Behaviorally Defined Patient-Centered Communication—A Narrative Review of the Literature

Michigan State University, B312 Clinical Center, East Lansing, MI 48824, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 02/2011; 26(2):185-91. DOI: 10.1007/s11606-010-1496-5
Source: PubMed
ABSTRACT
Touted by some as reflecting a better medical model and cited by the influential IOM report in 2000 as one of the six domains of quality care, patient-centered medicine has yet to fully establish its scientific attributes or to become mainstream. One proposed reason is failure to behaviorally define what the term 'patient-centered' actually means.
(1) To identify patient-centered articles among all reported randomized controlled trials (RCT); (2) to identify those with specific behaviorally defined interventions; (3) to identify commonalities among the behavioral definitions; and (4) to evaluate the relationship of the well-defined RCTs to patient outcomes.
Medline from April 2010 to 1975. ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: RCTs having any specific, behaviorally defined patient-centered skill(s) in an intervention with some patient outcome involving real adult patients and providers in real clinical situations. APPRAISAL AND SYNTHESIS METHODS: Critical appraisal via narrative review.
The prevalence of any mention of patient-centeredness among 327,219 RCTs was 0.50% (1,475 studies), from which we identified only 13 studies (0.90%) where there were behaviorally-defined patient-centered skills in an intervention. Although there were too few studies to make clinical recommendations, we identified common features of the behavioral definitions used: all went well beyond identifying individual skills. Rather, skills were grouped, prioritized, and sequenced by virtually all, often describing a stepwise patient-centered approach to, variously, gather data, address emotions, or inform and motivate.
The inherent subjectivity of our method for identifying behaviorally-defined studies could under- or over-represent truly replicable such studies considerably. Also, studies were few and very heterogeneous with interventions of widely differing intensity and foci.
RCTs identified as patient-centered were rare, and <1% of these were behaviorally defined and, therefore, possibly replicable. There were many common behavioral definitions in the studies reported, and these can guide us in identifying agreed-upon patient-centered interventions, the immediate next-step in advancing the field.

Full-text

Available from: Richard Frankel, Mar 06, 2014
REVIEWS
Behaviorally Defined Patient-Centered
CommunicationA Narrative Review of the Literature
Robert C. Smith, MD, MS
1
, Francesca C. Dwamena, MD, MS
1
, Madhusudan Grover, MD
2
,
John Coffey, MLS
1
, and Richard M. Frankel, PhD
3
1
Michigan State University, East Lansing, MI, USA;
2
Mayo Clinic, Rochester, MN, USA;
3
Indiana University, Indianapolis, IN, USA.
BACKGROUND: Touted by some as reflecting a better
medical model and cited by the influential IOM report in
2000 as one of the six domains of quality care, patient-
centered medicine has yet to fully establish its scientific
attributes or to become mainstream. One proposed
reason is failure to behaviorally define what the term
patient-centered actually means.
OBJECTIVES: (1) To identify patient-centered articles
among all reported randomized controlled trials (RCT);
(2) to identify those with specific behaviorally defined
interventions; (3) to identify commonalities among the
behavioral definitions; and (4) to evaluate the relation-
ship of the well-defined RCTs to patient outcomes.
DATA SOURCES: Medline from April 2010 to 1975.
ELIGIBILITY CRITERIA, PARTICIPANTS,
AND INTERVENTIONS: RCTs having any specific,
behaviorally defined patient-centered skill(s) in an
intervention with some patient outcome involving real
adult patients and providers in real clinical situations.
APPRAISAL AND SYNTHESIS METHODS: Critical
appraisal via narrative review.
RESULTS: The prevalence of any mention of patient-
centeredness among 327,219 RCTs was 0.50% (1,475
studies), from which we identified only 13 studies
(0.90%) where there were behaviorally-defined patient-
centered s kills i n an intervention. Although t here were
too few studies t o make clinical recommendations, we
identified common features of the behavioral defini-
tions used: all went well beyond identifying individual
skills. Rather, skills were grouped, prioritized, and
sequenced by virtually all, often describing a stepwise
patient-centered approach to, variously, gather data,
address emo tions, or infor m a nd m otivat e.
LIMITATIONS: The inherent subjectivity of our method
for identifying behaviorally-defined studies could under-
or over-represent truly replicable such studies consider-
ably. Also, studies were few and very heterogeneous with
interventions of widely differing intensity and foci.
CONCLUSIONS AND IMPLICATIONS: RCTs identified as
patient-centered were rare, and <1% of these were
behaviorally defined and, therefore, possibly replicable.
There were many common behavioral definitions in the
studies reported, and these can guide us in identifying
agreed-upon patient-centered interventions, the imme-
diate next-step in advancing the field.
KEY WORDS: patient-centered medicine; behavioral definitions;
psychosocial context.
J Gen Intern Med 26(2):18591
DOI: 10.1007/s11606-010-1496-5
© Society of General Internal Medicine 2010
INTRODUCTION
The Institute of Medicine (IOM) laments modern medicines
isolated focus on disease, ignoring the psychological and social
aspects of patients illnesses. The IOM averred that this quality
chasm be closed.
