Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7318.908 (Published 20 October 2001) Cite this as: BMJ 2001;323:908All rapid responses
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The article by Little et al. is a commendable contribution to advance
research on physician-patient consultations and in specific patient-
centered approach (1). In the spirit of dialogue and clarification, I am
concerned about the lack of information about the sex of physicians who
provided consultations in three local practices. Several studies suggest
that female general practitioners are more patient centered than male
general practitioners (2) (3) (4). Also, few studies suggest heightened
patient-centeredness in female-female dyad. Furthermore, some researchers
support these findings by the theory of early patterns of sex
socialization (5). This perspective has gained currency due to increasing
number of women entering family medicine. It would be interesting for
readers to know the influence of physicians' gender, if any, on the
results presented in this paper.
Reference List
(1) Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C et
al. Observational study of effect of patient centredness and positive
approach on outcomes of general practice consultations. BMJ 2001; 323: 908
-11.
(2) Bertakis KD, Helms J, Callahan EJ, Azari R, Robbins JA. The influence
of gender on physician practice style. Med Care 1995; 33: 407-16.
(3) Roter DL, Hall JA. Why physician gender matters in shaping the
physician-patient relationship. Womens Health 1998; 7: 1093-97.
(4) Law SA, Britten N. Factors that influence the patient centredness of
a consultation. Br J Gen Pract 1995; 45: 520-24.
(5) Weisman CS, Teitelbaum MA. Physician gender and the physician-patient
relationship: recent evidence and relevant questions. Soc Sci Med 1985;
20: 1119-27.
Note: No Competing interests
Competing interests: No competing interests
The observational study of the effects of patient centredness on the
outcomes of the consultation in general practice is empirically rich and
informative (1). We would like to comment on the way studies such as this
construct a dyadic model that implicitly presumes that the doctor bears
the major responsibility for patient satisfaction. Social research with
HIV positive people in Australia suggests an alternative approach in which
doctors and patients are seen as agents operating in ‘clinical space’ that
is wider than the consultation (2)(3). While this research has specific
contextual limits, it also suggests a way forward that allows increased
patient expertise to be taken seriously and engages with the changing ways
that medical knowledge circulates in the wider society, including the
media.
The consultation is a key element in the constitution of ‘clinical
space’, but it is not definitive of it. HIV positive people in Australia
rely heavily on specialist HIV GPs for information about their
pharmaceutical treatments, but distinguish between information and wider
perspectives on living with HIV (4). Their negotiation of decisions about
treatment occurs within a framework of self-care. Patients may pre-empt
the consultation at different times and on different issues. For example,
decisions about adherence, ‘drug holidays’ and the use of recreational
drugs appear to be made in the context of mostly, well informed self-care
practices rather than on the basis of a clinical consultation alone. We
are currently exploring the ways in which some of these decisions come
home to roost in the consultation and how self care and self harm are
understood.
If we locate doctor-patient interactions within an expanded notion of
‘clinical space’ then both doctors’ and patients’ perceptions of what is
possible in a brief consultation and doctors’ expectations of themselves
can be shifted into a more productive understanding of how self-care
occurs. Focussing solely on the consultation simply increases the pressure
and the likelihood of dissatisfaction with the doctor and the practice of
medicine.
Patients exercise an increasingly well informed medical gaze as an
ordinary part of everyday life. Expecting or requiring doctor
consultations to be responsible for all aspects of this by measuring
quantifiable units of practice without querying the realism of patients’
expectations simply reinforces the pressures on the consultation. Counsels
of perfectability tend to produce resentment and lower self-esteem, adding
to the desire to leave general practice (5).
We suggest that a wider understanding of clinical space and cultures
of care allows recognition of the productivity of consultations, even as
the inherent challenges are acknowledged.
References
1. Observational study of effect of patient centredness and positive
approach on outcomes of general practice consultations. Little, P.,
Everitt, H., Williamson, I., Warner, G., Moore, M. Gould, C., Ferrier, K.
and Payne S. British Medical Journal 2001; 323: 908-911.
2. Hurley M (2000) ‘Media loops. Information circuitry in the
community’, National AIDS Bulletin, 14 (1), 27-28.
3. Hurley M (2001) Strategic and Conceptual Issues for Community-
based HIV/AIDS Treatments Media, Monograph Series Number 20, Australian
Research Centre in Sex, Health and Society, La Trobe University,
Melbourne.
4. Grierson, J., Bartos, M., de Visser R., and McDonald, K. (2000)
HIV Futures II. The Health and Well-being of People with HIV/AIDS in
Australia: Australian Research Centre in Sex, Health and Society, La Trobe
University, Melbourne.
