Ronald M. Epstein, MD

Patient-centered care expands on the disease-oriented model by incorporating the patient’s experience of illness, the psychosocial context, and shared decision making.¹ This type of care has been adopted as a model of medical practice by many primary care physicians, medical educators, and specialists. Elements of patient-centered care have been described since antiquity. Although different authors have used different nomenclature, the fundamental idea is that the process of healing depends on knowing the patient as a person, in addition to accurately diagnosing their disease. Evidence that elements of a patient-centered approach improve important outcomes of care is abundant.² However, many myths about this type of care persist. For example, some clinicians conflate patient-centered and psychosocial. However, patient-centered care can apply equally to deciding which antibiotic to prescribe for a urinary tract infection and to an evaluation of domestic violence. Another myth is that being patient centered means giving patients what they ask for.

Patient-centered communication, a cluster of physician behaviors presumed to help the physician achieve the goals of this type of care, includes clearly defined components: (1) identifying and responding to patients’ ideas and emotions regarding their illness, and (2) reaching common ground about the illness, its treatment, and the roles that the physician and the patient will assume.¹ These components seem both obvious and radical. For example, asking the patient why he has come to the physician and eliciting his feelings, ideas, and expectations about the illness make perfect sense, but are done in less than half of medical visits, including those not constrained by the pressures of time imposed by managed care and governmental health systems.

The study by Stewart and colleagues³ in this issue of the Journal is a landmark in research about the patient-centered clinical method. Using a stratified sample of 39 family physicians and 315 of their patients, they conducted an observational cohort study in which they examined the interrelationships between 3 elements: patient perceptions of patient-centeredness, observed communication behaviors, and subsequent health and resource utilization. When patients perceived the visit to be patient centered they experienced better recovery, better emotional health, and dramatically fewer diagnostic tests and referrals 2 months later. The patient-centered communication measure (a validated coding scheme using audiotapes of physician-patient visits) correlated only with patients’ perceptions, but not directly with any health care outcome. Thus, this study further affirms that the patient is the ultimate arbiter of patient-centeredness. Because only the patient can report whether she has felt understood or if or has been adequately involved in developing a treatment plan, it is no surprise that the inside perspective is more highly correlated with outcomes than any objective measure of verbal content.

Improving physician training

What conclusions can be drawn about how physicians can be trained to be more patient centered? One might think that patients can be our best teachers when it comes to communication. After all, their perceptions correlate most strongly with outcomes. However, although patients can report how they feel, they often cannot comment with sufficient detail on the physician’s specific communication behaviors. Their effect can be indirect, though. Patients can learn to communicate more effectively with their physicians with brief training interventions.⁴ In the process, they can take an observer’s perspective on the encounter and guide the physician to engage in shared decision making.

Training is effective in producing measurable changes in physicians’ communication skills even 5 years later;⁵ physician training also improves relevant patient outcomes.⁶ However, we may be teaching only a few of the skills necessary to improve patient-centered care, and it is not clear whether these are the most important ones. For example, even in a technically oriented profession such as medicine, relationship building is largely related to nonverbal communication. A recent study⁷ showed that nonverbal communication predicted likelihood of malpractice litigation to a greater degree than either qualitative or quantitative analysis of verbal content of interviews. Physicians often regard communication as the art of medicine. With that realization, however, should come the obligation to refine that art using known tools and to develop new tools that will expand their own potential as healers.

Linguistic correctness in communication skills training is important but is no substitute for genuine human expression. The goal is not the politically correct interview that contains a requisite number of open-ended questions and empathic-sounding responses. Instead Stewart and colleagues suggest that arriving at a deeper level of connection is essential, and they propose 2 methods designed to promote mindful reflection: small group discussions with patients and videotape review with standardized patients. In my experience, videotape provides a powerful means for self-critique. Other methods include standardized patients trained to give immediate feedback,⁸ self-awareness groups,^9,10 modeling thinking out loud, and reflective questioning.¹¹ The goal of such exercises is to appreciate the biological and psychological uniqueness of each individual. Medical decisions can then be better informed by the evidence that the patient presents; healing relationships can be cultivated on the basis of who the patient is rather than who the physician would have him be.