13
The patient-centered communication (PCC)
needed to achieve this closure occurs when the provider facil-
itates the patients perspective and the psychosocial context of
their illness and also shares power and responsibility.
4
Many have blamed the medical establishment for creating the
chasm by not including more psychosocial material in our student
and resident curricula. Puzzling, though, there is considerable
evidence that the establishment supports patient-centeredness;
e.g., most schools teach interviewing and have patient-centere d
principles as part of their mission statement, often referencing the
biopsychoso cial model; residency governing boards and organiza-
tions also espouse these principles; and testing bodies evaluate
our success in teaching patient-centered medicine. An alternative
consideration, we propose, is that establishment educators may
not know what to do next and still be consistent with their guiding
principle of evidence-based medicine and medical education.
Perhaps sharing some responsibility for the chasm, the field of
patient-centered and psychosocial medicine itself has been
encouraged by those inside and outside the discipline to develop
greater scienti fic rigor.
510
In fairness, this new field has evolved
rapidly, and its successes suggest an upward trajectory of
progress. The biopsychosocial model (BPS) was articulated by
Engel only in the late 1970s,
11,12
followed shortly by general
descriptions of patient-centered approaches by McWhinney ,
13
followed in turn by wide-scale promulgation of patient-centered
practices by what are now called the American Academy on
CommunicationinHealthcare,
14
the European Association for
Electronic supplementary material The online version of this article
(doi:10.1007/s11606 -010-14 96-5) contains supplementa ry material,
which is available to authorized users.
Received January 27, 2010
Revised July 1, 2010
Accepted August 10, 2010
Published online September 8, 2010
JGIM
185
Page 1
Communication in Healthcare,
15
and the Institute for Healthcare
Communication
16
as well as many other groups including
several primary care organizations. Considerable research suc-
cess also has followed in areas such as a systems approach to
medicine,
11,12,17
identifying the functions of the interview ,
1820
pinpointing t he shortcomings of isolated disease-oriente d
approaches,
21
demonstrating the key components of the
provider-patient interaction,
22
and beg inning to show some impact
on health outcomes.
22,23
Many experts in the field, though, remain
restive and are pushing for further outcomes-based research.
4,6,9
The above successes have exposed the next problem to be
solved and, we propose, the new direction for the field. Specific
definitions of patient-centered medicine and explicit directions for
practice, many warn, are lacking,
4,5,7,8,2428
impeding both
research and teaching
10,29,30
and resulting in variable and
sometimes contradictory recommendations for educating
learners.
5,7,8,26
There currently is no accepted model/method of
PCC for teaching or research on PCC.
3134
We are warned that we
cannot simply say we teach patient-centered skills.
27
Our
students need to know exactly what to say, with behaviorally
defined PCC skills broken down into teachable components.
7
This approach does not create the automatons a few fear but,
research shows, it produces flexible, skilled students and
providers.
7,35,36
Lack of definition of PCC fosters the fields
reliance on anecdotal reports, opinion pieces, position articles,
consensus conferences, and exploratory/descriptive work,
6,32,37
which, in turn, encourage educators and students perceptions of
communication skills training as soft and of limited value.
38,39
Most scholars agree that, while data support some utility of
PCC,
5,7,9,10,23,40,41
the quality of studies does not allow firm
conclusions relating PCC to patient outcomes.
510
Indeed, the
higher the quality of the study, the less convincing the data tend
to be.
42
While rigorous noninterventional studies of provider-
patient interactions have been conducted and can inform the
more stringent behavioral definitions of PCC we are urged to
make,
3134
only the RCT-based patient-centered behaviors we
seek to synthesize here as our primary objective can provide the
evidence-based definition the establishment seeks.
Responding to requests for a behavioral definition of PCC in
a replicable model/method
35,36,4345
and for evidence-based
models,
32
we identified a basic PCC method to operationalize
the BPS model via literature review, consulting with others, and
our own experiences.
35,36
Our work in defining and studying this
model, included in this review, piqued our curiosity about other
replicable, behaviorally defined models and led to this search for
such PCC methods; our model, though, was not used to define
PCC criteria for entry into study.
METHODS
Overview
Our analysis is best classified as a narrative review with its
qualitative emphasis and acknowledged potential for bias.
46
The basic theory of change model we sought to inform can be
summarized as: a patient-centered approach identifies
patients biological (dise ase), psychological (personal), and
social (environmental) dimensions, thus operationalizing
Engels biopsychosocial model.
11,12
Compared with a biomedi-
cally focused, disease-oriented model, the patient-centered
approach integrates relevant biological and psychosocial data
about the patient, better establishing a more broadly focused
provider-patient relationship and communication. In turn, this
leads to improved patient satisfaction, adherence, understand-
ing, and, in some cases, health outcomes.
