Elsevier

Social Science & Medicine

Volume 51, Issue 7, 1 October 2000, Pages 1087-1110
Social Science & Medicine

Patient-centredness: a conceptual framework and review of the empirical literature

https://doi.org/10.1016/S0277-9536(00)00098-8Get rights and content

Abstract

A ‘patient-centred’ approach is increasingly regarded as crucial for the delivery of high quality care by doctors. However, there is considerable ambiguity concerning the exact meaning of the term and the optimum method of measuring the process and outcomes of patient-centred care. This paper reviews the conceptual and empirical literature in order to develop a model of the various aspects of the doctor–patient relationship encompassed by the concept of ‘patient-centredness’ and to assess the advantages and disadvantages of alternative methods of measurement. Five conceptual dimensions are identified: biopsychosocial perspective; ‘patient-as-person’; sharing power and responsibility; therapeutic alliance; and ‘doctor-as-person’. Two main approaches to measurement are evaluated: self-report instruments and external observation methods. A number of recommendations concerning the measurement of patient-centredness are made.

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.

References (121)

  • D. Armstrong

    The emancipation of biographical medicine

    Social Science and Medicine

    (1979)
  • L. Badger et al.

    Psychosocial interest, medical interviews and the recognition of depression

    Archives of Family Medicine

    (1994)
  • D.J. Bain et al.

    Difficulties encountered in classifying illness in general practice

    Journal of the Royal College of General Practitioners

    (1973)
  • R. Baker

    Development of a questionnaire to assess patients’ satisfaction with consultations in general practice

    British Journal of General Practice

    (1990)
  • R. Bales

    Interaction process analysis: a method for the study of small groups

    (1950)
  • E. Balint

    The possibilities of patient-centred medicine

    Journal of the Royal College of General Practitioners

    (1969)
  • E. Balint et al.

    The doctor, the patient and the group: Balint revisited

    (1993)
  • M. Balint

    The doctor, his patient and the illness

    (1964)
  • J. Birtchnell

    How humans relate: a new interpersonal theory

    (1993)
  • E. Bordin

    The generalizability of the psychoanalytic concept of the working alliance

    Psychotherapy

    (1979)
  • P. Bower

    Understanding patients: implicit personality theory and the general practitioner

    British Journal of Medical Psychology

    (1998)
  • P. Bower et al.

    Measuring general practitioner psychology: the personal construct perspective

    Family Practice

    (1997)
  • J. Brooke et al.

    Clinical decision=patient with problem+doctor with problem

  • J. Brown et al.

    The patient-centred clinical method 2: definition and application

    Family Practice

    (1986)
  • J. Brown et al.

    Assessing communication between patients and doctors: a manual for scoring patient-centred communication

    (1995)
  • P. Butow et al.

    Computer-based interaction analysis of the cancer consultation

    British Journal of Cancer

    (1995)
  • P. Byrne et al.

    Doctors Talking to Patients

    (1976)
  • J. Cape

    Psychological treatment of emotional problems by general practitioners

    British Journal of Medical Psychology

    (1996)
  • A. Cartwright

    Patients and their doctors

    (1967)
  • A. Cartwright et al.

    General practice revisited

    (1981)
  • E. Cassell

    The nature of suffering and the goals of medicine

    The New England Journal of Medicine

    (1982)
  • R. Cattell

    The scientific use of factor analysis

    (1978)
  • D. Cecil et al.

    Control, compliance and satisfaction in the family practice encounter

    Family Medicine

    (1997)
  • J. Cockburn et al.

    Measuring general practitioners’ attitudes towards medical care

    Family Practice

    (1987)
  • F. Crookshank

    The theory of diagnosis

    Lancet

    (1926)
  • R. Crow et al.

    The role of expectancies in the placebo effect and their use in the delivery of health care: a systematic review

    Health Technology Assessment

    (1999)
  • R. Croyle et al.

    Illness Cognition

  • C. deMonchy et al.

    Measuring attitudes of doctors: the doctor–patient (DP) rating

    Medical Education

    (1988)
  • The patients’ charter

    (1991)
  • L. Doyal

    The political economy of health

    (1979)
  • B. Ehrenreich et al.

    For her own good

    (1979)
  • R. Elliott

    A discovery-oriented approach to significant change events in psychological therapies: interpersonal process recall and comprehensive process analysis

  • G. Engel

    The need for a new medical model: a challenge for biomedicine

    Science

    (1977)
  • G. Engel

    The clinical application of the biopsychosocial model

    American Journal of Psychiatry

    (1980)
  • L. Fallowfield et al.

    Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom

    Journal of Clinical Oncology

    (1998)
  • F. Fitton et al.

    The doctor–patient relationship: a study in general practice

    (1979)
  • R. Fitzpatrick et al.

    Problems in the conceptual framework of patient satisfaction research: an empirical investigation

    Sociology of Health and Illness

    (1983)
  • F. Fransella et al.

    A manual for repertory grid technique

    (1977)
  • E. Friedson

    Client control and medical practice

    American Journal of Sociology

    (1960)
  • E. Friedson

    Profession of medicine: a study of the sociology of applied knowledge

    (1970)
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