Tag: healthcare

What is patient-centred care?

What do we mean by patient-centred care? This isn’t a trick question but an attempt to reach a consensual answer.

A common response is that it’s about placing the patient at the centre of the care process, and seeking to address what matters to them, akin to a tailor made suit, rather than using a ‘one size fits all’ approach.

Some definitions focus on the responsibility of health professionals to inform patients about their healthcare and give them a choice. It could be more than this, with patient-centred care being about the partnership between practitioner and patient, with this relationship rooted in sharing power, rather than upholding a paternalistic attitude.

It does not mean doing everything that a patient asks; it is not ‘patient centred’ to give out diazepam and opiates without restriction when the consequence can be a hard-to-manage addiction. Being patient centred in this scenario might include a discussion about the reasons for a request, negotiating and sticking to a management plan, arranging additional psychiatric support, or a number of other options.

Patient centred care is also about designing services that meet the needs of patients rather than the needs of the organisation. This implies that the public should participate in the planning and redesign of services, and the reshaping of policy.

There are pitfalls. One commentator points out: ‘Three proposals topped a poll of options for reform at the ‘listening exercise’ attended by more than 1,000 people in Birmingham: extending GP opening hours, annual health MOTs and more walk-in centres. This familiar list of the preoccupations of the professional middle classes confirms the way in which this focus group approach places the demands of the worried well over those of the seriously ill (or even of the not very well, but socially marginal).

‘Listening exercises’ tend not to include those who are ill, particularly the elderly, children, people with mental illness or learning disabilities, families with young children, those who are not fluent in English – in fact, the majority of our patients and certainly those patients most in need of healthcare services. These proposals will increase costs out of all proportion to benefits and are likely to disrupt continuity of care for those patients for whom this is the most important aspect of primary care services.’

The concept of patient-centred care encompasses all of the above – from the organisational, redesigning services end of the patient-centred care spectrum through to the individual interactions side. However, health professionals, educationalists, managers and patient representatives are all developing different meanings that reflect their own history and position. Without a consensus about patient-centred care, it is hard to see how we can agree on how to deliver it. 

Being patient centred does not just mean responding to the demands of a vocal few. It is also about providing accessible, reliable care to the sick, the sad, and the frequent attenders, and treating all patients with common decency.

Words that disempower patients

Linguistic determinism is a concept that says that the language you use shapes the way that you think. The words we choose can change the way we limit and frame understanding, knowledge and ideas, and alter memory, categorisation, and perception. It is no surprise, then, that it affects the relationship between doctors and patients.

I have kept an article from the British Medical Journal from April 2022 to reread. It discusses the use of medical language. The authors state that the medical profession, in using elitist and outdated language, ‘casts doubt, belittles or blames patients, and jeopardises the therapeutic relationship…’

Using language in a way that disempowers patients is endemic. I’m sure, as a younger doctor, and copying the phrases of my senior colleagues, it helped me overcome imposter syndrome. This sort of language is pervasive, and using it makes you ‘one of the team’.

One example describes the situation where the clinician is struggling to make sense of the patient’s story within the clinician’s attention span. The patient is described as being ‘a poor historian’ when their narrative account of their symptoms does not meet the expectations of the clinician. It is the clinician’s duty to listen, to understand their story, concerns and expectations. Our skill as doctors, nurses, or other health professionals, is to ask the right questions, to listen carefully and to recount the clinical history accurately.

Other examples, with alternative words:

  • Presenting complaint – reason for attendance – ‘complain’ has negative connotations.
  • Ceiling of care – goals of care – ‘ceiling’ implies a limit to the treatment on offer.
  • Not compliant – this phrase is used when the patient did not follow instructions, but there is usually no mention as to whether the patient had agreed to the initial plan. We could write ‘barriers to adherence include …’
  • Did not attend – barriers to attendance – some patients really struggle with transport, mental health, organisational skills; by identifying the barriers, we can help patients access care.
  • Patient claims – patient reports – ‘claim’ implies that the patient is not being truthful.
  • Patient denies – patient did not experience – ‘deny’ implies a lack of truthfulness, of withholding information.
  • Patient refused – patient declined
  • ‘Has the patient been consented?’ – in this example, the patient is a passive recipient of information, no record of what the patient has understood and retained about a procedure.
  • Substance abuse – has a substance use disorder – the first phrase is associated with patient blame.

Patients can report feeling child-like in clinical settings. For example in a diabetic setting, blood sugars can be ‘good’; does the opposite imply that the patient has been naughty and bad? Some patients recount feeling as if they have been scolded for their poor outcomes, or ‘treatment failure’.

Every so often, I come across another phrase that is part of routine clinical discussion, and discover a more human, collaborative way of putting my view across. I hope to find ways of validating the patient experience, and allowing patients the opportunity to collaborate in creating their care plans.

The key messages from the article:

  • Some commonly used language in healthcare characterises patients as petulant, passive, or blames them for poor outcomes.
  • Such language negatively affects patient-provider relationships and is outdated.
  • Clinicians should consider how their language affects attitudes and change as necessary.
  • Changing our language to improve trust and support shared decision-making is unlikely to harm patients.
  • Better use of language may help us to reach more patient-centred and realistic care plans.

Linguistic determinism https://en.wikipedia.org/wiki/Linguistic_determinism – The concept that language and grammar affect the way we limit and frame understanding, knowledge and thought, for example, memory, categorisation, and perception.

The article by Caitríona Cox and Zoë Fritz was published in the BMJ on 30th April 2022, (you can read it here: https://www.bmj.com/content/377/bmj-2021-066720)