44
Our goals were to: (1) conduct a literature review of article titles
or abstracts with any mention of RCT methodology; (2) identify
from the title or abstract of these RCTs any studies using the
terms doctor-patient relationship and/or patient-centered. The
latter did not become a MESH heading until 1995, but doctor-
patient relationship has been used since 1965, so we used this as
a proxy to capture patient-centeredness from 1975 to 1995; (3)
conduct a full review of abstracts of the identified studies to
further evaluate their qualifications as patient- centered; (4)
review full articles of abstracts we classified as patient-centered
to identify those with any behaviorally defined skill(s) in the
interventions; (5) analyze the identified articles for the details of
their replicable, behaviorally defined practices to inform our
search for common patterns or definitions; and (6) evaluate a
possible relationship to patient outcomes.
Search Strategy
The MEDLINE database was searched during the second week of
April 2010 back to 1975 (when abstracts first appeared) using the
PubMed interface. The searches were conducted by one of the
authors (JC) who is a professional librarian and is skilled and
experienced in professional searches. When performing the
search, the official medical subject heading (MeSH) t erm
professional-patient-relations was allowed to explode, a MED-
LINE MeSH feature that automatically included all patient-
relations terms with the following specific professionals: physi-
cians, nurses, dentists, and researchers. These same terms were
also searched as title phrases and included with the MeSH batch.
These combined results were pooled together (using OR)with
the results of a search using the MeSH term patient-centered-
care and the text words patient centered and the alternative
spelling patient centred. The combined results were limited to
randomized controlled trials by using the publication type limit
option as well as searching for the limit concept in the title field
using the full phrase or the abbreviation rct. The search was
also limited to those articles published in English. In addition, we
searched our own files, reviewed published reviews with related
goals, and consulted with experts for any potential additional
articles. We also searched all Cochrane Systematic Reviews
available for additional articles we may have missed. Because of
cost in this unfunded study, we did not search EMBASE.
Selection Criteria
We wanted to find those studies that most objectiv ely described the
patient-centered process in behavioral terms, so we restricted our
review to RCTs, where we expected the most carefully defined
interventions. We also restricted our evaluation to patient-centered
practices by the patients primary health care provider (major
caretaker, usually but not always the primary care provider)
because we believed the closest and most enduring relationship
would provide the best evidence.
186 Smith et al.: Behaviorally Defined Patient-Centered Communication JGIM
Page 2
(1) Inclusion criteria
(a) RCT with randomization of patients and/or providers
where an intervention had some patient-centered or
provider-patient relationship component addressed by
a primary provider (major caretaker) to a patient in
person and where some patient outcome was evaluat-
ed, whether related to patient-centeredness or not.
Teaching interventions designed to improve patient-
centered care were included only if some patient
outcome was evaluated, whether or not training out-
comes were recorded.
(b) The intervention was sufficiently described to be repli-
cable: the skill(s) used in the patient-centered interven-
tion was itself described in explicit behavioral terms.
(c) Published in English before April 2010.
(2) Exclusions:
(a) Study design: RCT studies with teaching outcomes
only, pilot RCT studies of any type, studies from prior
RCT databases, reviews, meta-analyses, and other
mentions of a RCT that did not meet inclusion criteria.
(b) Provider: non-primary caretaker providers, although
a major caretaker such as an acupuncturist or nurse
was not an exclusion; multiple providers or groups of
providers; psychotherapy.
(c) Patients: simulated patients; patients younger than
18 years.
(d) Patient-centered interventions that were: restricted to
nonverbal behaviors or general descriptions of an
alliance, Internet-based, restricted to handouts/
decision aids/wri tten material/electronic material,
not involving a real interacti on (e.g., observed
taped interaction of another), telephone-based,
directive (e.g., to a specific technique such as
rea ttribution), on ly general e ffor ts to help patient,
or manualized/guided treatments.
Procedure
(1) The abstracts were divided in approximately equal propor-
tions, and each was reviewed by two of three authors (MG,
FCD, RCS) for determination of inclusion or exclusion. Final
determinations were made by consensus.
(2) Two of three authors also rated each of the 13 RCTs selected
for study. To prevent any conflicts of interest, one of the
authors (RCS) did not evaluate studies in which he had
participated.
Data Abstraction
Based on the literature
47
and our e xperience with Cochrane
reviews, we outline in Text Box the criteri a we used. Data
were extracted from these criteria to form the seven
categories in the summary table ( available online): study
reference, ye ar, and loca tion; setting; participant s; training
and its impact; intervention, its i ntensity, and controls;
methods and their quality; and measures and patient out-
comes. The heterogeneity of the studies precluded pooling of
data and overall effect size calculations.
