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Patient Centred Care: Lessons From the Medical Profession

Posted on: Saturday, 23 April 2005, 03:00 CDT

Emergency nurse practitioners can learn valuable lessons from the medical profession's experience of patient centred care, says MARY DAWOOD

Keywords

* Patient centred care

* Doctor-patient relationships

* Communication

The reform of emergency care has led to a significant rise in the prevalence of emergency nurse practitioners (ENPs) in emergency departments (National Audit Office 2004).

Despite sometimes being regarded as substitutes for doctors, ENPs have been successful because their founding philosophy is deeply rooted in the enduring values and goals of professional nursing (Ford 1991).

However, as ENPs try to reconcile the medical and nursing aspects of their role, while being under increasing pressure to meet targets there is a danger that they will lose sight of these goals, particularly that of patient centred care.

It is timely then to look at the experience of medical colleagues, some of whom, particularly in general practice, have been practising patient centred medicine successfully for some time.

This article looks at various approaches to patient centred medicine and their successes in terms of patient outcomes. It explores some of the factors that influence doctor-patient relationships with a view to identifying pitfalls that ENPs can try to avoid, and examples of good practice from which they can learn.

PATIENT CENTRED MEDICINE

The concept of patient centred medicine is not new, having been introduced by Balint almost 50 years ago (Balint 1957). Central to this thinking is a recognition that effective treatment of patients calls for a holistic approach that frames disease within the context of the patients' lives and experiences and does not view patients as purely biomedical entities.

The success of modern medicine in the 20th century has been attributed to the medical ability to understand the nature and cause of disease, and the development of effective treatments.

While acknowledging and celebrating this achievement, it must also be recognised that focusing on disease has its limitations; it fails to engage and encompass whole person experiences, thereby omitting important psychological and social components of illness and disease.

A defining feature of contemporary medical practice however has been 'the dislocation of the case from the patient's bedside and indeed from the patient's physical presence' (Atkinson 1995).

Coulter (2002) defines patient centred care as that which responds to patients' needs and wishes, and ensures that they are treated in a dignified and supportive manner.

Communication is a thread that weaves its way in and out of patient centred medicine, so effective doctor-patient communication is essential if medical care is to improve health (Ong 1995).

Recently, the shift toward patient centred medicine has been given impetus by a growing consumerism that has lead patients to expect greater choice in health care. The public is also becoming better informed about health care, and demands greater accountability from clinicians for their practice.

Sir Ian Kennedy's report into the adverse outcomes of paediatric heart surgery at Bristol Royal Infirmary (BRI) (Coulter 2002) is one example of a response to this growing demand.

However, whether the goal of patient centred medicine is possible, or even desirable, in a post-modern, relativistic society, in which the demand for health care is escalating and often exceeding the ability of providers to deliver, is arguable.

DOCTOR-PATIENT RElATIONSHIPS

Paternalism

Traditionally, primary care services have been organised in the UK to give precedence to the relationship between doctors and patients.

Until the late 1980s, most GPs worked alone, looking after the same patients for continuous episodes of care. Patients knew and trusted their doctors and mostly accepted their advice.

Since before the inception of the NHS, doctor-patient relationships have usually been paternalistic, such that patients acquiesce to the professional authority of doctors and accept the decisions made for them.

Doctors are regarded as dominant and able to act as parent figures who decide what is in patients' best interests (Morgan 1997), while patients' desire to get well leads them to accept medical advice (Scambler 2003).

For many people, this approach works well. They may consider that the relationship represents a partnership in that their attendance at a doctor's surgery implies consent to some form of reciprocal relationship between themselves and their doctors.

In recent years, however, this paternalistic approach has come under scrutiny and has been drawn into question by feminists as well as The Patient's Charter (Department of Health 1991 ) and other documents that focus on patients' rights as consumers.

They argue that the rise of health care as a commodity and the consequent notion of consumer choice have altered the balance of power between doctors and patients and so challenged paternalism.

Charles et al (1999b) identify these factors as contributors, or facilitators, of patient participation in decision making about health care. But they also highlight the imprecision, or 'art', of medical care that causes disparities in medical practice and outcomes, as another reason for challenging paternalism.

