Elsevier

Social Science & Medicine

Volume 61, Issue 7, October 2005, Pages 1516-1528
Social Science & Medicine

Measuring patient-centered communication in Patient–Physician consultations: Theoretical and practical issues

https://doi.org/10.1016/j.socscimed.2005.02.001Get rights and content

Abstract

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.

Introduction

Patient-centered communication (PCC) is widely endorsed as a central component of high-quality health care (Committee on Quality of Health Care in America, 2001), but it is not clear what it is, upon what theories it is based, or how to measure it. Too often, the terms patient-centeredness, patient-centered care and PCC are used interchangeably. In our view, patient-centeredness should be reserved to describe a moral philosophy with three core values: (1) considering patients’ needs, wants, perspectives and individual experiences; (2) offering patients opportunities to provide input into and participate in their care; and (3) enhancing partnership and understanding in the patient–physician relationship (McWhinney, 1995). The term patient-centered care refers to actions in service of patient-centeredness, including interpersonal behaviors, technical interventions and health systems innovations. This paper focuses on PCC—communication among clinicians, patients and family members that promote patient-centeredness. An operational definition of PCC includes:

  • (1)

    Eliciting and understanding the patient's perspective—concerns, ideas, expectations, needs, feelings and functioning.

  • (2)

    Understanding the patient within his or her unique psychosocial context.

  • (3)

    Reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient's values.

  • (4)

    Helping patients to share power and responsibility by involving them in choices to the degree that they wish.

Clarity about how to measure PCC will lead to a more coherent body of research that provides an understanding of the structure of complex clinical interactions, and relationships between specific communication behaviors and desired subjective and objective outcomes. Measures of PCC also inform educational institutions, certifying organization and licensing bodies which increasingly include PCC as a criterion for physician competence (Campion, Foulkes, Neighbour, & Tate, 2002; Reznick et al., 1993).

Building on work by Mead & Bower (2000a), Mead & Bower (2002), Stewart (2001), and Howie, Heaney, and Maxwell (2004), this paper proposes next steps in operationalizing PCC. We propose principles for choosing among methods to assess PCC, and developing new ones. While our focus is on patient–physician interactions, similar issues apply to other health professionals.

Section snippets

Theoretical issues: operationalizing patient-centered communication (PCC)

The Institute of Medicine defines patient-centered care as not only a quality of an individual practitioner, but also of the health system as a whole (Committee on Quality of Health Care in America, 2001); there can be patient-centered physicians, patient-centered patients, patient-centered relationships and patient-centered health systems (Fig. 1). However, few instruments measure contributions of relationships, health systems and patients to PCC. PCC is both a trait (an overall style of

Choosing tools for assessing patient-centered communication (PCC)

A particular challenge in measuring PCC is how to gather information about communication behaviors and their effects from several points of view—an objective description of communication in the consultation, and the subjective experiences of patients and clinicians. However, patient and physician report measures often do not correlate closely with objective ratings of the same encounters.

Even within one method, components of PCC are not highly correlated—there is little evidence that

Identifying mediators between communication and outcomes

Theories of PCC indicate that outcomes improve by means of various mediators, such as enhanced adherence, patient self-efficacy and trust. However, in studies that include measures of outcomes of interventions, putative mediators and observational measures of the patient–physician interaction are rare. The few studies that demonstrate effects of PCC on chronic disease outcomes are all studies of patient training interventions (Griffin et al., 2004). Patients trained to take a more active role

Clarifying outcomes of patient-centered communication

In a comprehensive review of interventions to improve PCC, Lewin, Skea, Entwistle, Dick, and Zwarenstein (2001) concluded that while changes in communication behavior and changes in physician or patient perceptions and health behaviors outcomes are commonly achieved, changes in more distal outcomes, such as health status and utilization, are uncommon. Patient-directed activation interventions more likely improved disease outcomes, whereas physician-directed interventions to elicit and respond

Recommendations

Stewart (2001) described PCC as containing components that “are used for ease in teaching and research,” but that “patient-centered clinical practice is a holistic concept in which components interact and unite in a unique way in each patient–doctor encounter”. Despite the appeal of a single organizing principle to guide health care and health policy, empirical evidence suggests that PCC is not a unified construct. Even with further clarification and improved measures, correlations among

Conclusions

PCC is regarded by the public, health care organizations, funding agencies and licensure bodies as a component of high-quality care. We do not advocate abandoning patient-centeredness as a guiding philosophy of care. Rather, we suggest that PCC is a multifaceted construct, the components of which each advance the values of patient-centeredness in a different way. On the other hand, there may be an elusive trans-contextual ‘way of being’ that defines the essence of PCC—a unifying principle. Such

Acknowledgments

Tony Jerant, MD, provided valuable comments on the manuscript. Moira Stewart, Judith Belle Brown, Geoff Williams, Paul Little and Lisa Sturdy provided details on development of their measures.

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    Grant support: Patient-Centered Care and Health Care Costs, R.M. Epstein, Principal Investigator, AHRQ R01-HS1610-01A1.

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