Criteria Used in Data Extraction
1. Location of study
2. Practice type and number of centers
3. Provider type, inclusion/exclusion criteria, numbers of providers, and provider recruitment rate
4. IRB approval
5. Sponsor of study
6. Overall study duration
7. Summary of trial design/methods
8. Randomization type (provider or patient) and method
9. Primary aims of study (education vs. treatment)
10. Number of patients and patient recruitment rate
11. Patient age, gender, culture, education, and employment status
12. Patient diagnoses and inclusion/exclusion criteria
13. Blinding of data gatherers, providers, and patients
14. Training procedure, structure, duration, objectives, and method
15. Training by whom and who was trained
16. Training outcomes (knowledge, attitude, skills, personal awareness) and measures and test
characteristics
17. Training summative and formative outcome
18. Patient intervention type (drug, mental, physical, educational, multidimensional)
19. Intervention primary endpoint, hypothesis, intention to treat, and pre-hoc power calculation
20. Patient-centered intervention details in behavioral terms and evaluation of replicability
21. Intensity of patient-centered intervention: number of and duration of visits
22. Patient-centered intervention primary or secondary focus
23. Other interventions (e.g., medications, exercise)
24. Patient outcomes (satisfaction, adherence, health status), effect sizes, percent variance explained,
post-hoc analyses
25. Patient-centered contribution to outcomes, mediator/moderator/subgroup analyses
25. Author recommendation
187Smith et al.: Behaviorally Defined Patient-Centered CommunicationJGIM
Page 3
In constructing the summary table (onli ne), we sought t o
provide the details to support what we judged to be replicable
studies. We paid particular attenti on to r ecording the spe cific
PCC behaviors/skills and the details of how they were
deployed, including their timi ng, priorit ization, and sequenc-
ingaswellasanyguidingstepsandsubstepsthatwereused
to organize the skills. We also identified how they were used
over time. Also, to highlight the potentially most useful
studies for informing a relationshi p of pati ent-centered
practices to health outcomes, we defined the f ollow ing criteria
post-hoc. St udies with a ny positive outcome were so des ig-
nated, and the others were called negative studies. We then
evaluated positive studies for adequate generalizability,
which we defined as at least 30% recruitment rates for
providers in cluster randomized studies and at least 50%
recruitment rates when patients were the f ocus of randomi-
zat ion . We evaluate d negative studies f or sufficient pow er,
and for either a positive training impact or demonstrated
fidelity to the interve ntion. In the absence of these criteria, a
negative study could be due to insufficient numbers of
subjects or failure to deploy the intervention.
RESULTS
Summarized in Figure 1, we identified 327,219 publications
with any mention of RCT in the title or abstract from 1975 to
April 2010. Of these, 1,475 (0.5%) referred to patient-centered
and/or provider-patient relationship. From review of these
abstracts, we identified 75 articles (5%) for full article review
and identified 13 (0.9%) meeting our criteria for analysis in this
review. To maximize our results, we also searched all 33
Cochrane Systematic Reviews, 25 of which did not address
patient-centered material by review of their titles and
abstracts; of the remaining 8 reviews, we found no articles
not already identified. We did not exclude studies rated as
negative.
The summary table (online) summarizes the key features of the
study, which we now synthesize and integrate. Nearly all studies
recorded some funding, and they occurred in health centers and
HMOs, private settings, and university settings. Most studies had
from 2060 providers; recruitment rates were presented in the
majority of studies and varied from 7% to 100%, most falling at
the extremes of this range. Providers usually were physicians,
mostly primary care, but with some physician assistants, nurse
practitioners, and others. Subjects were characteristically general
medical patients, although many had psychosocial problems; e.g.,
pain management, alcohol and tobacco cessation, and medically
unexplained symptoms. Recruitment rates were generally >50%.
All but one study included training, the majority of which took 10
or fewer hours, typically over one to two workshop sessions.
Outcomes of training were measured in less than one-half of the
studies, and most showed a positive impact of training. Most
interventions involved only one visit and most controls were usual
care.
There was a very wide range of behaviorally defined interven-
tions, but common features were noted. Toward generally
expressed goals of achieving improved communication and
provider-patient relationships, trust, and positive regard, some
well-defined behavioral features were using open-ended skills,
eliciting and responding to emotion, expressing support and
willingness to help, exploring patient understanding and expla-
nation of their problem, asking what the patient would like to
have happen, motivating and encouraging a positive approach,
giving specifics of recommended behavioral change, linking
treatment to the patients needs and level of understanding,
advising but acknowledging the patients choice, and accepting
the patientschoice.
All studies used these individual skills and also aggregated
them in a multidimensional approach, grouping related skills
together for a given purpose of the intervention (e.g., tobacco
cessation); some further specified sequences of skills. In turn, to
better achieve the aims of the intervention, many identified
multiple such skill sets, more complex interventions identifying
them as steps where they then indicated how to sequence and
prioritize the steps at one visit and over multiple visits. Such
steps were not skills per se and, instead, identified general goals
within an overall patient-centered intervention. For example, the
first step might focus on an individual patient-cente red goal of a
multidimensional intervention (e.g., the patients agenda), while
another step focused on another goal (e.g., the patientsemotion),
and another focused on a third goal (e.g., stopping alcohol use).
The more complex interventions outlined the amount of time for
each step and some identified high or low priority steps. Parts or
all of this process of using a step-wise model to learn a complex
skill were present in many of the studies.
In assessing the methods and quality of the studies, most
involved randomization of providers/practices (rather than
patients), nearly half with details of the randomization method
provided, and most recorded blinding of outcome assessors;
blinding of others was rarely mentioned.Unitofanalysiserror
usually was not reported, intention to treat evaluations occurred
in about half, and power calculations for patient outcomes were
provided in the majority of studies.
Figure 1 . Selection of publications for review.
