PATIENT-CENTREDNESS AND CONCORDANCE
Byrne and Long (1976) contrasted doctor-centred and patient-centred consultations.
Doctor-centred (or illness-centred) consultations focus on eliciting information
necessary for precise diagnosis and prescription of appropriate treatment. The doctor
tends to dominate such consultations asking direct, closed questions that demand short
factual answers, which can clarify details (e.g. ‘Where do you feel the pain?’). In such
consultations, little time is spent eliciting or understanding the patient’s ideas or
providing information other than instructions on medical management of the problem.
By contrast, in patient-centred consultations, doctors ask more open questions, which
allow the patient to explain their perspective (e.g. ‘So what do you think is wrong?’).
The doctor also allows time to reflect back what the patient has said to demonstrate
understanding and/or show empathy (e.g. ‘you’re worried about side effects’) and to
check that any treatment plans are acceptable to the patient. The Byrne and Long
consultation phases, Calgary-Cambridge model of consultation management and
Pendleton et al.’s seven-tasks model all highlight the importance of patient-centredness
in consultations because evidence suggests that patients are less likely to be satisfied
and less adherent following doctor-centred consultations.
Extending the work undertaken by Byrne and Long, Little et al.(2001) observed
865 consultations with general practitioners (or family doctors). These researchers
identified five aspects of patient-centredness: (1) building a partnership, that is, being
sympathetic, taking an interest in patients’ worries and sharing planning; (2) taking an
interest in the patient’s life; (3) establishing a personal relationship, that is knowing
the patient and their emotional needs; (4) providing health promotion, for example,
addressing risk factors in the patient’s lifestyle; and (5) taking a positive and definite
approach including providing concrete guidance on what was wrong and when it
would be resolved. Each of these five components could be reliably identified across
consultations. They found that patient satisfaction was related to building a partnership
and taking a positive approach. They also found that patients felt more empowered
to deal with their problem when doctors had taken an interest in their lives, provided
health promotion and adopted a positive approach. Patients also reported fewer
symptoms one month after the consultation when doctors adopted a positive approach.
Note how such results relate to the finding that doctor’s concern/anxiety was associated
with malpractice claims (see Chapter 8). It seems that patients expect partnership
building and do not appreciate or benefit from doctors airing their uncertainties or
concerns.
In most cases, including medication prescription, health care professionals can only
contribute to improved health through shaping their patients’ behaviour patterns.
Consequently, consultation management involves a lot more than ticking off the phases
or tasks highlighted by the models discussed above. If health care professionals are to
change patients’ behaviour patterns then it is important that those professionals are
respectful and responsive to individual patients and ensure that patient values guide
clinical decision-making (as was evident from Korsch et al.’s early work).
It has been proposed that health care professionals should strive to establish
‘concordance’ with their patients, that is, a mutual understanding and agreement about
treatment and its implementation (Mullen, 1997; Bissell, May and Noyce, 2004). For
example, using qualitative analyses of interviews with type 2 diabetic patients of
240 RELATING TO PATIENTS