Review
Paternalism, participation and partnership—The evolution of patient centeredness in the consultation

https://doi.org/10.1016/j.pec.2008.08.017Get rights and content

Abstract

Objective

There is much discussion at present on the need for a more patient-centered health service. However, it is not always clear what exactly this means for patients or healthcare providers. Furthermore many current trends in healthcare and society may in fact move the consultation further from the patient-centered model. In this article I shall critically review the current state of the consultation.

Methods

This article is based on a critical review of the literature. I shall firstly outline what is meant by the terms ‘patient centeredness’ and ‘participation’. I shall then examine what wider factors may facilitate or impede effective communication within the consultation.

Results

Patient centeredness and participation is challenged by several factors including the ‘co-modification’ of healthcare, the information revolution, the tension between choice and continuity, the process of medicalisation, population health strategies and the availability of resources.

Conclusion

I will argue that precisely because of these wider trends in society the consultation is now more important than ever as a point of access, communication, understanding and delivery of healthcare.

Practice implications

The structure and aims of the consultation must be re-visited in the light of the rapid pace of change in service delivery. As such, healthcare professionals may need to advocate for the continuing role of the patient-centered 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.

References (69)

  • J.R. Hampton et al.

    Relative contributions of history-taking, physical examination and laboratory investigations to diagnosis and management of medical out-patients

    Brit Med J

    (1975)
  • C. Barry

    Patients unvoiced agendas in general practice consultations: qualitative study

    Brit Med J

    (2000)
  • D. Pendleton et al.

    The consultation: an approach to learning and teaching

    (1991)
  • S. Gillam et al.

    Modernisation and the future of general practice

    The Kings Fund

    (2001)
  • M. Fitzpatrick

    The tyranny of health: doctors and the regulation of lifestyle

    (2001)
  • A. Coulter

    Paternalism or partnership?

    Brit Med J

    (1999)
  • J. Balint et al.

    Regaining the inititative. Forging a new model of the patient-physician relationship

    J Am Med Assoc

    (1996)
  • M. Stewart

    Towards a global definition of patient centered care

    Brit Med J

    (2001)
  • J.F. Middleton

    The exceptional potential of the consultation revisited

    BJGP

    (1989)
  • C. Charles et al.

    What do we mean by partnership in making decisions about treatments?

    Brit Med J

    (1999)
  • N. Steel

    Thresholds for taking anti-hypertensive drugs in different professional and lay groups: questionnaire study

    Brit Med J

    (2000)
  • G. Jones

    Prescribing and taking medicines

    Brit Med J

    (2003)
  • N. Britten et al.

    Misunderstandings in general practice prescribing decisions: qualitative study

    Brit Med J

    (2000)
  • S. Greenfield et al.

    Patients’ participation in medical care

    J Gen Intern Med

    (1988)
  • M. Marinker

    From compliance to concordance: achieving shared goals in medicine taking

    Brit Med J

    (1997)
  • P.D. Mullen

    Compliance becomes concordance

    Brit Med J

    (1997)
  • P. Little et al.

    Preferences of patients for a patient-centered approach to consultation in primary care; observational study

    Brit Med J

    (2001)
  • H. Winefield et al.

    The usefulness of distinguishing different types of general practice consultation, or are needed skills always the same?

    Fam Pract

    (1995)
  • J. Launer

    A narrative approach to mental health in general practice

    Brit Med J

    (1999)
  • P. Kinnersley et al.

    The patient centeredness of consultations and outcome in primary care

    BJGP

    (2000)
  • R. Fitzpatrick

    Telling patients there is nothing wrong

    Brit Med J

    (1996)
  • L.F. Degner et al.

    Information needs and decisional preferences in women with breast cancer

    J Am Med Assoc

    (1997)
  • R. Savage et al.

    Effect of a general practitioner's consulting style on patients satisfaction: a controlled study

    Brit Med J

    (1990)
  • R. Kravitz et al.

    Engaging patients in medical decision making

    Brit Med J

    (2001)
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