Improving responsiveness to patients has been a health policy goal in the UK for several decades, but one that has been continuously thwarted by rising costs and lack of resources, and which has been perceived by many clinicians as little more than political rhetoric (Coulter 2002).

Partnership

The BRI inquiry introduced a new urgency to the concept of patient centred medicine, and the inquiry report recommends that patients should be at the centre of the NHS and that health professionals treat them as partners or as 'equals with different expertise' (Coulter 2002).

The report makes 198 recommendations, including engaging patients in the decision making process and ensuring that they are involved actively in their own care. It also suggests that systematic feedback from patients is essential to improve care and public accountability (Coulter 2002).

The idea of doctor-patient partnerships is laudable and certainly challenges the traditional medical profession to consider approaches other than paternalism, but it is an intricate process and not without attendant problems of resource provision and communication.

Alternative models

In recent years, there has been a shift from biomedical to more humanistic medicine (Ong 1995), which suggests that there are three alternative models of doctor-patient relationships that depend on setting, situation and individual patient: 'informed', 'shared' and 'intermediate' (Charles et al 1999a).

The informed model involves a consumerist approach, in which doctors provide patients with relevant research information about risks, benefits and treatments, and wait for the patients, who take an active role, to make informed decisions.

In the shared model, doctors commit to interactive relationships: a two-way process in which patients and doctors reveal treatment preferences to arrive at shared decisions.

In the intermediate model, a hybrid of the previous two is used.

The reality of practice can demand that doctors slip in and out of these models, or combine them, as the need arises or as situations change.

These models are more applicable to primary care and chronic illness management than acute or emergency care. In emergency situations, it is generally necessary for doctors to assume more directive roles (Morgan 1997) and make decisions for patients without consultation.

Because ENPs are more likely however to work with minor injury and illness, they can be flexible about which models they perceive to be suitable to individual patients and their presentations.

DOCTOR-PATIENT INTERACTION

Regardless of the approach taken by doctors, achieving patient centred medicine is not simple and the development of doctor- patient relationships is influenced by other factors, such as communication and power balance.

Communication

At the most fundamental communication level, language itself can give rise to problems. For example, doctors and patients may not share the same language and, even if they do, patients may not understand the terminology that doctors use.

The 'voice' of medicine is characterised by its terminology: objective descriptions of physical symptoms and the classification of these within a reductionist biomedical model (Mishler 1984).

A study by Hadlow and Pitts (1991) investigating the understanding of common medical and psychological terms shows a wide gap between what patients understand and what doctors mean.

For example, the study found that just 14 per cent of patients and 35 per cent of GPs chose the correct definition of 'neurosis', which suggests there is little consensus on clinical definition between professionals or patients, and even between professionals.

This study also reveals that many healthcare terms have different clinical and lay meanings, misunderstanding of which can lead to dissatisfaction and non-compliance.

Power balance

Consultations are dynamic and their nature can silence patients, with the typical power balance allowing doctors to control encounters.

Levenstein et al (1986) introduce the concept of 'agendas' as the key to understanding patients, such that patients' agendas are influenced by how doctors present themselves.

Their study found that doctors failed \to elicit 54 per cent of patients' reasons for consulting and 45 per cent of their worries, which shows that, although patients can have many needs, they are not always voiced, and unvoiced needs can result in poor outcomes (Barry et al 2000).

An experimental study by Graugaard et al (2000) using medical students emphasises the importance of subjects' emotional and psychological characteristics in determining their responses to doctors' communication styles.

It found that students with a high trait ' anxiety responded more positively to a doctor centred than a patient centred communication style, possibly because they prefer a firmer consultation structure and a more paternalistic approach.

This is an interesting finding but it should be regarded cautiously because the study was undertaken outside an authentic clinical setting and the students presented with mainly minor complaints.

Developing a partnership between clinicians and patients can be more important in some circumstances than in others.

Indeed, it is possible that, given the increasing medicalisation of normal life events, doctors will deliberately avoid making relationships to discourage patients from attending with what they perceive to be trivial complaints.

