Person-centred care: more than just improving patient satisfaction?

Health policy has increasingly signalled a move away from an emphasis on specific organs and disease, towards placing the ‘whole’ person at the centre of medicine. The health professional must try to understand what the illness means for the individual, within a social and psychological context. This necessitates listening to that particular person’s point of view, with the ultimate goal of sharing responsibility with them. Clinicians should learn to ask not only ‘what is the matter?’, but ‘what matters?’ In other words, what are the patient’s interests, concerns, and fears about the specific conditions, symptoms, or treatment options? This moves us from the strictly biomedical view to a broader bio-psycho-social and spiritual view, with power shared between the healthcare professional and the patient. Despite widespread pressure for a move from the paternalistic ‘doctor knows best’ approach, progress has been rather slow. All agree that improved communication between patients and professionals is a legitimate goal, but a survey across several developed countries has reported that the majority of patients are not asked for their ideas or opinions about treatment. This is particularly troubling as disease management shifts towards chronic rather than acute disease. Many factors influence how person-centred the interactions between a healthcare professional and a patient may be, including the characteristics of the patient and the professional, the context of the interaction, and the nature of the consultation (Figure 1). Primary care physicians are typically more enthusiastic about person-centred care than specialist physicians. They tend not merely to focus on the successful treatment of a specific disease, but to work towards a joint understanding of illness and its management. Perhaps it is not surprising that cardiologists have been slower to embrace this approach—much of their work relates to very specific pathology and its treatment. Of course, a very directive approach may be appropriate and appreciated for a simple physical complaint due to an easily treatable acute condition, but too often this approach is also applied to the much more complex situation of ill-health related to a number of diseases, most of which are chronic. Clinical guidelines in cardiology are largely silent about the person-centred approach, other than to state or imply that the clinician must consider how best to apply the evidence base to their patient. In the guidelines for chronic conditions (such as heart failure) the multidisciplinary approach is strongly supported, with professionals working together (with the patient and family) in a co-ordinated manner. An explicit discussion of the personcentred approach is not given, but rather indicators of which ‘type’ of patients might or might not benefit from specific interventions. This approach is still directive—the application of what the professionals consider the best treatment—without a fuller discussion of the issues on a more equal basis. Two key components of person-centred care are collaborative goal setting and action planning: agreeing on what, when, where, and how often specific actions are required and the barriers to such actions for that individual patient. Such an approach helps foster self-efficacy and may assist the person in moving from a position of dependence to that of being an ‘expert’, if that is what they wish. Some may fear that the person-centred approach runs contrary to evidence-based medicine (EBM), but Sackett himself considered EBM as an integration of the best research evidence with clinical experience and patient values: ‘the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient’. There is a need for more robust research on the impact of adopting a person-centred approach on outcomes, which should include the traditional ‘end’ points of mortality and hospitalization, in addition to patient satisfaction, quality of life, health status, and healthcare utilization. Most of the published literature on the effect of a person-centred approach in healthcare reports the impact on patient satisfaction, but few studies assess health behaviour, health status, or healthcare system process measures.