188 Smith et al.: Behaviorally Defined Patient-Centered Communication JGIM
Page 4
With fewer studies than expected, evaluation of a relationship
between patient-centeredness and outcomes was difficult. There
were six studies with any positive patient outcome and seven
were negative. In applying our post-hoc criteria, we found that
only four positive studies and one negative study were sufficiently
rigorous to inform a relationship of patient-centered practices to
health outcomes. In the eight rejected studies, nonrepresentative
study samples, stemming from low recruitment rates, were
problematic in positive studies. Additionally, negative studies
were plagued by low po wer or lack of e vidence that the
intervention could have been effectively deployed. In the last
column of of the summary table (online), we note our summary of
the post-hoc outcome evaluations. The patient outcomes studied
varied considerably: pain reduction; evaluation of the providers
patient-centered characteristics; satisfaction, adherence, and
confidence in care; alcohol and cigarette reduction; antibiotic
use; reduction in mental health problems.
DISCUSSION AND CONCLUSION
Trying to understand why patient-centeredness might play
such a small role in outcomes-based research, we focused on
the lack of explicit behavioral definitions of what is meant by
patient-center edness.
5,7,8,26
Among the small fraction of studies
mentioning the doctor-patient relationship or being patient-
centered, only 13 (0.9%) could be classified as behaviorally
defined. This makes it difficult to design replicable patient-
centered research interventionsor replicable teaching
methodsand m ay account for the dearth of RCTs i ncorpo-
rating patient-centered practices.
We believe the significant story here is identifying a common
process among the replicable studies we evaluated, one that can
perhaps guide the field in its next steps. All defined specific
behavioral skills to be deployed with patients; e.g., use open-
ended inquiry and inquire about emotions. But, to a greater or
lesser extent, all went well beyond describing individual skills.
Skills were grouped, prioritized, and sequenced by virtually all,
and many provided stepwise guidance. For the more complex
interventions, specific steps and their subset skills were identi-
fied, and the steps were similarly sequenced and prioritized.
While not prescriptive, steps provided signposts for bases to be
touched along the way of a complex PCC interaction that a new
learner or researcher would want to incorporate. Sometimes
noted was an indication of when to transition to the more
disease-based part of the interactionand some provided longi-
tudinal guidelines for use of PCC over time.
In stepwise approaches, an analogy is learning the physical
examination where, for example, one learns the vital signs step
(with subset skills of measuring blood pressure, pulse, respira-
tion, and weight); then proceeds, starting at the top, to the eyes
step (with subset skills of pupillary reflexes, vision, conjunctiva,
funduscopic, etc.); then to the ears step (and its multiple subset
skills); and so on through the rest of the exam. While PCC skills
are far more complex than physical examination skills, the
comparison can help understand what our studies were doing.
Our studies meet the recommendations of many educators
that behaviorally defined models be employed to teach any
complex skill or set of skills.
24,34,41,4850
We highlight also that
the PCC interventions in this study concerned the fundamental
functions of the interview,
1820
which were deployed as two
models: Model 1data-gathering and emotion-handling and/or
Model 2informing and motivating patients.
We acknowled ge serious limitations in this review: the
potential for subjectivity in the inclusion of studies we believed
to be behaviorally defined and replicable is a limitation that
could lead to under- or over-identification of replicable inter-
ventions. We invite others to submit to us or to the Journal
examples they believe are sufficiently behaviorally defined to be
replicableand to object to those we have included if they are
not sufficiently defined behaviorally. Developing such a bank of
examples could provide further guidance for future research
and teaching. Some conclusions also are limited by the wide
diversity and heterogeneity of studies in both content and
intensity of their interventions. We also recognize that the small
number of studies raises the possibility of publication bias.
Further, we considered only RCTs because we reasoned that
they would have the most stringently defined interventions, but
that assumption may be incorrect.
51
Finally, we read only a
fraction of the quarter of a million articles considered and could
well have missed patient-centered material that was not identified
by our screening procedure. We also did not screen for possibly
related terms like relationship-centered care or collaborative care.
The clinical implications of this review are minimal because of
the paucity of clinical trial data. Clinicians should still continue
being patient-centered based upon strong humanistic and moral
reasons, strong theoretical backing, and the fields impressive
indirect evidence that being patient-centered is effective.
The pedagogic and research implications, on the other hand,
are profound. Our findings show that we have yet to develop
large-scale empirical studies based on agreed-upon definitions
that would answer some of the most fundamental questions
about patient-centeredness and its impact on processes and
outcomes of care and on teaching.
The studies we reviewed can provide guidance: they represent
examples of the well-described behaviorally defined skills and
sets of skills that, many conclude, must be further developed as
the critical next-step in advancing the field. We recommend a
specific next-step: the field agree upon two basic patient-centered
models: Model 1 for data-gathering and emotion-handling; Model
2 for informing and motivating patients. These represent the
basic functions of the interview.
1820
Model 1 will be involved as
part of virtually all interactions and all treatment interventions.
Model 2 is more specific to situations where informing and
motivating the patient are additionally required and where
sharing decisions is key. The components of the Model 1 always
are integrated with Model 2. Examples of generalizable, evidence-
based models from our study exist: Model 1
43
and Model 2.
