Family Practice ��Oxford University Press 1989 Vol. 6, No. 4 Printed in Great Britain Patient-Centredness in the Consultation. 1: A Method for Measurement RONALD J HENBEST AND MOIRA A STEWART* Henbest R J and Stewart M A. Patient-centredness in the consultation. 1: A method for measurement. Family Practice 1989 6: 249-254. This paper presents a method for assessing the doctor-patient interaction in te.rms of its patient- centredness. Patient-centredness was defined in terms of doctor responses which enabled patients to express all of their reasons for coming, including symptoms, thoughts, feelings and expectations. The method was tested and found to be valid (correlations for criterion validity rs = 0.51 and 0.89), reliable (inter-rater correlation rs = 0.91, intra-rater correlation rs = 0.88), and sensitive, in that it was able to detect differences among doctors (P 0.001) and among doctor responses to different patient offers (P 0.001). The method was also found to be practical in that it was inexpensive and could be used for a variety of purposes such as by tutors to give feedback to their students, by examiners as part of the evaluation of candidates' consultation skills, and by students and clinicians alike, for self-assessment. The finding that the score for the first two minutes of the consultation correlated highly with the score for the entire consultation (rs = 0.806) greatly increases the time effectiveness of the method, suggesting that it would be practical for use on a large scale, including student assessment and future studies of the relationship between patient-centredness and patient outcomes. The importance of the doctor-patient interaction has received much attention, especially in the past two decades, and one of the key concepts to emerge has been that of patient-centred care. The term 'patient-centred medicine' was introduced into the medical literature by Michael Balint in 1970 in order to give a name to a particular way of thinking. Patient-centred medicine referred to ��� the attempt to 'understand the complaints offered by the patient and the symptoms and signs found by the doctor, not only in terms of illnesses, but also as expressions of the patient's unique individuality, his tensions, his conflicts, and problems.'1 This was in contrast to the illness or disease-centred way of thinking which considered man to be a complex machine and which attempted to understand the patient's symptoms in terms of pathology. But the concept of patient-centred care is not a new one. It has its roots in holism that can be traced back to the writing of Hippocrates and beyond.2 Rather, Department of Family Medicine, Medical University of Southern Africa. 'Department of Family Medicine, University of Western Ontario, London, Canada. Correspondence to Dr R J Henbest, Department of Family Practice, University of Alberta, Royal Alexandra Hospital Family Clinic, 10240 Kingsway Avenue, Edmonton, AJberta, Canada T5H 3V9. the concept of patient-centred care may best be thought of as a rediscovery, one that can be identified in the medical literature of this century as expressed in a number of recurring and inter-related themes, including: the primacy of the person, the significance of the subjective, the importance of the interpersonal relationship, the whole person, the deeper diagnosis, the patient's real reasons for coming, and the personal qualities of the physician.3 Perhaps of equal importance, has been the recognition of the need to evaluate the quality of the process of patient care in terms of outcomes.4 A number of instruments have been developed to measure the interpersonal aspects of the process of care, but all of them, including two that were designed specifically to measure patient-centredness, have limitations.5 The main aim of this paper is to describe a method for assessing the doctor-patient interaction in terms of its patient-centredness, a method that is simple and practical and that can be performed equipped solely with pencil and paper and an audiotape recorder. The method to be described in this paper was developed and tested as part of a master's thesis5 researching the relationship between patient-centred care and patient outcomes. It is a modification of a 249 at The University of British Colombia Library on January 27, 2012 http://fampra.oxfordjournals.org/ Downloaded from

250 FAMILY PRACTICE���AN INTERNATIONAL JOURNAL method piloted by the Department of Family Medicine at the University of Western Ontario, Canada, that was based on a model for the consultation proposed by J Levenstein of the Family Practice Unit of the University of Cape Town, South Africa.6 METHOD The method can be applied either to an audiotape or to direct observation of the doctor-patient interaction transcripts are not required. The reviewer uses a score sheet to record the offers made by the patient in the order in which they happen in the consultation (Figure 1). A brief phrase stated in the patient's own words is used to document each patient offer. The doctor's response to each offer is then categorized as to whether the doctor: (0) ignores it altogether, (1) uses a closed response, (2) uses an open-ended response, or (3) specifically facilitates the expression of the patient's expectations, thoughts or feelings. Doctors may initially respond to patients' offers with closed questions and the move to more facilitating responses, or they may ignore patients' offers at first and then return to them later. In any case, all responses to a given offer are recorded by circling the appropriate categories and the highest category marked is used to determine the patient- centred score. The total score for a particular interview is calculated by summing the scores for the doctor's responses to each patient offer and then dividing by the total number of offers to give a score ranging in value from 0 to 3. This method can be seen as an attempt at a practical application of Balint's thesis that patients 'offer or propose various illnesses', and that the main effect of the doctor 'is his response to the patient's offers'.7 Patient-centredness was defined as a response by the doctor to a patient's offer in a way that allows the patient to express all of his or her reasons for coming to the doctor, including symptoms, thoughts, feelings and expectations. In doing so, the doctor tries to understand the whole meaning of the illness for the patient that is, attempts to understand the person as well as the disease. Patient Offers Patients may present to a doctor for any of a number of different reasons. McWhinney" has proposed a taxonomy of patient behaviour consisting of five mutually exclusive categories: 'limit of tolerance', 'limit of anxiety', 'problems of living presenting as symptoms', 'administrative', and 'no illness' (or prevention). Others have used similar taxonomies to study different aspects of the consultation such as problem differentiation,9 and doctor-patient agreement about the primary purpose of the visit.10 Another approach has been to classify the patients' reasons for coming to the doctor in terms of expectations, feelings, and fears.611 Practitioner Patient's offers (include: symptoms, thoughts, feelings, expectations and prompts) 1 s 7 R q in 11 n 14 is JMn nfnffprs Signature Ignore 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total score Purpose Date Doctor's response(s) Closed Open Specific facilitation (thoughts, reelings or expectations) 1 2 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 Avera 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5? score FIGURE 1 Patient-centred score sheet Balint's- term 'patient offers' was chosen as a general heading for patients' verbal communications because of its inclusiveness it was meant to refer to all that is potentially significant that a patient brings to the doctor. Other terms considered for this purpose, such as symptoms, expectations and cues, were found to be too narrow, referring to only a portion of the patient's offers. Therefore, patient offers were defined as any verbal expression of patients which signal or hint at their expectations, thoughts, or feelings. The following categories of patient offers were defined: 'symptoms', 'expectations', 'thoughts', 'feelings', 'prompts', and 'non-specific cues'. Symptoms were defined as the verbal descriptions by the patient of internal experiences or sensations presented as, 'subjective evidence of disease or physical disturbance'.12 The definition of symptom was limited in this way, in order to differentiate it from the other categories described below, all of which could be considered symptoms in a broader sense of the term. Expectations referred to 'things looked forward to or anticipated'.12 Although many expectations may be implied in a consultation, only those that were referred to in words by the patient were classified as expectations. For example, a patient presenting with a sore throat may have been expecting penicillin. If he at The University of British Colombia Library on January 27, 2012 http://fampra.oxfordjournals.org/ Downloaded from