GPs' frustration about the proportion of trivial complaints or self-inflicted illness they encounter is well documented and voiced through the medical press (Cartwright 1967, Gatenby 2002). In order to discourage frequent attenders, therefore, they can adopt abrupt and paternalistic approaches.

More than 25 years ago, Jeffery (1979) found that some A&E doctors categorise several patients as 'normal rubbish', which questions what model of doctor-patient relationship, if any, was being employed to care for these 'unwanted visitors'.

EXAMPLES OF GOOD PRACTICE

There is, however, evidence that patient centred medicine is increasingly prevalent in chronic illness and that this offers better outcomes for patients. Patients with breast cancer, for example, suffer less depression and anxiety if they are treated by doctors who adopt a participative consultation style (Fallowfield et al 1990).

With long-term or recurring illness, patients are often better informed of their diagnoses and treatment options, and often establish more equal partnerships with their doctors as a result.

Laine and Davidoff (1996) suggest that doctors who practise patient centred medicine are familiar and comfortable with this knowledge base and encourage their patients to self-care and self- medicate when they think it appropriate.

Gupta et al (2001) evaluated a patient centred protocol for managing recurrent urinary tract infection (UTI) in young women attending their clinic.

They taught them how to collect clean urine samples to give to the study nurse if symptoms developed. The patients would also then take a course of antibiotics given to them at the start of the project.

Fifty per cent self-diagnosed one or more UTIs during the eight- month study and 94 per cent of these were considered to need antibiotics. Thirty seven per cent had mild symptoms that resolved without treatment, and 90 per cent of the proven episodes were cured without complication.

This study demonstrates that patients can learn to diagnose and manage chronic health problems safely if supported, respected and trusted by their doctors.

The doctors in this study were effectively facilitators of health care, and practised a shared model of patient centred medicine and, by according patients more autonomy, they increased satisfaction and compliance.

This view concurs with that of O'Connor et al (1999), who assert that, contrary to conventional medical opinion, patients are more likely to make rational choices and less likely to take maverick approaches to self-care when they are given appropriate evidenced based information about treatment options.

In a sense, encouraging patients to take greater responsibility for their health contradicts paternalism, which has traditionally fostered dependence by effectively sanctioning docile and subservient patient behaviour, a role that was once, and sometimes still is, expected of patients (Parsons 1951).

LEGAL ASPECTS

Fully informing and involving patients is the essence of patient centred medicine. There is evidence that positive health outcomes are the result of good clinical encounters in which the illness, treatment choices, side effects and prognosis are discussed and shared (Mullen 1997).

Conversely, poor communication and failure to acknowledge and respect patients' views and opinions not only results in poor compliance and disenfranchised patients, but is often also a catalyst for complaint and litigation.

Thus emergency nurse practitioners need to be very conscious of this because of their autonomous roles.

One study of litigants (Vincent et al 1994) finds that their decision to take legal action is determined, not only by the nature of their original injuries, but by the inadequate and insensitive responses of staff.

It found that patients suing doctors wanted greater honesty and believed that doctors, or the organisation in which they worked, should have to account for their actions. Where explanations for injuries were given by hospital staff, less than 15 per cent of patients considered them satisfactory.

Litigation is a controversial issue and, even when patients' rights are not explicitly denied, the constant threat and fear of litigation can work against patient centred medicine by steering doctors, and indeed ENPs, towards defensive medicine, which, by its nature, focuses on practitioners rather than patients.

Sharing information with patients and respecting their views and decisions may be a 'gold standard' for patient centred care and a means of minimising the risk of litigation. But it is not always straightforward and is often complicated by the contingencies of illness.

Reaching diagnoses can be complex, and one of the great unspoken dilemmas of the medical profession is about telling patients the truth when they are seriously ill (Court 1996).

The use of deception in medicine is also contentious; no one denies it happens but few discuss it openly. In almost all cases, deception is wrong but there are times when erroneously it might seem justified.

Sokol (2004) cites the case of an older patient diagnosed with metastatic cancer about to go on a long awaited holiday to the Caribbean.