Stewart and coworkers used the patient as the unit of analysis and controlled for clustering of patients by physician. Their analysis raises questions about the extent to which individual physician differences accounted for the differences in outcomes. More plainly, they could not determine whether some physicians are more patient centered than others. Instead their discussion suggests that individual physicians show a range of patient-centered scores, test ordering, and referrals. Why might a physician be more patient centered with some patients and not others? Perhaps patients can induce patient-centeredness from physicians .¹² If so, patient-centeredness would be a quality of the patient as well as the physician. The same physician might be perceived as more patient centered by one patient than by another, perhaps because of previous experiences, biases, and expectations.

Patient-centeredness may also be more important to some patients than others. Some patients may gravitate to physicians who are more patient centered; thus, patient-centeredness is also a quality of their relationship. Finally, the context of the visits may determine the degree of patient-centeredness; physicians may appear to be less patient centered during some types of visits or in certain practice environments. In that regard, it would be interesting to study the effect of time constraints on the physician’s patient-centered care.

Understanding patient-centeredness

Good research generates more questions than it answers. It is clear, however, that future studies of patient-centered care will require more than just the application of quantitative ratings to observational data. To understand patients’ constructs of patient-centeredness, we need to understand the patient as a person rather than as a cluster of attributes. Given the diversity of patient needs and personalities, our conceptualization of what it means to be patient centered may not have adequately incorporated diverse patients’ perspectives. Our current understanding of patient-centeredness should be a complex web of physician, patient, and interactional factors, rather than one simple coherent construct. We may not have adequately characterized many of the relevant elements. I have wondered: Do physicians who have a rigid style (regardless of whether it is patient centered) do less consistently well with their patients? If so, does flexibility become an important component to measure? Do demographics, such as the age of the patient and physician-patient race or sex concordance, affect measures of patient-centeredness? Do certain situations, such as a discussion of an emotionally charged topic, evoke less patient-centered responses from physicians? It appeared that patient perceptions and physician measures of reaching common ground had the most robust associations with outcomes. Is shared decision making the final common pathway of diverse actions that comprise patient-centeredness?

Interpreting the results

The study by Stewart and coworkers should not be overinterpreted by claiming that the patient’s perceptions are all that matter, that teaching physicians to explore the meaning of the illness with a patient does not make a difference, or that measures of patient-centered communication are meaningless because they are not directly linked to outcomes; it should also not be underinterpreted by claiming that it is flawed because it used the patient as the unit of analysis. They have shown that thoughtful studies of the science of the art of medicine can make a difference and that the questions raised open new worlds of possibilities for further exploration.

Patient-centered care expands on the disease-oriented model by incorporating the patient’s experience of illness, the psychosocial context, and shared decision making.¹ This type of care has been adopted as a model of medical practice by many primary care physicians, medical educators, and specialists. Elements of patient-centered care have been described since antiquity. Although different authors have used different nomenclature, the fundamental idea is that the process of healing depends on knowing the patient as a person, in addition to accurately diagnosing their disease. Evidence that elements of a patient-centered approach improve important outcomes of care is abundant.² However, many myths about this type of care persist. For example, some clinicians conflate patient-centered and psychosocial. However, patient-centered care can apply equally to deciding which antibiotic to prescribe for a urinary tract infection and to an evaluation of domestic violence. Another myth is that being patient centered means giving patients what they ask for.

Patient-centered communication, a cluster of physician behaviors presumed to help the physician achieve the goals of this type of care, includes clearly defined components: (1) identifying and responding to patients’ ideas and emotions regarding their illness, and (2) reaching common ground about the illness, its treatment, and the roles that the physician and the patient will assume.¹ These components seem both obvious and radical. For example, asking the patient why he has come to the physician and eliciting his feelings, ideas, and expectations about the illness make perfect sense, but are done in less than half of medical visits, including those not constrained by the pressures of time imposed by managed care and governmental health systems.

