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. 2001 Jun 23;322(7301):1544.

Patients' preferences for patient centred approach to consultation

What is patient centredness?

John R Skelton 1
PMCID: PMC1120583  PMID: 11439994

Editor—Little et al's study seems to show patients' overwhelming preference for a patient centred approach to consultation in primary care.1 The issue is not so much whether most patients agree that, for example, they “want the doctor to understand [their] main reason for coming” as whether a desire for the contrary would represent a belief in some other kind of approach to the consultation or just be plain odd. In other words, what kind of person could possibly say, and be thought rational, “I don't want the doctor to understand my main reason for coming”?

I invite readers to review the questionnaire, putting the opposite case in this way and asking themselves how many of the questions are of this type: “I don't want the doctor to be friendly and approachable,” “I don't want the doctor to find out how serious my problem is,” and so on. They might also like to consider how easy it would be to construct a mirror questionnaire, couching doctor centred values in a way that no one could reject (“I want to trust my doctor's expertise”).

The difficulty is that there is an implicit contrast in the minds of everyone who works in this field between patient centredness and doctor centredness. The same contrast, though, is not necessarily in the minds of patients, who lack the context of the professional debate.

Researchers may believe that patients are expressing a preference for one type of consultation rather than the other, whereas they are simply expressing a preference for the commonsensical rather than the perverse. Patient centredness requires a more sophisticated approach than this.

References

  • 1.Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ. 2001;322:468–472. doi: 10.1136/bmj.322.7284.468. . (24 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Jun 23;322(7301):1544.

Authors' reply

Paul Little 1,2,3,4,5, Hazel Everitt 1,2,3,4,5, Ian Williamson 1,2,3,4,5, Clare Gould 1,2,3,4,5, Kate Ferrier 1,2,3,4,5, Greg Warner 1,2,3,4,5, Michael Moore 1,2,3,4,5, Sheila Payne 1,2,3,4,5

Editor—Skelton questions the methodology of our study, and whether patients would ever disagree with particular items about expectations—that is, he is saying that the elicited expectations were meaningless.

We used a standard psychometric questionnaire design, asking the patients to agree or disagree with statements on a balanced seven point scale, with items based on the patient centred model. We could have limited patients' responses to how strongly they agreed. However, to assume that it is perverse and irrational to disagree is patronising to those who didn't agree that the doctor needed, for example, to deal with their worries (12%), be interested in the treatment they wanted (23%), or understand their emotional needs (30%). We too would have been surprised if most patients disagreed with the statements, but it would have been incorrect to constrain, and potentially bias, patients' responses by such a priori assumptions.

Citing dichotomised or polarised agreement or disagreement with particular items is a simplistic critique of the method; it overlooks the fact that we elicited the strength of expectations and that most of the variance in the response was in how strongly patients agreed. We showed how strongly patients wanted different aspects of the patient centred approach; how strongly this contrasted with other expectations (for example, for a prescription); and which patient groups most strongly wanted a patient centred approach.

If the measurements are meaningless then two points are important. Firstly, there would be no pattern among such meaningless measurements, which would be unreliable. In fact, we showed that there were distinct aspects of patients' expectations—for communication, partnership, health promotion, interest in the effect on life, and personal understanding. Where it was possible to construct scales (that is, more than one item related to the same area) the scales were highly reliable. This is clearly important theoretically in understanding the nature of patient centredness (is it one thing or many?) and practically (doctors need to be aware of several dimensions of care that their patients may want).

Secondly, measuring how well expectations were met (using identical scales) should also be meaningless, and unrelated to outcome. This is not so: using the same cohort we have found that how well these expectations were met strongly determines a range of outcomes important to patients and the health service.

The strength of patients' expectations that we measured is meaningful and reliable and should not be dismissed too lightly.

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

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