Patient centredness is becoming a widely used, but poorly understood, concept in medical practice. It may be most commonly understood for what it is not—technology centred, doctor centred, hospital centred, disease centred (Miller, 2001: 322).
There are a lot of practitioners and professional bodies that claim that their practice is patient centred. And why not. If people expect this to be stated as a defining feature of health professional practice today, why wouldn’t you say it? After all, we work with patients don’t we? We treat people every day. How could we not be patient centred?
But isn’t it interesting that this needs stating at all? Because how could health care not be patient centred?
So why is it only recently that the phrase has appeared in the health literature and in the mission statements of professional bodies?
Perhaps it needs stating so much because, perversely, people no longer feel at the centre of health care?
A great deal of literature has been written over the last few years explaining how health care, and especially medicine is patient centred, but many of these explanations offer quite a weak definition of patient centred care. These tend to keep the health professional at the centre of decision-making, ’empowering’ patients to be more involved. Patients are listened to and consulted, but at no time is the professional’s power weakened or authority questioned. Take this example from a recent paper by Kvåle and Bondevik, for example;
Today…both healthcare professionals and administrators clearly recognize that patient centred care is important. Patients’ values and perceptions must be acknowledged to make care evidence based and to meet the demands of quality improvement processes. Patient centred care is a widely used phrase, but the concept is complex and not well defined. Lewin et al. suggest the following definition of patient centred care: healthcare providers share control of consultations, decisions about interventions or the management of health problems with patients. Kitwood and Bredin suggest that patient centred practice can be achieved if practitioners understand users’ needs and engage in positive work with them…Studies have identified important aspects of good care from the patient’s perspective. These include telling them in understandable language what is important for them to know about the disease and treatment, being honest with them about their medical conditions, listening to them, checking their perceptions before initiating action and helping them in their thinking with regard to their disease and treatment (10–12)’ (Kvåle and Bondevik, 2008: 582-3).
Like Kvåle and Bondevik, most of the literature supports the view that patient-centred care is achieved when patients are listened to, consulted and involved in clinical decisions. But when has health care not been about these things? What then differentiates patient-centred care for what we should take to be normal everyday care?
To answer this question, we have to acknowledge that ‘[h]ealthcare professions have traditionally adopted a patriarchal model of practice – one that acts in the patient’s ‘best interest’’ (from our own Gwyn Owen, writing about patient centred care for the CSP in 2013, link). In a recent study looking at physiotherapy’s level of ‘comfort’ with patient centred care, Suzie Mudge and Caroline Stretton recently suggested that ‘Previously we considered person-centredness to be the antithesis of the biomedical model and by extension, dichotomous. We either were or we weren’t and therefore we were. Of course we rejected the biomedical model and embraced client-centred practice! Our assumption of our own person-centred practice was evidenced by the good rapport that physiotherapists invariably develop with patients. We like to think that, as physiotherapists, we understand what patients need; after all, our expertise in health and functioning gives us considerable insight’ (Mudge & Stretton, 2013: 460). There is a different though, between ‘liking to think we are patient centred, and the reality of the principal.
Patient-centred care is a radical shift in the power relationships that have long governed health care. Here the consumers or service user is literally at the centre of all decision-making: not at the centre because we want them to think and feel as if they are important, but actually in the centre of their care. This means that health professionals do not ‘consult’ with people before making their clinical decisions, but instead consumers and service users consult with us. People are no longer clients of the health care system, we are their clients. ‘Lay’ perspectives – the slightly patronising term used for the knowledge people have about their own bodies, their own health, activities, beliefs and interests – become the starting point for discussions about assessment, diagnosis, rehabilitation and treatment and not a nice-to-have addition to our supposedly more rational and detached objective outcome measurements. As well as people being in charge of their own personal health care, decisions are also made at the community level and are driven by consumers and service users not professionals. And at a regional and national policy level, professional bodies and vested interests play second fiddle to democratically representative groups of patients that call on health professional advice when they need it.
Naturally, health professionals and their professional bodies are unlikely to relinquish their power and radically change the way that health decisions are made. Everyone these days is scrabbling to ensure that their profession survives the austerity measures and neoliberal economic reforms sweeping through health and social care. When patient-centred care is ‘Enshrined by the Institute of Medicine’s “quality chasm” report as 1 of 6 key elements of high-quality care’ and ‘health care institutions, health planners, congressional representatives, and hospital public relations departments now include the phrase in their lexicons’ with ‘Insurance payments…increasingly linked to the provision of patient-centered care’ (Epstein & Street, 2011: 100), it is no surprise that we claim we are patient centred.
It is ironic then that the physiotherapy profession – which also claims that it is ‘evidence based’ – has produced almost no evidence to justify its claim that it is patient centred. Physiotherapy is very much an orthodox profession which has long centralised power around the professional body. This doesn’t mean that we do not care for people, or that patients aren’t pivotal to our very existence, but to claim that we are patient-centred may be the health care equivalent of the kinds of ‘greenwash’ that we are now seeing in the environmental movement.
In summary, we were uncomfortable with aspects of person-centred practice, because as we now understand, our practice is often more focused on a ‘‘body as a machine’’ perspective that separates the mind from the body and positions the physiotherapist as the primary expert in a way that discounts the views and preferences of the patient. As a consequence, we prioritise ‘‘doing to’’ rather than ‘‘being with,’’ the collaborative approach that underpins person-centred practice (Mudge & Stretton, 2013: 461).
If you would like to read more on this radically different view of patient centred care, there is a good overview post here, and Gwyn Owen’s piece for the CSP provides an excellent overview of patient-centred physiotherapy with some useful follow-on resources (link). There is also a lot of related material in the fields of emancipatory practice, post-colonial and indigenous research, critical theory, feminist research, queer theory and disability rights work that you will find by many of the people in the Critical Physiotherapy Network.
References
Epstein, R. M., & Street, R. L. (2011). The values and value of patient-centered care. The Annals of Family Medicine, 9(2), 100-103. doi:10.1370/afm.1239
Kvåle, K., & Bondevik, M. (2008). What is important for patient centred care? A qualitative study about the perceptions of patients with cancer. Scandinavian Journal of Caring Sciences, 22(4), 582-589. doi:10.1111/j.1471-6712.2007.00579.x
Miller, L. (2001). Towards a global definition of patient centred care. British Medical Journal, 322.
Mudge, S., Stretton, C., & Kayes, N. (2013). Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability and Rehabilitation. doi:10.3109/09638288.2013.797515
just exactly where is a patient’s centre anyway ?