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Rapid response to:

Primary Care

Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations

BMJ 2001; 323 doi: (Published 20 October 2001) Cite this as: BMJ 2001;323:908

Rapid Response:

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

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


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

16 November 2001
Jason Pimental
Community Medicine, University of New South Wales
Stephen Wilson
Macarthur Health Service, P.O. Box 149, Campbelltown 2560