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Developing professional ability to involve patients in their care: pull or push?
  1. A Edwards,
  2. G Elwyn
  1. Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Llanedeyrn, Cardiff CF3 7PN, UK Edwardsag{at}

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    The involvement of patients in the decisions about their treatment or care seems an unquestionable advance.1 There are philosophical and ethical justifications for this.2 Evidence is also accruing about its benefits—namely, increased satisfaction with care and communication, increased certainty about making the best decision, reduced anxiety levels, and greater adherence to chosen management plans.3 Some of the practical barriers that limit the greater involvement of patients in clinical practice are also being recognised and addressed,4 including the wider availability of information to patients, often outside the consultation.5 Yet patient involvement and informed choices are still not a reality in routine health care. There still appear to be barriers that directly relate to healthcare professionals which must be addressed if patient involvement is indeed to become a wider reality.

    Healthcare professionals need to assimilate a number of principles and practices if they are to facilitate patient involvement.6 Some of these apply more to global changes in attitudes and approaches to healthcare provision (“macro” level), and are the fundamental competences which professionals acquire as the platform for their practice.7 Others relate to their skills in providing care to the hundreds, or perhaps thousands, of patients with whom they interact—that is, the “competences” of practice7—and apply to the process within the consultation (“micro” level), the way professionals deal with individuals, their needs, concerns, desires, and expectations.

    At the “macro” level professionals need to appreciate the dilemmas that exist regarding the goals of modern health care. There is an increased focus on standardisation of health care which aims to reduce unacceptable variations in treatments or investigations offered and “consumed”. In practice, much of the effort towards this depends on guidelines and protocols which are often rigorously developed. The momentum in this direction has increased recently in the UK with the output from the National Institute for Clinical Excellence and the National Service Frameworks (NSF) for ischaemic heart disease, cervical screening, and others shortly to follow (care of the elderly, management of diabetes).

    But there is a tension here. The public health efforts of guidelines and NSFs may result in less flexibility in dealing with individual patients. It may therefore limit the scope for informed choices by the consumers—that is, the patients—and, by implication, they will have less true involvement in the decision making in practice. More informed choices by consumers can result in some opting out of treatment or surveillance programmes.3 We need to recognise that we may not be able to fulfil the requirements of both greater involvement and informed choice at the individual level and adherence to guidelines and NSFs at the public health or population level.8 Awareness and acceptance of the issue is an important first step. Professionals need to arrive at a personal view of how they reconcile this dilemma in their own practice, perhaps even choosing whether to pursue the public health or the individually focused approach. They must integrate this personal perspective into their approach to delivery of health care for the patients they see. At the moment practitioners are perhaps more aware of the pressure to meet targets in guidelines and NSFs than they are of the pressures from or desires of patients for more involvement, information, and informed choice. Greater awareness of the latter may depend, at least partly, on acquiring experience and skills in involving patients in clinical decision making—the “micro” level issues.

    At the micro level professionals need to acquire or enhance their skills in involving consumers in decisions. The competences required to do this are becoming established910 but, as yet, and as in every other area of health care, gaps between competence and performance still need to be addressed. There are developments now which seek to address these needs of professionals by training. The use of simulated patients to work through scenarios in which participants can experience, observe, and discuss new consulting approaches in a “safe” environment appears to hold promise.61112 They can also gain confidence in using decision support information that might be appropriate for use in the short consultations of general practice.13 Both professionals and experienced patient simulators can discuss and explore their reactions to the process of these new consulting approaches. By asking participants to review the process for each scenario undertaken, “reflection-on-action” is promoted.1415 The ethical issues are also exposed and brought to the forefront for consideration. Participants address how the skills and techniques may apply in their own practice and how they can accommodate the tension between individual and public health goals. These work based experiential learning approaches engender a sense of ownership of the process and are consistent with educational theory.16

    However, although these training programmes may help professionals to assimilate the philosophy and skills required for involving patients more in decision making, more is still required. Clearly, professionals need to engage with such training and this is not automatic. Motivation for participation in the training is achieved in some healthcare systems by financial incentives or the requirements of revalidation or re-certification. However, a further stimulus should not be neglected—namely, the expectations of patients and patient advocate groups. At present, in the UK at least, a substantial proportion of consumers do not apparently wish to be involved in making choices about their treatment or care,17 but evidence is also accruing about the benefits of involvement and decision support.3 There is therefore justification for continued pressure on professionals from patient advocate groups to promote and expect newer consulting approaches. This may prove to be the most crucial influence. At a wider level, it may also be a case study in making explicit the links between patient expectations, professional development requirements, and training programmes. It may provide a model in which professionals identify their needs for continuing professional development directly from the needs of patients and seek new training opportunities.

    Many of the points raised in this editorial are considered more fully in the supplement on Engaging Patients in Decisions which accompanies this issue of Quality in Health Care. Free access to the supplement is available on the website at