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September 2000 · Vol. 49, No. 9
Commentary
The Science of Patient-Centered
Care
Ronald M. Epstein, MD
Rochester, New York
All correspondence should be addressed to Ronald M. Epstein, MD, University of
Rochester, Family Medicine Center, 885 South Avenue, Rochester, NY 14620. E-mail:
[email protected].
Commentary about The Impact of Patient-Centered Care on Outcomes
Patient-centered care expands on the disease-oriented model by incorporating the patient’s
experience of illness, the psychosocial context, and shared decision making. 1 This type of care
has been adopted as a model of medical practice by many primary care physicians, medical
educators, and specialists. Elements of patient-centered care have been described since
antiquity. Although different authors have used different nomenclature, the fundamental idea is
that the process of healing depends on knowing the patient as a person, in addition to accurately
diagnosing their disease. Evidence that elements of a patient-centered approach improve
important outcomes of care is abundant.2 However, many myths about this type of care persist.
For example, some clinicians conflate patient-centered and psychosocial. However, patientcentered care can apply equally to deciding which antibiotic to prescribe for a urinary tract
infection and to an evaluation of domestic violence. Another myth is that being patient centered
means giving patients what they ask for.
Patient-centered communication, a cluster of physician behaviors presumed to help the physician
achieve the goals of this type of care, includes clearly defined components: (1) identifying and
responding to patients’ ideas and emotions regarding their illness, and (2) reaching common
ground about the illness, its treatment, and the roles that the physician and the patient will
assume.1 These components seem both obvious and radical. For example, asking the patient why
he has come to the physician and eliciting his feelings, ideas, and expectations about the illness
make perfect sense, but are done in less than half of medical visits, including those not
constrained by the pressures of time imposed by managed care and governmental health
systems.
The study by Stewart and colleagues3 in this issue of the Journal is a landmark in research about
the patient-centered clinical method. Using a stratified sample of 39 family physicians and 315 of
their patients, they conducted an observational cohort study in which they examined the
interrelationships between 3 elements: patient perceptions of patient-centeredness, observed
communication behaviors, and subsequent health and resource utilization. When patients
perceived the visit to be patient centered they experienced better recovery, better emotional
health, and dramatically fewer diagnostic tests and referrals 2 months later. The patient-centered
communication measure (a validated coding scheme using audiotapes of physician-patient visits)
correlated only with patients’ perceptions, but not directly with any health care outcome. Thus, this
study further affirms that the patient is the ultimate arbiter of patient-centeredness. Because only
the patient can report whether she has felt understood or if or has been adequately involved in
developing a treatment plan, it is no surprise that the inside perspective is more highly correlated
with outcomes than any objective measure of verbal content.
IMPROVING PHYSICIAN TRAINING
What conclusions can be drawn about how physicians can be trained to be more patient
centered? One might think that patients can be our best teachers when it comes to
communication. After all, their perceptions correlate most strongly with outcomes. However,
although patients can report how they feel, they often cannot comment with sufficient detail on the
physician’s specific communication behaviors. Their effect can be indirect, though. Patients can
learn to communicate more effectively with their physicians with brief training interventions. 4 In the
process, they can take an observer’s perspective on the encounter and guide the physician to
engage in shared decision making.
Training is effective in producing measurable changes in physicians’ communication skills even 5
years later;5 physician training also improves relevant patient outcomes. 6 However, we may be
teaching only a few of the skills necessary to improve patient-centered care, and it is not clear
whether these are the most important ones. For example, even in a technically oriented
profession such as medicine, relationship building is largely related to nonverbal communication.
A recent study7 showed that nonverbal communication predicted likelihood of malpractice
litigation to a greater degree than either qualitative or quantitative analysis of verbal content of
interviews. Physicians often regard communication as the art of medicine. With that realization,
however, should come the obligation to refine that art using known tools and to develop new tools
that will expand their own potential as healers.
Linguistic correctness in communication skills training is important but is no substitute for genuine
human expression. The goal is not the politically correct interview that contains a requisite number
of open-ended questions and empathic-sounding responses. Instead Stewart and colleagues
suggest that arriving at a deeper level of connection is essential, and they propose 2 methods
designed to promote mindful reflection: small group discussions with patients and videotape
review with standardized patients. In my experience, videotape provides a powerful means for
self-critique. Other methods include standardized patients trained to give immediate feedback, 8
self-awareness groups,9,10 modeling thinking out loud, and reflective questioning. 11 The goal of
such exercises is to appreciate the biological and psychological uniqueness of each individual.
