely that a large majority of doctors would agree with
these statements. Yet any reporting of such results would surely be
accompanied by a careful consideration of the reasons why doctors might
respond in this way, and the relationship between responses and actual
conduct during consultations. Doctors know what constitutes being a good
doctor, and are likely to portray and indeed see themselves as such.
However, it would be highly naïve to assume that the relationship between
their expressed preferences and their actual conduct was anything but
complex and indirect.
Likewise, patients know what constitutes ‘being a good patient’ in
current society, and this will be among the influences on their expressed
preferences. However, as careful, and truly observational studies of
doctor patient consultations (2,3,4) have shown, patients’ conduct within
consultations makes enactment of some of the principles of patient focused
care difficult. For instance, patients often refrain from asking
questions and entering dialogue even when provided with opportunities to
do so (2,3).
Both doctors and patients have good ‘social’ reasons for portraying
themselves in surveys as desiring a patient focused approach. But
different preferences and orientations may come to the fore in face to
face consultations. Developing and informing actual practice therefore
requires more complex investigations than merely surveying what people say
‘should’ happen.
REFERENCES
1 Little et al (2001): Preferences of patients for patient centred
approach to consultation in primary care: observational study. Vol 322, 1-
7, 24th February
2 Heath,C (1992): The delivery and reception of diagnosis in the
general-practice consultation. In: Talk at Work - Interaction in
Institutional Settings. (Eds: Drew,P; Heritage,J) Cambridge University
Press, Cambridge, 235-267.
3 Have,P ten (1991): Talk and institution: A reconsideration of the
"Asymmetry" of doctor-patient interaction. In: Talk and Social Structure.
(Eds: Boden,D; Zimmerman,DH) Polity Press, Cambridge, 138-163.
4 Perakyla,A (1998): Authority and accountability: the delivery of
diagnosis in primary health care. Social Psychology Quarterly 61, 4, 301-
320.
Competing interests: No competing interests
Dear Sir,
Re: Little, P et al – Preferences of patients for patient
centred approach to consultation in primary care:
observational study. BMJ 2001; 322: 468 - 72
It is ironic that Little et al‘s paper should be published
in the same issue of the British Medical Journal in which it
is reported that ‘complaints against UK doctors rise 50%’.
Although the reason for the latter is not given, we can be
confident that a significant proportion of these complaints
is due to doctors not listening to patients.
I hope that hospital specialists will accept that this study
applies to them, too, and not only to primary care. Perhaps
an unintended (second) irony is that the study implies that
all consultations must be patient centred, in order to find
out whether the patient values such an approach, or not.
Yours faithfully,
Dr. Sebastian Kraemer
Consultant Ps
Competing interests: No competing interests
A factor apparently not considered by Little et al was whether
patients were attending because of a concern about an acute problem,
because of a concern about an ongoing problem or for routine preventive
care about which they had little or no anxiety. I suggest that this simple
classification is one which most GPs would recognise.
Patients attending because of an ongoing problem (hypertension,
arthritis, diabetes etc) might, quite reasonably, be expecting a
prescription, whereas those attending for preventive care (immunisation,
breast check, Pap smear etc) might well not be expecting one.
What would be interesting would be an analysis of those attending
because of concern about an acute problem. Do they expect to be prescribed
for, and are they disappointed if this expectation is not met?
Competing interests: No competing interests
Editor,
The study by Little et al adds to the growing body of research into
patient-centred consultations. Previous studies have shown patients’
preference for the patient-centred approach. Little et al set about
finding out which aspects of this approach patients consider most
important, prior to a primary care consultation. They also aimed to
investigate whether there were any trends in preferences between different
groups of patients.
The study design initially appeared appropriate, a questionnaire
grouping the patient centred approach into four domains; partnership,
communication, health promotion and understanding the whole person.
However, the questionnaire may be biased, focusing mainly on communication
and partnership, with few questions addressing health promotion and
understanding the whole person.
Results confirmed patients’ desire for a patient-centred approach,
but failed to show convincingly differences between patients’ choices of
the four domains. However, they did find that there were differences in
preferences between groups of patients. For example, those feeling more
ill or from lower socioeconomic groups, felt more strongly about wanting
good communication, partnership and education. This is an interesting
finding, but the authors have not made it clear how this can be applied in
primary care.
