Patient-Centred Care

“In patient-centered care, an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements. Patients are partners with their health care providers, and providers treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial perspective.” [NEJM-Catalyst Ref]

It further states that “The primary goal and benefit of patient-centered care is to improve individual health outcomes, not just population health outcomes, although population outcomes may also improve. Not only do patients benefit, but providers and health care systems benefit as well.”

The Eight Picker Principles of Patient-Centered Care are:

  • Respect for patients’ values, preferences and expressed needs
  • Coordination and integration of care
  • Information, communication and education
  • Physical comfort
  • Emotional support and alleviation of fear and anxiety
  • Involvement of family and friends
  • Continuity and transition
  • Access to care

Patient-centered care in the doctor’s office. [NEJM- Catalyst]

Under patient-centered care, care focuses more on the patient’s problem than on his or her diagnosis. Patients have trusted, personal relationships with their doctors in patient-focused care models. Empathy, two-way communication, and eye-to-eye contact are crucial, as is the ability of the doctor to see beyond a patient’s immediate symptoms or pain. This broader look at the needs of the whole patient requires providers to offer services or referral to services such as peer support programs, social workers, financial counselors, mental and emotional health providers, transportation and daily living assistance, and in some communities, language and literacy education. While human interaction takes a primary role in patient-centered care, physician practices may also employ a variety of technology-based tools to help patients take ownership of their health care outside of the doctor’s office. Tools range from 24/7 online portals that let patients schedule appointments, get information about their condition and care instructions, review lab results and doctor’s notes, and pay bills at their convenience, to wearable technology and apps that let patients track their “important numbers” such as weight, blood pressure, glucose levels, and cholesterol.

Why is it important?

PCC is widely advocated and is the mantra in about all health care forums from doctor-patient consultations, conferences to grant applications.

‘The patient centred approach is widely advocated, but implementation in practice is limited and related to characteristics of both doctors and patients.1–3 Some aspects of patient centredness may have important benefits for patients: improved communication can improve satisfaction and biomedical outcomes4–9 and involving patients in partnership can have benefits without increasing their anxiety10 11 and with the potential to reduce adverse outcomes connected to 2 prescribing.’ Ref[Little]

Do doctors practice it? [Stewart]

Regarding the question whether doctors practise patient centred care, data indicate that doctors vary but on the whole provide most patients with partially patient centred care. Specifically, the average patient centred score on a scale of 0-100 is 50.7 (SD 17.9, range 8-93).3 Some doctors are very patient centred and show a wide range of scores, indicating a flexible style. Many others are not very patient centred and show a narrow range of scores, indicating a fixed style.4

Measuring PCC

Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Free- man TR. Patient-centred medicine transforming the clinical method. Thousand Oaks: Sage Publications, 1995.

Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796-804.
Stewart M, Brown JB, Weston WW. Patient-centred interviewing part III: five provocative questions. Can Fam Phys 1989;35:159-61.

Stewart M. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:1423-33.

PCC -time to deliver it

Patient centred care is central to the mission of healthcare, yet traditionally neither patients nor the public have had the power to shape the services they use and pay for, or define their value.1 As a result, many patients find services difficult to navigate, disempowering, burdensome, and seemingly designed to frustrate.2

There have been repeated calls to enlist patients’ help to reform systems poorly geared to meet current health challenges, subject to political meddling, and permeated by competing interests that fuel overdiagnosis and overtreatment3-5 UK and US policy supports person centred care and shared decision making,6 7 and the World Health Organization champions it. We know it improves the quality of care and promotes appropriate use of services.8 There is broad agreement on what it is,9 and guidance on how to deliver it.10 11 The challenge remains one of overcoming “system” inertia and paternalism.

Bauman et al states criteria that need to be addressed:

For patient-centred care to become standard, four issues need to be addressed:
■ The healthcare system needs to recognise patient-centred care, to invest in the community teams and professionals required, and to support its delivery in primary care. This will involve re-orienting and re-investing some of the real savings from decreased hospital admissions and shorter hospital stay for patients with chronic disease.
■ Medical student training and values need to focus more on patient-centred care; new entry criteria to medical courses and new curricula are cognisant of this approach.

■ In addition to linking GPs to community teams, the notion of patient-centred care could also become a greater part of secondary and tertiary specialised medical practice. ■ Patient-centred care is more than just empathic inter- viewing of patients, it is about re-organising healthcare systems to maximise the partnerships of patients and doc- tors in managing chronic disease.1

This is a challenge, because real innovation and change require political commitment, which is sometimes slow to be implemented in health services, even though the evidence for patient-centred approaches to chronic disease manage- ment is already strong.

Some Comments and Questions

  • PCC – is it culturally transferable from western to eastern cultures? how do we know what our patients expect from us in SL? have we done our homework?
  • Even now, can we ask our patients?
  • How can we do this representing patients from primary and secondary care? at least

The SLMA debate re patient-centred versus doctor-centred care made me think again, perhaps even changed my views about the whole notion of what PCC means in Sri Lankan settings.

In SL the majority of doctor-patient consultations are more paternalistic than patient-centric. It may be closely related to our culture of the respect people have for doctors. Going back even further it may have roots in Traditional Medicine consultations where the Sinhala Veda Mahathmaya made the treatment decisions after patients told their problem. Sometimes the traditional doctors did not even obtain a history put diagnosed the illness/disease by feeling the pulse.  In a way, I do not see this paternalistic model of care contradicting PCC.

If a patient, having understood the illness or disease and the available management options, requests the doctor for his advice/opinion as to what should be done, then what’s wrong if the doctor advice the best option? Is this not PCC?  It all depends on whether we have the best interest of the patient.

Is there is another way we can look at this?

Should PCC be change to Doctor Assisted PCC? DA-PCC  at last in SL settings?

PCC ————– <  START   > ——————DA-PCC

I am concerned of what we teach our students. After practising in Australia as a GP for 10 years, living in the Netherlands and visiting UK for more than five years, I have been fortunate (or unfortunate!) to experience the western doctor-patient consultations. In SL we seem to embrace everything ‘Foreign/British’ that may not really compatible with our culture (e.g. consultation frameworks) but do not even notice the best things such as the importance of keeping good medical records or the value of referrals.

We do not have to do this. Here I see the Dutch as a unique country (2/3 the size of SL with a population of 15 million) preserving their unique lifestyle, medical practice from the British and Americans, getting the best out of the other cultures and deciding for themselves what they require.

I would like very much to have your opinion because you come from different medical specialities closest to general practice / family medicine -internal medicine, paediatrics. You all have experience in working in western countries and you are now medical teachers in Sri Lanka.

I hope you will have five minutes to read some of the patient’s views from UK, (and in SL from our registrars and the MRCGP international) in using patient ICE – Ideas, Concerns and Expectations. At least some patients do not want to be ICEd


PS you may also like to read this interesting blog

When I read this BMJ Blog, ‘Shared Decision Making essential but hard to measure‘ and the Cochrane Review which concludes that “it is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.”