Patient-centered care and communication in primary care practice: what is involved?

OBJECTIVE This secondary, qualitative analysis examined physician-patient interaction and patient-centered care in a random sample of encounters of 44 physicians in 18 family practices. METHODS Fieldworkers were trained in qualitative and quantitative data collection strategies including participatory observation, narrative description, interviewing techniques and note-taking regarding practice observations, patient encounters and community assessment. Fieldworkers spent 4-8 weeks in each practice. Data included descriptions of practices, personnel, office systems, patient encounters, chart audits and physician, practice personnel and community informant interviews. Data analysis included comparison of results with Stewart et al. patient-centered model. RESULTS Results support and extend the work of Stewart et al. The content and expression of clinical discourse in the exam room springs from complex sources, including physician and patient characteristics, practice and community cultures, and related medical care expectations. DISCUSSION Patient-centered values often conflict with other competing values. Ideas drawn from complexity science helped make sense of how "attractors" identified in findings influenced outcomes of patient-centered care and communication. CONCLUSION Physician, patient, practice and community characteristics, values and expectations impact the effectiveness of patient-centered care and communication. IMPLICATIONS Medical students, residents and practicing physicians need opportunities to evaluate competing values affecting the delivery of patient care.