43,5254
The field is urged to adopt these, as a starting point, or to produce
other evidence-based alternatives.
By successfully addressing this logical next step, we can
extend our already remarkable progress and more fully meet the
fields humanistic, moral, and theoretical potential. This also will
provide compelling data for evidence-based educators and
scholars of the establishmen t by giving them the information
needed to further integrate patient-centeredness into modern
medicinetaking a long step towards closing the quality chasm.
Acknowledgements: There was no funding involved in this project.
Conflict of Interest: None disclosed.
189Smith et al.: Behaviorally Defined Patient-Centered CommunicationJGIM
Page 5
Corresponding Author: Robert C. Smith, MD, MS; Michigan State
University, B312 Clinical Center, East Lansing, MI 48824, USA
(e-mail: Robert.smith@ht.msu.edu).
REFERENCES
1. Institute of Medicine. 1st Annual Crossing the Quality Chasm Summit.
In: 1st Annual Crossing the Quality Chasm Summit; 2004 (January 67)
January 67, 2004; 2004 (January 67). p. 112 (Executive Summary).
2. Institute of Medicine. Improving the quality of health care for mental and
substance-use conditions: Quality chasm series (Free Executive Sum-
mary). In; 2006; 2006.
3. Institute of Medicine. Crossing the quality chasm: a new health system
for the 21st century. Washington: National Academy Press; 2001.
4. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered
communication in patient-physician consultations: theoretical and
practical issues. Soc Sci Med. 2005;61(7):151628.
5. Mead N, Bower P. Patient-centred consultations and outcomes in primary
care: a review of the literature. Patient Educ Couns. 2002;48(1):5161.
6. Bensing J, van Dulmen S, Tates K. Communication in context: new
directions in communication research. Patient Educ Couns. 2003;50
(1):2732.
7. Headly A. Communication skills: a call for teaching to the test. Am J
Med. 2007;120(10):912 5.
8. Mead N, Bower P, Hann M. The impact of general practitioners patient-
centeredness on patients post-consultation satisfaction and enable-
ment. Soc Sci Med. 2002;55:28399.
9. Cegala DJ. Emerging trends and future directions in patient communi-
cation skills training. Health Commun. 2006;20(2):1239.
10. Griffin SJ, Kinmonth AL, Veltman MW, Gillard S, Grant J, Stewart M.
Effect on health-related outcomes of interventions to alter the interaction
between patients and practitioners: a systematic review of trials. Ann
Fam Med. 2004;2(6):595608.
11. Engel GL. The clinical application of the biopsychosocial model.
American Journal of Psychiatry. 1980;137:53544.
12. Engel GL. The need for a new medical model: a challenge for biomed-
icine. Science. 1977;196:12936.
13. McWhinney I. The need for a transformed clinical method. In: Stewart
M, Roter D, eds. Communicating with medical patients. London: Sage
Publications; 1989:25 42.
14. American Academy on Communication in Healthcare (AACH). reuwee@-
drakeco.ccsend.com; chris@aachonline.org; 16020 Swingley Ridge Road,
Suite 300 Chesterfield, MO 63017; www.AACHonline.org, (Accessed
August 12, 2010).
15. EACH. European Association for Communication in Healthcare. In:
NIVEL (Netherlands Institute for H ealth Services Resea rch); P.O .
Box 1568; 3500 BN Utrecht; http://www.each.eu/ (Accessed August
12, 2010).
16. Institute for Healthcare Communication. http://www.healthcarecomm.
org/index.php?sec=who (Accessed August 12, 2010).
17. Brody H.
The systems view of man: implications for medicine, science,
and ethics. Perspect Biol Med. 1973;17:7192.
18. Bird J, Cohen-Cole SA. T he three-function model of the medical
interview: an educational device. In: Hale M, ed. Models of Teaching
Consultation-Liaison Psychiatry. Basel: Karger; 1991:6588.
19. Cohen-Cole SA. The medical interview: The three function approach. St.
Louis: Mosby-Year Book, Inc; 1991.
20. Lazare A, Putnam S, Lipkin M. Three functions of the medical interview.
In: Lipkin M, Putnam S, Lazare A, eds. The medical interview. New
York: Springer-Verlag; 1995:319.
21. Beckman HB, Frankel RM. The effect of physician behavior on the
collection of data. Ann Intern Med. 1984;101:6926.
22. Roter D. Which facets of communication have strong effects on outcomea
meta-analysis. In: Stewart M, Roter D, eds. Communicating with medical
patients. London: Sage Publications; 1989:18396.
23. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered
care on outcomes. J Fam Pract. 2000;49(9):796804.
24. Maguire P. Teaching interviewing skills to medical students. Medical
Encounter. 1992;8:45.
25. Michie S, Miles J, Weinman J. Patient-centredness in chronic illness:
what is it and does it matter? Patient Educ Couns. 2003;51(3):197206.
26. Mead N, Bower P. Patient-centredness: a conceptual framework and
review of the empirical literature. Soc Sci Med. 2000;51(7):1087110.
