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Why patient-centredness is central to your consulting

What are we trying to achieve when we consult with our patients, and what do we have to learn? The principal advantage of basing teaching on tasks is that it enables a clear statement about the purposes of the consultation, which can be discussed and negotiated. These tasks can be derived from the needs of patients, the aims of the doctor, the desired outcomes, and the evidence that links them. This approach also recognises that individual doctors use a variety of approaches and skills to achieve the same tasks.

The principal limitation of focusing on tasks is that the feelings of the patient and doctor can be relatively neglected. Patient-centredness is central to consulting, but what exactly does it mean? Cohen-Cole1 described three functions that take place in the medical interview:

lgathering data to understand the patient

lbuilding rapport and responding to patients' emotions

leducation, negotiation and motivation.

More recently Mead and Bower2 reviewed the literature and identified five concepts of patient-centredness.

lA biopsychosocial perspective, expanding the scope of the consultation to include the social and psychological dimensions of health.

lThe 'patient-as-person', understanding the individual's experience of illness.

lSharing power and responsibility in the consultation.

lThe therapeutic alliance, recognising the relationship is not just about management but has therapeutic potential.

lThe doctor-as-person, considering the contribution that the individual doctor makes to the relationship.

Bensing3 suggested the concept of 'patient-centredness' could be clarified by contrasting it to both disease and doctor-centred care. The characteristics of patient-centredness are therefore:

lconcern for the whole person rather than just their disease

lthe patient's involvement in controlling the consultation and setting the agenda

lpatients' expectations and power to make decisions.

Greater attention has also been given to what has been described as 'the neglected second half of the consultation' in which decisions are made about management4. These ideas can be used to work out the key tasks of a consultation (see box above).

In order to make the tasks more easily memorable, and more easily taught, here is a summary version of them:

lUnderstand the problem

lUnderstand the patient

lShare that understanding

lShare decisions and responsibility

lMaintain the relationship

....and do it all within the allocated time!

Points to remember

lEveryone can improve their consultation skills

lNearly all doctors have a range of sophisticated communication skills; sometimes these are not used in the consultation

lPeople need to base new learning on their current understanding, so learners' understanding needs to be sought before teaching occurs

lLearning experiences should match the messages in the teaching

lDifferent people learn in different ways so teaching needs to have different methods, levels of abstraction and sources but the message needs to be consistent.

Tasks of consultation

Task 1 To understand the reasons for the patient's attendance, including:

lThe patient's problem: its nature and history, its aetiology

and its effects.

lThe patient's perspective: their personal and social circumstances; ideas and values about health; their ideas about the problem, its causes and its management; their concerns about the problem and its implications; their expectations for information, involvement, and care.

Task 2 Taking into account the patient's perspective, to achieve a shared understanding:

lAbout the problem

lAbout the evidence and options for management

Task 3 To enable the patient to choose an appropriate action for each problem:

lConsider options and implications

lChoose the most appropriate course of action

Task 4 To enable the patient to manage the problem:

lDiscuss the patient's ability to take appropriate actions

lAgree doctor and patient actions and responsibilities

lAgree targets, monitoring and follow-up

Task 5 To consider other problems:

lNot yet presented

lContinuing problems

lAt-risk factors

Task 6 To use time appropriately:

lIn the consultation

lIn the longer-term

Task 7 To establish or maintain a relationship with the patient that helps to achieve the other tasks

References

1 Cohen-Cole SA. The medical interview: the three-function approach. St Louis: Mosby Year Book, 1991

2 Mead N, Bower P. Patient-centredness:

a conceptual framework and review

of the empirical literature.

Soc Sci Med 2000;51:1087-110

3 Bensing J. Bridging the gap. The separate worlds of evidence-based medicine and patient-centered medicine.

Patient Educ Couns 2000;39:17-25

4 Elwyn G et al. Shared decision-making

in primary care: the neglected

second half of the consultation.

Br J Gen Pract 1999;49:477-82

Peter Tate is a GP in Abingdon, Oxfordshire, and convenor of the panel of examiners of the RCGP

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