5. Quarter of GPs want to quit, BMA survey shows. Kmietowicz Z.
British Medical Journal 2001; 323: 887.
Competing interests: No competing interests
Editor,
Little et al state that ' doctors should be aware that airing their
uncertainties... might reduce satisfaction & empowerment". This
conclusion is not really supported by their research because the positive
approach statements dealt with the patient's problem and not the specific
diagnosis. It is perfectly possible to acknowledge uncertainty about a
diagnosis or prognosis whilst giving the patient a clear positive message
about what they can expect to happen, or what the doctor thinks they could
do about the problem and what to do if things do not go according to
expectation. This 'safety-netting' is likely to be perceived as positive
by the patient who may feel even more empowered as the doctor has clearly
planned for the uncertainty that all patients know exists. Pretending to
know the future or exact diagnosis fools no one and is likely to lessen
satisfaction and empowerment. I would suggest that helping our patients to
handle uncertainty effectively is an important part of enablement. This
clarification of what is meant by a positive approach should be addressed
in future research.
Competing interests: No competing interests
Time to do More in Primary Care
The article by Little et al1 suggests that there are five factors
defining general facilitation of patient centredness. The domains are
communication and partnership, personal relationship, health promotion, a
positive approach to diagnosis and prognosis, and interest on effect on
life. The outcomes of patient satisfaction, enablement, and symptom
burden were then measured and shown to be positively effected by patient
centredness. Nonetheless, there are three points which merit discussion
either by their omission or inconsistency with a patient centred approach.
Firstly, the authors concede that a perceived limitation of a patient
centred model is pressure on consultation time.1 Yet the question remains
as to whether or not there is enough time in a standard consultation to
touch on all the domains that have been presented. Proponents of the
Balint-style approach to general practice emphasise that there is, in
fact, a need for adequate time to be spent, in order to form a
patient/physician alliance.2 This view is bolstered by research which
shows that approaches which contribute to the personal continuity of care
and the building of trust in the doctor-patient relationship, in turn
provide the opportunity for consultation time to be used more
productively.3 To this end, the result of the initial investment of time
can be seen to have dividends. In addition, programs that provide
financial incentives for longer consultations such as the Enhanced Primary
Care program in Australia may also encourage more time to be spent with
patients.
Secondly, the authors seem to have missed an opportunity to point out
an important deficiency, which their study detected. Their data show the
domain with the highest overall percentage of neutrality or disagreement
was health promotion.1 Though the aims of this study may not have been to
point out shortfalls in the consultations, perhaps it would have been
pertinent to bring this finding to attention. Especially in light of the
fact that the authors show that one quarter of the participants wanted
health promotion and that it was the domain second most strongly related
to patient enablement.1
Finally, a factor that may be contrary to the idea of a patient
centred model is the positive approach domain as described by the
authors.1 Statements that were used to define the positive approach were:
‘Explained clearly what the problem was,’ ‘Was definite about what the
problem was,’ and ‘Was positive about when the problem would settle.’1 A
clear explanation of a problem is of course, necessary. However, the
authors advise that in respect to the second two statements that, “doctors
should be aware that airing their uncertainties about diagnosis and
prognosis might reduce satisfaction and empowerment.”1 It has been
recognised that a doctor’s choice of words can influence and even pre-empt
a patient’s decisions about treatment.4 This may result in the patient not
being able to participate to their fullest potential in the management of
their own illness. It seems that in spite of advocating the benefits of a
patient centred model, at this point the authors suggest a more
paternalistic approach.
In conclusion, it can be seen that the practice of a patient centred
approach although seemingly more time consuming, can actually help
alleviate time constraints. We are also left with the recognition that
although many patients are interested in health promotion, it may still be
under-utilised by general practitioners. Lastly, the positive approach to
diagnosis and prognosis may require modification to a more open and
forthcoming approach in instances where uncertainty is present, in order
to foster the communication and partnership that is vital to a patient
centred approach.5
References.
1. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C,
Ferrier K, and Payne S. Observational study of effect of patient
centredness and positive approach on outcomes of general practice
consultations. BMJ 2001; 323: 908-911
2. Balint JA. The Doctor, his Patient, and the Illness - Revisited.
Forging a New Model of the Patient/Physician Relationship. Journal of
Balint Society 1996; Vol. 24: 8-13
3. Mechanic D. How should hamsters run? Some observations about
sufficient patient time in primary care. BMJ 2001; 323: 266-268
4. Freeman A C, Sweeney K. Why general practitioners do not implement
evidence: qualitative study. BMJ 2001; 323: 1100
5. Coulter A. Paternalism or partnership? BMJ 1999; 319: 719-720
Competing interests: No competing interests