27. Cegala DJ, Broz SL. Physician communication skills training: a review
of theoretical backgrounds, objectives and skills. Medical Education.
2002;36:100416.
28. Levenstein JH, Brown JB, Weston WW, Stewart M, McCracken EC,
McWhinney I. Patient centered clinical interviewing. In: Stewart M,
Roter D, eds. Communicating with medical patients. London: Sage
Publications; 1989:10720.
29. Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions
for providers to promote a patient-centered approach in clinical con-
sultations (Review). In; 2005.
30. Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions
for providers to promote a patient-centered approach in clinical con-
sultations (Cochrane Review). In: The Cochrane L, ed. The Cochrane
Library, Issue 4, 2003. Chichester: John Wiley & Sons; 2001:169.
31. Roter D. The enduring and evolving nature of the patient-physician
relationship. Patient Education and Counseling. 2000;39:5 15.
32. Inui TS, Carter W B. Problems and prospects for health services
research on p rovider-patient communication. Med Care. 1985;23
(5):52138.
33. Stew art M, Roter D. Conclusions. In: Stewart M, Roter D, eds.
Communicating with medical patients. London: Sage Publications;
1989:2525.
34. Engel GL. Foreword - Being scientific in the human domain: from
biomedical to biopsychosocial. In: Smith RC, ed. The Patients Story:
integrated patient-doctor interviewing. Boston: Little, Brown and Co;
1996:ixxxi.
35. Smith RC, Marshall-Dorsey AA, Osborn GG, et al. Evidence-based
guidelines for teaching patient-centered interviewing. Patient Education
and Counseling. 2000;39:2736.
36. Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive
training for residents in interviewing. A randomized, controlled study.
Ann Intern Med. 1998;128:11826.
37. Lurie SJ. Raising the passing grade for studies of medical education.
JAMA. 2003;290:12102.
38. Hart I. Best evidence medical education (BEME). M edical Teacher.
1999;21:4534.
39. Harden RM, Grant J, Buckley G, Hart IR. BEME Guide No. 1: Best
evidence medical education. Medical Teacher. 1999;21:55362.
40. Stewart MA. Effective physician-patient communication and health
outcomes: a review. Can Med Assoc J. 1995;152(9):142333.
41. Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interven-
tions make a difference in conversations between physicians and
patients: a systematic review of t he evidence. Med Care. 2007;45
(4):3409.
42. Hulsman RL, Ros JFG, Winnubst JAM, Bensing JM. Teaching
clinica lly experiences physicians communication skills. A review of
evaluation studies. Medical Education. 1999;33:65568.
43. Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat
patients with medically unexplained symptomsA randomized con-
trolled trial. J Gen Intern Med 2006;21:6717. PMCID: PMC1924714.
44. Smith RC. Patient-centered interviewing: an evidence-based method.
2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2002.
45. Smith R. Videotape/DVD of Evidence-Based Interviewing (2001): 1)
Patient-Centered Interviewing and 2) Doctor-Centered Interviewing. In.
East Lansing, MI 48824: Produced by Michigan State University
Broadcasting Services, Eric Schultz, Producer - Available from http://
shop.msu.edu/ProductDetails.asp?ProductCode=MSUT%2D17 (Accessed
August 12, 2010).
46. Crowther MA, Cook DJ. Trials and tribulations of systematic reviews
and meta-analyses. Hematology Am Soc Hematol Educ Program.
2007;2007:4937.
47. Downs SH, Black N. The feasibility of creating a checklist for the
assessment of the methodological quality both of randomised and non-
randomised studies of health care interventions. J Epidemiol Commu-
nity Health. 1998;52(6):37784.
48. Schunk DH. Self-efficacy and classroom learning. Psychology in the
Schools. 1985;22:20823.
49. McKeachie WJ, Pintrich PR, Lin Y, Smith DAF, Sharma R. Teaching
and Learning in the College Classroom %7 2nd. Ann Arbor, MI: Regents
of the University of Michigan, Suite 2400, School of Education Bldg.;
1990.
50. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship,
communication, and efficiency in the medical encounter: creating a
clinical model from a literature review. Arch Intern Med. 2008;168
(13):138795.
190 Smith et al.: Behaviorally Defined Patient-Centered Communication JGIM
Page 6
51. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S. Publication
guidelines for quality improvement studies in health care: evolution of
the SQUIRE project. J Gen Intern Med. 2008;23(12):212530.
52. Ockene JK, Wheeler EV, Adams A, Hurley TG, Hebert J. Provider
trainin g for patient-centered alcohol counseling in a primary care
setting. Arch Intern Med. 1997;157(20):233441.
53. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief
physician- and nurse practitioner-delivered counseling for high-
risk drinkers: does it work? Arch Intern Med. 1999;159(18):2198
205.
54. Williams GC, Deci EL. Activating patients for smoking cessation
through physician autonomy support. Med Care. 2001;39(8):81323.
