Patient-centredness: a conceptual framework and review of the empirical literature
Introduction
In the past 30 years, an extensive body of literature has emerged advocating a ‘patient-centred’ approach to medical care. Yet despite popularity of the concept there is little consensus as to its meaning. Edith Balint (1969) describes patient-centred medicine as “understanding the patient as a unique human being” while for Byrne and Long (1976) it represents a style of consulting where the doctor uses the patient’s knowledge and experience to guide the interaction. McWhinney (1989) describes the patient-centred approach as one where “the physician tries to enter the patient’s world, to see the illness through the patient’s eyes”. Giving information to patients and involving them in decision-making have also been highlighted (e.g. Lipkin et al., 1984, Grol et al., 1990, Winefield et al., 1996). For Laine and Davidoff (1996), patient-centred care is “closely congruent with, and responsive to patients’ wants, needs and preferences”. The most comprehensive description is provided by Stewart, Brown, Weston, McWhinney, McWilliam and Freeman (1995a) whose model of the patient-centred clinical method identifies six interconnecting components: (1) exploring both the disease and the illness experience; (2) understanding the whole person; (3) finding common ground regarding management; (4) incorporating prevention and health promotion; (5) enhancing the doctor–patient relationship; (6) ‘being realistic’ about personal limitations and issues such as the availability of time and resources.
Lack of a universally agreed definition of patient-centredness has hampered conceptual and empirical developments. This paper elucidates the key dimensions underlying published descriptions of patient-centredness, and critically reviews the empirical literature in order to explore relationships between the concept and its measurement. In ‘taking stock’ of the existing literature, the paper attempts to provide a clearer framework for future theoretical and empirical developments.
Section snippets
Key dimensions of patient-centredness
Development of the concept of patient-centredness is intimately linked to perceived limitations in the conventional way of doing medicine, often labelled the ‘biomedical model’. Although inaccurate to view the ‘biomedical model’ as a single, monolithic approach (Friedson, 1970), it is generally associated with a number of broad concepts that determine the way in which medicine is practised (e.g. Siegler and Osmond, 1974, Engel, 1977, Cassell, 1982, McWhinney, 1989). These concepts exert
Measuring patient-centredness
Concerns about variation in standards of medical care, coupled with increasing managerialism throughout the public sector have served to encourage quantification of all aspects of quality of care (Roland, 1999). However, gaps can occur between the concepts put forward by theorists and measures of those concepts in empirical work (Meehl, 1978). This is particularly likely in the case of ‘patient-centredness’ where development of valid and reliable measures is constrained by lack of theoretical
The search strategy
Relevant empirical literature was identified from searches of computerised databases (Medline and Psychlit) using both UK and US spellings of the term ‘patient-centred(ness)’. Searches were restricted to English language (non-nursing) journals published within a 30-year period (1969–1998 inclusive). Studies were included in the review if they (1) utilised a quantitative measure of patient-centredness (however defined) and (2) provided sufficient detail concerning the measurement method to
Results
Studies employed two main methodological approaches: (a) self-report measures of doctors’ patient-centredness and (b) measures involving external observation of the consultation process.
Focus of the review
The aim of this review was to explore relationships between the concept of patient-centredness and its measurement. Searches of empirical literature were therefore limited to explicitly defined measures of ‘patient-centredness’. This effectively excluded work addressing related themes but using other labels (e.g. ‘patient communication control’ — Kaplan et al., 1989; ‘relationship-centred care’ — Tresolini, 1996). Only further theoretical and empirical work will determine whether such concepts
Conclusion
This paper identifies a multiplicity of conceptual definitions and empirical measures of patient-centredness. It is proposed that these various approaches can be understood in terms of five distinct dimensions relating to the doctor–patient relationship. The measures reviewed can be seen to relate to these dimensions to varying degrees, though not all dimensions have proved accessible to current measurement technology. Overall, a significant number of measures have proved reliable, and a number
Acknowledgements
The authors would like to thank Martin Roland, Anne Rogers and two anonymous referees for helpful comments on earlier drafts of this paper. This work was conducted as part of the programme of the National Primary Care Research and Development Centre, supported by the Department of Health. The views expressed are those of the authors and are not intended to represent the views of NPCRDC or its funders.
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