Should the doctor in this case wait until the patient's return to break the bad news? After all, there are patients who would not want to be given such information before the trip; there are others who would be angry at the doctor's deception (Court 1996).

Coulter (2002) suggests that attempts to protect patients from bad news merely fuels false hopes, which in the long run will benefit neither patients nor clinicians.

This may be true, but one can argue that such edicts are inappropriate to the ethos of patient centred medicine because each case should be judged on its own merits.

CONSENT

Telling the truth is integral to the process of gaining fully informed consent. This process however, which is often characterised by hasty discussions and signatures, falls short of the ideal (Coulter 2002).

For consent to be patient centred, clinicians need to ask patients what they want and expect from treatment before discussing options; it must be founded on patient objectives (Bridson et al 2003).

If these objectives are not established and discussed, consent given for any treatment, even where risks, benefits and alternatives are disclosed, is not truly informed and patient centred.

CLINICAL FRAMEWORKS

The admission of market forces into the NHS has impinged increasingly on clinical work because clinicians now have to be more accountable for their practice and work within clinical frameworks.

The inquiry into events at the BRI highlighted how the self- governing medical profession failed to control the practice of some of its members. One of the responses to this by the medical profession and government has been to advocate evidence based medicine (Coulter 2002).

Undoubtably, evidence based medicine affords the profession some defence against challenges to its traditional autonomy, but it can also contradict aspirations towards patient centred medicine.

It is paradoxical therefore that demands for a more patient centred approach to medicine come just as the configuration of general practice and the delivery of primary care services are undergoing substantial changes that, in some ways, will mitigate against a patient centred approach.

The concept of primary care teams challenges, and to an extent undermines, the feasibility of patient centred medicine because patients are likely to be seen by different practitioners every time they attend.

Consumerism and the choices it allows, and government attempts to exert greater control over the medical profession, have empowered patients, some of whom now depend on doctors less than they used to.

Consequently, the greatest barriers to achieving patient centred medicine are time and other resources. Most GPs already feel overburdened and allocate only about eight minutes to each patient (Campbell 2001).

While the instrumental aspects of care can most likely be achieved during such brief encounters, pressured interactions inhibit patients from revealing concerns and doctors from responding appropriately (Mechanic 1996).

Hospital doctors are similarly constrained, albeit by targets, and it is the quest to modernise and expedite emergency care that has led to the meteoric rise in ENP numbers.

It is important that nurse practitioners exploit this opportunity in autonomous practice to carve out their unique brand of 'patient centredness' in each patient encounter. But in the process, ENPs should be judicious, adopting only best practice in establishing their role. If lack of time impedes the provision of patient centred care, perhaps their focus should b\e redirected to time management.

Spending more time in a shared approach can represent a good long term investment because patients can become empowered to self-care in the future as a result. Indeed, one of the central tenets of ENP practice is health promotion, which in itself is time consuming.

CONCLUSION

The evidence suggests that patient centred care is possible and can lead to better outcomes for patients. But achieving this entails changes for patients and healthcare providers.

Developing communication skills in both parties acknowledges that both have equally important contributions to make to healthcare encounters.

One of the consequences of the traditional, paternalistic doctor- patient relationship is that patients too often abdicate personal responsibility when they become ill, allowing clinicians to make decisions on their behalf whether appropriate or not.

Moreover, paternalistic attitudes can stifle active patient participation, and the government's introduction of the 'expert patient' concept for those with long-term conditions recognises the fact that patients who are actively involved in their own health care have fewer symptoms and less pain, and are happier and more satisfied (Donaldson 2003).

The beauty of advanced emergency nursing practice is its inherent flexibility and creativity to adapt to changing health needs quickly (Bigbee and Nouri 1996).

Medical and nursing education needs to reflect changing times and clinicians must learn to respond positively to knowledgeable and expert patients.

While the patient centred approach may appear to some as giving in to patient demands, it could be a step towards more satisfied patients who become true partners in their own care.

This article has been subjected to double blind peer review

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Mary Dawood RGN, BSc(Hons), PGD is an A&E consultant nurse, St Mary's Hospital, London

Copyright RCN Publishing Company Ltd. Apr 2005

Source: Emergency Nurse

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