Medical decisions can then be better informed by the evidence that the patient presents; healing
relationships can be cultivated on the basis of who the patient is rather than who the physician
would have him be.
Stewart and coworkers used the patient as the unit of analysis and controlled for clustering of
patients by physician. Their analysis raises questions about the extent to which individual
physician differences accounted for the differences in outcomes. More plainly, they could not
determine whether some physicians are more patient centered than others. Instead their
discussion suggests that individual physicians show a range of patient-centered scores, test
ordering, and referrals. Why might a physician be more patient centered with some patients and
not others? Perhaps patients can induce patient-centeredness from physicians .12 If so, patientcenteredness would be a quality of the patient as well as the physician. The same physician might
be perceived as more patient centered by one patient than by another, perhaps because of
previous experiences, biases, and expectations.
Patient-centeredness may also be more important to some patients than others. Some patients
may gravitate to physicians who are more patient centered; thus, patient-centeredness is also a
quality of their relationship. Finally, the context of the visits may determine the degree of patientcenteredness; physicians may appear to be less patient centered during some types of visits or in
certain practice environments. In that regard, it would be interesting to study the effect of time
constraints on the physician’s patient-centered care.
UNDERSTANDING PATIENT-CENTEREDNESS
Good research generates more questions than it answers. It is clear, however, that future studies
of patient-centered care will require more than just the application of quantitative ratings to
observational data. To understand patients’ constructs of patient-centeredness, we need to
understand the patient as a person rather than as a cluster of attributes. Given the diversity of
patient needs and personalities, our conceptualization of what it means to be patient centered
may not have adequately incorporated diverse patients’ perspectives. Our current understanding
of patient-centeredness should be a complex web of physician, patient, and interactional factors,
rather than one simple coherent construct. We may not have adequately characterized many of
the relevant elements. I have wondered: Do physicians who have a rigid style (regardless of
whether it is patient centered) do less consistently well with their patients? If so, does flexibility
become an important component to measure? Do demographics, such as the age of the patient
and physician-patient race or sex concordance, affect measures of patient-centeredness? Do
certain situations, such as a discussion of an emotionally charged topic, evoke less patientcentered responses from physicians? It appeared that patient perceptions and physician
measures of reaching common ground had the most robust associations with outcomes. Is shared
decision making the final common pathway of diverse actions that comprise patientcenteredness?
INTERPRETING THE RESULTS
The study by Stewart and coworkers should not be overinterpreted by claiming that the patient’s
perceptions are all that matter, that teaching physicians to explore the meaning of the illness with
a patient does not make a difference, or that measures of patient-centered communication are
meaningless because they are not directly linked to outcomes; it should also not be
underinterpreted by claiming that it is flawed because it used the patient as the unit of analysis.
They have shown that thoughtful studies of the science of the art of medicine can make a
difference and that the questions raised open new worlds of possibilities for further exploration.
REFERENCES
1.
Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR.
Patient-centered medicine: transforming the clinical method. Thousand Oaks, Calif: Sage
Publications; 1995.
2.
Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on
patient-doctor communication. Cancer Prev Control 1999;3:25–30.
3.
Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on
patient outcomes. J Fam Pract 2000;49:796–804.
4.
Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care:
effects on patient outcomes. Ann Intern Med 1985;102:520–28.
5.
Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: I.
Benefits of feedback training in interviewing as students persist. BMJ 1986;292:1573–
76.Published erratum appears in BMJ 1986;293:26.
6.
Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’
interviewing skills and reducing patients’ emotional distress: a randomized clinical
trial. Arch Intern Med 1995;155:1877–84.
7.
Ambady N. Thin slice analysis on non-verbal physician patient interaction and its
association with malpractice risk. Bayer Institute for Healthcare Communication
Symposium. Phoenix, Ariz; 1998.
8.
Levenkron JC, Greenland P, Bowley N. Teaching risk-factor counseling skills: a
comparison of two instructional methods. Am J Prev Med 1990;6:29–34.
9.
Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating
the physician: personal awareness and effective patient care. JAMA 1997;278:502–09.
10.
Novack DH, Kaplan C, Epstein RM, et al. Personal awareness and professional
growth: a proposed curriculum. Med Encounter 1997;13:2–7.
11.
Epstein RM. Mindful practice in action: evidence-based medicine and
relationship-centered are. Fam Syst Health. In press.
12.
Street RL Jr. Information-giving in medical consultations: the influence of
patients’ communicative styles and personal characteristics. Soc Sci Med 1991;32:541–48.
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