Patient-centred care (PCC) has become a buzz slogan throughout the medical profession. While there is a growing feeling that it must be integrated across the healthcare service, levels of understanding continue to vary. The basic idea is to encourage collaboration between patients and practitioners but, beyond this, factors such as interpretation, implementation and merit continue to be debated.
As much of that dialogue is being reduced to lip service, some have come to define the movement as nothing more than political correctness.
In 2005, the American Academy of Orthopaedic Surgeons (AAOS) approved a major new PCC initiative, defining PCC, within an orthopaedic context, as: ‘the provision of safe, effective and timely musculoskeletal care achieved through cooperation among the orthopaedic surgeon, an informed and respected patient (and family) and a coordinated healthcare team’. Now armed with a definition, PCC’s supporters can open the debate and look towards the day when it is established as standard practice.
I spoke to a leading advocate of PCC, the University of Iowa’s Stuart L Weinstein, to find out what the appeal was and how much progress had been made.
PF: Why is PCC so important?
SW: It has proved to be successful, efficient and beneficial to practitioners and patients alike. It will improve patient safety, increase levels of transparency, allow doctors to learn from their mistakes and minimise liability suits.
In order to perform one’s role as a practitioner properly, you need patients not only to respect your opinion but to feel that they are playing a key part in the process. This goes much further than merely listening to symptoms and prescribing a course of action; the patient must feel in control and responsible for driving the course of treatment.
Beyond benefiting the patient, it has been demonstrated that physicians feel a much greater sense of job satisfaction. There is an increased level of engagement and empathy. The practitioner feels that he or she is making more of a tangible difference through knowing the patients better, following their progress more closely and over a longer period. The relationship created makes for a better and happier doctor.
PF: How likely is PCC adoption across the board?
SW: It will happen through a process of evolution rather than revolution, but the concept has begun to filter through the entire healthcare service.
This is a movement that has gained considerable momentum in the last few years. Ten years ago, PCC was simply not a topic of conversation apart from among a small intellectual elite. Now everybody within our organisation is discussing it, as well as those from other sectors with whom I have contact.
We are still at the planning stage, but nobody can deny that it is a very hot issue. Key features of PCC practice are now being taught at medical schools throughout this country and key concepts are becoming common currency, not just within the medical profession but also beyond.
PF: Is it surprising that many elements of PCC are not already standard?
SW: We used to have a television show in the States called Marcus Welby MD. Here was a doctor who’d listen all day, turn up at your house, attend your graduation. Life’s not like that. Physicians are increasingly finding that they have less and less time with patients; it can only make sense for them to optimise it. An avenue must be left open to enable continual patient-practitioner contact.
This may sound like a lot of extra work, but studies have shown that making the effort can actually save a practitioner time in the long run; the patient is likelier to recover more quickly, to amend poor lifestyle practices and to follow guidelines worked through with their doctor. These are all things that should be happening, but it is naive to believe that they already are.
PF: As chairman of Doctors for Medical Liability Reform, can you see the adoption of PCC reducing the number of legal disputes that the profession currently faces?
SW: Claims should fall. There is currently a medical liability crisis in America, with the vast majority of cases having no real foundation. A great number of patients pursue litigation because they have not been properly informed prior to treatment and therefore have unreasonable expectations as to how it may go.
In medical schools throughout the USA communication skills are becoming an integral part of the curriculum; their importance cannot be overemphasised. People need to know that there are inherent risks involved with almost any course of action. With hip surgery, for example, complications can often arise; there are inherent risks.
If a poorly informed patient undergoes surgery and a common complication occurs, this person may feel very angry and look for someone to blame. As communication skills improve, a great number of claimants will desist and the public’s faith in the profession will improve.
PF: Is there not a fear of giving the patient too much power over their treatment?
SW: That argument is fundamentally flawed. It’s the patient, more or less, who dictates the level of information he or she gathers. Some only want level one information, others ask for level two explanations and there are always a few who don’t just want to be shown the cockpit, they want to fly the plane.
It is true that some people do want to micro-manage what is a very complex process in an area that they have no background in. A patient can be over-informed, but not if the only source is their doctor. It makes a practitioner’s job much harder that there are so many other unreliable sources out there.
Giving the patient information becomes all the more important when it involves clarifying or dismissing facts gleaned from the internet. One now also gets direct consumer advertising from pharmaceutical companies and private medical firms: ‘Get the same hip replacement as Jack Nicklaus’, ‘Providing bowel movements to the stars’, ‘Beat depression the Hollywood way’.
People are being bombarded with bad information and quick-fix schemes for which there is no filter. It is our duty to offer that service.
PF: What is the background to the PCC movement in America?
SW: The concept existed for many years without building up much momentum until relatively recently. It was the 1999 Institute of Medicine publication To Err Is Human that shook everything up.
The report revealed the degree to which medical error was costing both the patient and the profession. It was a call to arms, exposing the gap between patient requirements and eventual treatment.
In 2001, the institute published Crossing the Quality Chasm, which laid out six ways of bridging the divide: care must be safe, timely, effective, efficient, equitable and patient centred.
PF: Is the reform being driven from above or below?
SW: For a long time the patient’s voice was absent from debates on medical reform. The Institute of Medicine’s report, and others like it, led to a public crisis of confidence in the healthcare system, mobilising patient groups.
Their demands and expectations have shifted accordingly. The pressure to reform has increased, but within the profession it has become widely accepted that reform is necessary. Patient pressure is beneficial for maintaining that focus.
PF: Why was it not until last year that the AAOS introduced this initiative? Did consensus not already exist?
SW: I should stress that we have been patient focused for a long time. As with almost any large organisation, turning the wheels of reform can be a timely process, but over the last few years we have worked hard in organising and defining our main mission statements.
The academy does have a history of implementing a variety of PCC programmes, and this has allowed for a solid base to work on. Now is the time to define our interpretation of PCC, cement our support and encourage others to do likewise.
It was something we had to get our weight behind, but nothing would have got done unless we agreed on a course of action.
PF: Would you say that you have always practised PCC?
SW: In my own practice, I’d have to say yes. However, I am not alone in making that claim. Pose that question to almost any physician and you will receive the very same answer. The greater proportion of practitioners already believe they are placing their patients at the centre of their practice.
Many interpretations of PCC are outdated or misconceived and the actual patient’s interpretation will often be very different indeed. The point of PCC isn’t the amount of time you spend with a patient; it’s the quality of time spent. That can often be overlooked.
USA PLAYING CATCH UP
The Picker Institute is at the forefront of patient research and works alongside healthcare professionals and institutions encouraging PCC reform.
Picker Institute Europe’s chief executive Angela Coulter believes Europe lags behind the USA in recognising the need for adopting a PCC approach.
"In many ways, the American health system is completely disastrous," says Coulter. "It's inequitable and inefficient, but because of this there is general recognition that the system needs to perform better and that patients must be more involved."
Coulter believes that, unlike in the USA, patient groups are struggling to make an impression within Europe. In her eyes, the European Commission-backed European Patients Forum has made little impact in the three years since its inception.
"We have worked with the International Alliance of Patients, which has recently drawn up its Declaration of Patient-centred Care," she says. "But that organisation is more global in scope. The movement is being pushed by professionals rather than the patients, but is not centralised at all. Standards vary widely and there is still a very long way to go."