191Smith et al.: Behaviorally Defined Patient-Centered CommunicationJGIM
Page 7
  • Source
    • "For example: Balint [3] defines patient-centered medicine as understanding the patient as a unique human being; McWhinney [4] refers to understanding the patient's experience of illness. Other definitions offer specific components such as: maintaining a bio-psychosocial perspective, understanding the patient as a person, sharing power and responsibility, developing a therapeutic alliance and being aware of the subjectivity of the physician as a person567. There is no doubt, however, that medical care requires effective physician-patient communication that can be achieved through patient centeredness [6]. "
    [Show abstract] [Hide abstract] ABSTRACT: The traditional dyadic dynamics of the medical encounter has been altered into a triadic relationship by introducing the computer into the examination room. This study defines Patient-Doctor-Computer Communication (PDCC) as a new construct and provides an initial validation process of an instrument for assessing PDCC in the computerized exam room: the e-SEGUE. Material and methods Based on the existing literature, a new construct, PDCC, is defined as the physician’s ability to provide patient-centered care while using the computer during the medical encounter. This study elucidates 27 PDCC-related behaviors from the relevant literature and state of the art models of PDCC. These were embedded in the SEGUE communication assessment framework to form the e-SEGUE, a communication skills assessment tool that integrates computer-related communication skills. Based on Mackenzie et al.’s methodological approach of measurement construction, we conducted a two-phased content validity analysis by a general and expert panels of the PDCC behaviors represented in the e-SEGUE. This study was carried out in an environment where EMR use is universal and fully integrated in the physicians’ workflow. The panels consisted of medical students, residents, primary care physicians, healthcare leaders and faculty of medicine members, who rated and provided input regarding the 27 behaviors. Overall, results show high level of agreement with 23 PDCC-related behaviors. The PDCC instrument developed in this study, the e-SEGUE, fared well in a rigorous, albeit initial, validation process has a unique potential for training and enhancing patient-doctor communication (PDC) in the computerized examination room pending further development.
    Full-text · Article · Feb 2015 · Health & medicine: journal of the Health and Medicine Policy Research Group
  • Source
    • "This leads to a heterogeneous use of the term [21], resulting in a wide variation in the dimensions included in scales that purport to measure patient-centeredness303132. Thus, research results regarding the effectiveness of patient-centered interventions, found by such various measurement instruments, are inconsistent [19,20]. Part of the mixed results regarding outcomes of patient-centered care could be explained by the variation in the definition of the concept which may constitute a barrier to the implementation of patient-centered care into routine clinical practice [33]. "
    [Show abstract] [Hide abstract] ABSTRACT: Existing models of patient-centeredness reveal a lack of conceptual clarity. This results in a heterogeneous use of the term, unclear measurement dimensions, inconsistent results regarding the effectiveness of patient-centered interventions, and finally in difficulties in implementing patient-centered care. The aim of this systematic review was to identify the different dimensions of patient-centeredness described in the literature and to propose an integrative model of patient-centeredness based on these results.
    Full-text · Article · Sep 2014 · PLoS ONE
  • Source
    • "Patient-centered care is a philosophical orientation that seeks to place patients at the center of their own care (Berwick, 2009). Over the last decade, patient-centered care has been held up as an ideal to guide different facets of medical practice (Smith, Dwamena, Grover, Coffey, & Frankel, 2011; Swenson, Zettler, & Lo, 2006), health outcomes (Charlton, Dearing, Berry, & Johnson, 2008; J. H. Robinson, Callister, Berry, & Dearing, 2008), and health care system redesign (Hibbard, 2004). For example, in 2011 the Department of Veterans Affairs (VA) launched the Office of Patient Centered Care and Cultural Transformation to develop and evaluate new health care models to provide effective, patient-centered, and culturally appropriate services to veterans in an attempt to improve health care quality (Planetree, 2011; Office of Public and Intergovernmental Affairs, 2011). "
    [Show abstract] [Hide abstract] ABSTRACT: This article uses the theoretical and methodological framework of Grounded Practical Theory (GPT) to provide a lens for analyzing and interpreting discourse as a situated form of social action in routine Type 2 diabetes visits. Drawing on a total data-set of 400 audio-recorded routine visits, we randomly selected 55 visits for qualitative analysis. In this article, we use Conversation Analysis to document communication techniques, which we in turn use as evidence to ground our claims within the GPT framework. We use two single cases of interaction to analyze communication techniques physicians use when recommending a change from oral medication to insulin. We argue treatment intensification is a key moment in health communication to reflect about patient centeredness because physicians can find themselves in an interactional dilemma: while insulin may effectively help control unstable disease, an insulin recommendation may simultaneously counter patient values and treatment preferences. Our analysis suggests that physicians use what we call interactional sensitivity to balance medical need and patient preferences when making medical decisions by tailoring their communication according to the local situation and the patient's larger illness trajectory. We propose that interactional sensitivity is a type of communication work and a quality of patient-centered communication characterized by the theoretical relationship between tailoring communication to the contingencies of the local interaction and the global illness trajectory. Overall, this article contributes to health communication scholarship by proposing a normative model for reflecting on how physicians negotiate challenging interactions with patients during routine chronic illness visits.
    Full-text · Article · May 2014 · Journal of Applied Communication Research
Show more