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


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.

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Available from: Richard Frankel, Mar 06, 2014
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    • "These criticisms have led some to eschew PCI practices, dismissing them as 'soft science' [3]. Our group developed an evidence-based, behaviorally defined PCI method that enabled us to study the PCI experimentally and, in this particular case, to better understand its neurobiological underpinnings [3] [4] [5] [6] [7] [8]. "
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    ABSTRACT: OBJECTIVE: To identify the functional magnetic resonance imaging (fMRI) changes associated with a patient-centered interview (PCI) and a positive provider-patient relationship (PPR). METHODS: Nine female patients participated, five randomly selected to undergo a replicable, evidence-based PCI, the other four receiving standard clinician-centered interviews (CCI). To verify that PCI differed from CCI, we rated the interviews and administered a patient satisfaction with the provider-patient relationship (PPR) questionnaire. Patients were then scanned as they received painful stimulation while viewing pictures of the interviewing doctor and control images (unknown doctor). RESULTS: Interview ratings and questionnaire results confirmed that PCIs and CCIs were performed as planned and PCIs led to a much more positive PPR. We found significantly reduced pain-related neural activation in the left anterior insula region in the PCI group when the interviewing doctor's picture was shown. CONCLUSION: This study identifies an association between a PCI that produced a positive PPR and reduced pain-related neural responses in the anterior insula. This is an initial step in understanding the neural underpinnings of a PCI. PRACTICE IMPLICATIONS: If confirmed, our results indicate one neurobiological underpinning of an effective PCI, providing an additional scientific rationale for its use clinically.
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    • "This leads to an ambiguity concerning relevant and adequate dimensions for the measurement of patient-centeredness.1,4,16 Consequently, outcomes regarding the effectiveness of patient-centeredness are related to its definitions used in respective studies,25 which limits the comparability of their results.26 However, consistent measurement instruments are indispensable2,8,26 for implementing the concept of patient-centeredness in routine clinical practice, which is demanded from a health policy level. Therefore, the following objectives will be addressed in this study: "
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    • "Patient-centered interviewing (PCI) has been extensively studied, with recent work specifically defining PCI behaviorally and providing evidence that it is effective in improving patient outcomes [1] [2] [3] [4] [5]. This paper describes the emergent linguistic effects that distinguish standard clinician-centered interviewing (CCI) from a well-established, evidence-based method that integrates PCI and CCI, summarized in Table 1. "
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    ABSTRACT: To evaluate interactional effects of patient-centered interviewing (PCI) compared to isolated clinician-centered interviewing (CCI). We conducted a pilot study comparing PCI (N=4) to CCI (N=4) for simulated new-patient visits. We rated interviews independently and measured patient satisfaction with the interaction via a validated questionnaire. We conducted interactional sociolinguistic analysis on the interviews and compared across three levels of analysis: turn, topic, and interaction. We found significant differences between PCI and CCI in physician responses to patients' psychosocial cues and concerns. The number and type of physician questions also differed significantly across PCI and CCI sets. Qualitatively, we noted several indicators of physician-patient attunement in the PCI interviews that were not present in the CCI interviews. They spanned diverse aspects of physician and patient speech, suggesting interactional accommodation on the part of both participants. This small pilot study highlights a variety of interactional variables that may underlie the effects associated with patient-centered interviewing (e.g., positive relationships, health outcomes). Question form, phonological accommodation processes, and use of stylistic markers are relatively unexplored in controlled studies of physician-patient interaction. This study characterizes several interactional variables for larger scale studies and contributes to models of patient-centeredness in practice.
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