ReviewPaternalism, participation and partnership—The evolution of patient centeredness in the consultation
Introduction
The consultation has long been regarded as the focal point for healthcare delivery in general practice. On one level it involves the transaction between two individuals. On another it represents the interface between the medical profession and society [1]. Recently the nature, style and purpose of this interaction have been questioned. In a relatively short period of time we have moved from a dominant paternalistic model of communication towards a pluralistic model which attempts to democratize decision making, share understanding and empower individuals.
This transition is occurring as a result of several trends in society, evolution of ethical principles and pragmatic evidence of how varying communication style may affect clinical and non-clinical outcomes.
Yet in an age of increasing choice, consumerism and abundance of information this re-interpretation of the medical consultation has led some to question its continued relevance to individuals and to society. As one scoping exercise suggests “..the consultation is essential, but insufficient as a basis for considering the future of general practice and primary care.” [2]
There are a number of challenges to the medical consultation today. Some of these may help us to improve individual and societal health while others may hinder this. These challenges include the ‘co-modification’ of healthcare, the profusion of alternative means of accessing information, the phenomena of medicalisation, the pressure to improve population health, the perennial tension between choice and continuity and of course the availability of resources.
In this paper however, I shall argue that because of these pressures, the consultation is now more important than ever as a point of access, communication, understanding and delivery of healthcare. In this article I shall critically review the current state of the consultation.
Firstly I shall discuss what constitutes ‘the medical interview’ and how it may be conceptualized in primary care. In particular I will attempt to define what exactly we mean by ‘patient participation’ and ‘patient centeredness’ and how these terms can imply different things to different parties. I shall outline some of the challenges to patient centeredness—some of which may be welcomed and some regarded with suspicion. In discussing how these challenges may be met, I shall argue that personal interaction between individuals must continue to be the cornerstone of an effective and humane healthcare system.
This paper was conceived as a critical rather than a systematic review. Medline was used as a search platform with the search terms ‘patient-centered care’ and ‘patient participation’. Papers were chosen on the basis of their relevance to the general practice consultation. Additional hand searching of the authors and colleagues resources was also undertaken.
Section snippets
The evolution of the consultation
The consultation is traditionally described as comprising processes such as history taking, examination, investigation and diagnosis. These may be further subdivided into several tasks reflecting the agenda of the doctor and the patient [3], [4], [5]. This is of course a simplification as a consultation may involve all or none of these processes. In the context of the general practice consultation, the ‘interview’ may occur throughout. During examination for instance valuable verbal and
Partnership and participation—what does it mean in practice?
Broadly, communication dynamics in consultations can be perceived as a spectrum of locus of control [7], [15]. At one end is the ‘paternalistic doctor’, at the other the ‘informed patient’. In between is the ‘shared’ style where control is mutual or exchanged thus leading to a ‘negotiated plan’ [16]. Attempts have been made to sub-categorise aspects of shared communication into task-based competencies including exploration of patients’ ideas, developing an integrated understanding of the
Does patient centeredness matter?
Perhaps the most convincing explanation for the shift towards patient participation in the consultation is the growing amount of research evidence that it ‘works’. In one analysis of misunderstandings associated with prescribing decisions, all were associated with a lack of patient participation in decision making [21]. Communication problems are more likely to occur where patients agendas have been incompletely elicited or ignored [6]. There is also evidence that involving patients in decision
Limits to patient centeredness
An apparent dichotomy has emerged in the consultation with the emergence of two seemingly opposing paradigms; ‘evidence-based medicine’ and ‘narrative’ medicine. In addition, several developments within and out-with the profession are challenging the advancement of patient-centered communication. I shall examine these in turn.
Discussion
At the heart of this debate is the question of what our cultural expectations of the doctor-patient relationship are. We know that patients value continuity, interpersonal care and shared decision making [63]. What though of the wider dichotomy of expectation? Between the doctor as ‘rational scientist’ and the doctor as ‘witness to the patients suffering’? As one commentator cautions…
“Much more work needs to be done to analyse and describe the limitations of biomedical science, the importance
Conflict of interest
None.
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