Patient‐centered Medicine, Transforming the Clinical Method (2nd edition)

By Moira Stewart, Judith Belle Brown, W.Wayne Weston, Ian R McWhinney, Carol L McWilliam and Thomas R Freeman. Radcliffe Medical Press, 2003, PB £24.95, 376 pp, 1-85775-981-8 The quality of the doctor–patient relationship is a major determinant of whether or not patients’ expectations will be met and favourable health outcomes achieved. Current thinking on models of health care reflects an ever-growing shift away from the traditional paternalistic models of the doctor–patient relationship, towards more patient-centred models that focus on the wider psychosocial issues, which influence an individual's illness experience. Patient-centred medicine views the patient's perspective and agenda as being equally important to that of the doctor's. This book is the second edition of the influential text first published in 1995 that comprehensively described the patient-centred model of medicine. In this latest edition, the fundamental components of the patient-centred clinical method remain the same. However, there is more emphasis on the importance of ‘finding common ground’ with patients and there is an updated section on qualitative and quantitative studies which illustrate the outcome benefits of using this approach in practice. Although written from a Canadian standpoint, the patient-centred model can be applied to most international systems of modern health care. To be patient-centred, the authors state that ‘the practitioner must be able to empower the patient, share the power in the relationship and this means renouncing control which traditionally has been in the hands of the professional’. The text is divided into four main sections. The first is an overview of the patient-centred method, which includes its evolution, and relationship to other models of communication. There is an interesting whistle stop tour of the development of the clinical method of medicine, beginning with the 17th century European Enlightenment period, featuring influential thinkers such as René Descartes and Thomas Sydenham, who helped lay the foundations for the modern disease-based clinical method. This concludes with Engel's critique of the modern clinical model and briefly describes his use of systems theory for integrating biological, psychological and sociological factors into the clinical process. In the second section the six interactive components of the patient-centred model are described. These are: Exploring both the disease and the illness experience Understanding the whole person Finding common ground Incorporating prevention and health promotion Enhancing the patient–doctor relationship Being realistic The text is richly interspersed with real (anonymized) case examples that illustrate each distinct concept of the model. These examples make the model come alive by combining theory with realism and it is worth dipping into the text for these alone. In the expanded chapter on ‘finding common ground’, there is a short discussion on the role of shared decision-making and motivational interviewing as strategies to assist achieving this aim. Finding common ground is described as the process through which the patient and doctor reach a mutual understanding in three key areas, namely: ‘defining the problem, establishing the goals and priorities of treatment and/or management and identifying the roles to be assumed by both patient and doctor’. The authors emphasize that not all patients feel well or confident enough to be active participants in decisions about their care and that respecting patient choice to abdicate decisions to the doctor is an example of patient-centred care. Chapter 9 raises issues concerning ‘being realistic’ and acknowledges that average consultation times in primary care vary around the world. These range from 5 min in the UK to 21 min in Sweden. Empirical evidence is cited that challenges the common belief that patient-centred consultations take longer to conduct. However, the authors report a UK study that found patients were more satisfied when their consultation lengths were extended from 5 to 10 min – suggesting that the length of visit is an important predictor of satisfaction. Part 3 of the book is concerned with learning and teaching the patient-centred clinical method through the application of the learner-centred method of education. This approach enables learners to use their experiences of relationships with teachers to help them understand relationships with patients. The learner-centred method comprises six interactive components, each one corresponding to the six tenets in the patient-centred framework (above). This section is also embedded with case examples detailing the experiences of learners and teachers to illustrate each component. As in section 1, these make for a fascinating and thought provoking read irrespective of the main text. Chapter 13 provides useful practical tips for teaching the patient-centred method including how to give constructive feedback to learners without undermining their confidence. In chapter 15, there is a discussion of how to develop a patient-centred curriculum. This is highly topical, particularly in the UK where communication skills are now being systematically taught and examined in medical schools. The authors outline the fundamentals of curriculum development and illustrate the theoretical principles with a case study of the curriculum revision in the Faculty of Medicine and Dentistry at the University of Western Ontario. They bravely present ‘failures’ as well as ‘successes’ with the aim of providing constructive instruction for their readers. In the fourth and final section, a summary of qualitative and quantitative research relevant to the patient-centred clinical method is presented. Recent qualitative studies are cited in order to highlight how this method of research is helpful in gaining an understanding of the motives, needs and expectations of patients. The section on quantitative work includes examples of the instruments designed to measure patient-centredness in the consultation and a summary of the elements of patient-centred communication that have been found to be positively associated with beneficial outcomes. For patients, these include satisfaction with the consultation, adherence to treatment and improvement in health outcomes; for doctors these include fewer malpractice claims, efficient use of time and satisfaction. This is a well-written, weighty book, which will be of interest to medical educationalists, primary and secondary health care professionals, including medical students and individuals who have an interest in enhancing the practitioner–patient relationship. Although easy to read, its length might be a little daunting to time-pressured health professionals. However, it is the kind of text that can be usefully dipped in and out of as circumstances allow.

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