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
Rapid Response:
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)
Competing interests: No competing interests