This subject may have been better addressed with a qualitative
approach. The questionnaires may lead the patient instead of allowing the
patient to come up with their own ideas about how they would like their
consultation to be conducted. A further approach would be a randomised
controlled trial, single-blind to the patient. In this, the GP would
conduct a consultation, concentrating on one of the four domains of the
patient-centred approach. Following the consultation, the patient should
be briefly interviewed and asked to comment on how satisfied they were
with the doctor’s approach. Obviously this would be more demanding of
time and money than a simple questionnaire.
Competing interests: No competing interests
Editor
Little et al. describe primary care patients as strongly wanting a
patient centered approach, and state that doctors should be sensitive to
patients with a strong preference for this approach. (1) These findings
are derived from a survey undertaken before the consultation, and raise
intriguing questions about the ensuing consultations and their outcome.
Principal questions are whether the patient centered expectations were
met, and the part the patient and the doctor played in that outcome. Our
professional agenda should include the ability to recognize the patient’s
wishes for centredness, both hidden and overt, and then to deliver a
harmonizing consultation style that enables effective care.
Consultation skills are core to primary care and are widely taught,
including Transactional Analysis with it’s Freudian roots. (2) Less
frequently studied is the effect of the doctor’s personality on the
consultation style outcome, although clear links have been shown for
clinical behavior. (3) The ability to recognize the normal range of
personalities should be part of our professional development. Training can
enable us to recognize the patient’s and doctor’s preferred learning and
decision-making types, and generate the skills to be able to flex to match
all types. The Myers-Briggs Type Inventory, based on Jung’s theories, is
one method for determining personality types, and can be used to feed back
to the doctor his preferred type, and implications for interactions with
contrasting types. (4) Learning styles could also be used to feed back a
clinician’s preferred learning style, and to deliver training in flexing
to less preferred styles to harmonize consultations. (5)
To deliver a patient centered agenda we have to understand both our
own and our patient’s personalities, and have the skill and confidence to
harmonize them.
Geoff Robinson
General Practitioner
The Lake Road Research and Development Practice
Portsmouth.
PO1 4JT
Geoff.Robinson@btinternet.com.
(1) Little, P. et al.
“Preference of patients for patient centered approach to consultation
in primary care: observational study.”
British Medical Journal 2001;322:468-72
(2) www.ita.org.uk
(3) Ornstein, S. et al.
“Association between family residents’ personality and laboratory
test-ordering for hypertensive patients.”
Journal of Medical education 62(7): 603-5; 1987
(4) Houghton, A.
“Using the Myers-Briggs type indicator for career development.”
British Medical Journal Classified 3rd June, 2000, p2-3
(5) Lewis, A. and Bolden, K.
“General Practitioners and their Learning Styles.”
Journal of the Royal college of General Practitioners.”
39: 187-189; 1989
Competing interests: No competing interests
Dear Sir
The paper by Little et all(1) raises interesting questions. As
regards the research itself, which seems to demonstrate the overwhelming
preference of patients for a patient-centred approach, the issue is not so
much whether the vast majority of patients agree that, for example, they
"want the doctor to understand [their] main reason for coming", as whether
a desire for the contrary would represent a belief in some other kind of
approach to the consultation, or be just plain odd. What kind of person,
in other words, could possibly say, and be thought rational: "I don't
want the doctor to understand my main reason for coming?"
I would invite readers to review the questionnaire, putting the
opposite case in this way and asking themselves how many of the questions
are of this type - "I don't want the doctor to be friendly and
approachable", "I don't want the doctor to find out how serious my problem
is", and so on. They might also like to consider how easy it would be to
construct a mirror questionnaire, couching doctor-centred values in a way
that no-one could reject - "I want to trust my doctor's expertise", etc.
The difficulty is clearly that there is an implicit contrast in the
minds of everyone who works in this field between "patient-centredness"
and "doctor-centredness": but the same contrast is not necessarily present
in the minds of patients, who lack the context of the professional debate.
Researchers may believe patients are expressing a preference for one
rather than the other, when they simply express a preference for the
common-sensical rather than the perverse.
"Patient-centredness" requires a more sophisticated approach than
this.
Yours sincerely
John R Skelton
Senior Lecturer
Reference
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.
Competing interests: No competing interests
Patient-centredness in Primary Care
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 of 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 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.
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.
4Howie 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.
Competing interests: No competing interests