The study by Stewart and colleagues³ in this issue of the Journal is a landmark in research about the patient-centered clinical method. Using a stratified sample of 39 family physicians and 315 of their patients, they conducted an observational cohort study in which they examined the interrelationships between 3 elements: patient perceptions of patient-centeredness, observed communication behaviors, and subsequent health and resource utilization. When patients perceived the visit to be patient centered they experienced better recovery, better emotional health, and dramatically fewer diagnostic tests and referrals 2 months later. The patient-centered communication measure (a validated coding scheme using audiotapes of physician-patient visits) correlated only with patients’ perceptions, but not directly with any health care outcome. Thus, this study further affirms that the patient is the ultimate arbiter of patient-centeredness. Because only the patient can report whether she has felt understood or if or has been adequately involved in developing a treatment plan, it is no surprise that the inside perspective is more highly correlated with outcomes than any objective measure of verbal content.

Improving physician training

What conclusions can be drawn about how physicians can be trained to be more patient centered? One might think that patients can be our best teachers when it comes to communication. After all, their perceptions correlate most strongly with outcomes. However, although patients can report how they feel, they often cannot comment with sufficient detail on the physician’s specific communication behaviors. Their effect can be indirect, though. Patients can learn to communicate more effectively with their physicians with brief training interventions.⁴ In the process, they can take an observer’s perspective on the encounter and guide the physician to engage in shared decision making.

Training is effective in producing measurable changes in physicians’ communication skills even 5 years later;⁵ physician training also improves relevant patient outcomes.⁶ However, we may be teaching only a few of the skills necessary to improve patient-centered care, and it is not clear whether these are the most important ones. For example, even in a technically oriented profession such as medicine, relationship building is largely related to nonverbal communication. A recent study⁷ showed that nonverbal communication predicted likelihood of malpractice litigation to a greater degree than either qualitative or quantitative analysis of verbal content of interviews. Physicians often regard communication as the art of medicine. With that realization, however, should come the obligation to refine that art using known tools and to develop new tools that will expand their own potential as healers.

Linguistic correctness in communication skills training is important but is no substitute for genuine human expression. The goal is not the politically correct interview that contains a requisite number of open-ended questions and empathic-sounding responses. Instead Stewart and colleagues suggest that arriving at a deeper level of connection is essential, and they propose 2 methods designed to promote mindful reflection: small group discussions with patients and videotape review with standardized patients. In my experience, videotape provides a powerful means for self-critique. Other methods include standardized patients trained to give immediate feedback,⁸ self-awareness groups,^9,10 modeling thinking out loud, and reflective questioning.¹¹ The goal of such exercises is to appreciate the biological and psychological uniqueness of each individual. Medical decisions can then be better informed by the evidence that the patient presents; healing relationships can be cultivated on the basis of who the patient is rather than who the physician would have him be.

Stewart and coworkers used the patient as the unit of analysis and controlled for clustering of patients by physician. Their analysis raises questions about the extent to which individual physician differences accounted for the differences in outcomes. More plainly, they could not determine whether some physicians are more patient centered than others. Instead their discussion suggests that individual physicians show a range of patient-centered scores, test ordering, and referrals. Why might a physician be more patient centered with some patients and not others? Perhaps patients can induce patient-centeredness from physicians .¹² If so, patient-centeredness would be a quality of the patient as well as the physician. The same physician might be perceived as more patient centered by one patient than by another, perhaps because of previous experiences, biases, and expectations.

Patient-centeredness may also be more important to some patients than others. Some patients may gravitate to physicians who are more patient centered; thus, patient-centeredness is also a quality of their relationship. Finally, the context of the visits may determine the degree of patient-centeredness; physicians may appear to be less patient centered during some types of visits or in certain practice environments. In that regard, it would be interesting to study the effect of time constraints on the physician’s patient-centered care.

Understanding patient-centeredness

Good research generates more questions than it answers. It is clear, however, that future studies of patient-centered care will require more than just the application of quantitative ratings to observational data. To understand patients’ constructs of patient-centeredness, we need to understand the patient as a person rather than as a cluster of attributes. Given the diversity of patient needs and personalities, our conceptualization of what it means to be patient centered may not have adequately incorporated diverse patients’ perspectives. Our current understanding of patient-centeredness should be a complex web of physician, patient, and interactional factors, rather than one simple coherent construct. We may not have adequately characterized many of the relevant elements. I have wondered: Do physicians who have a rigid style (regardless of whether it is patient centered) do less consistently well with their patients? If so, does flexibility become an important component to measure? Do demographics, such as the age of the patient and physician-patient race or sex concordance, affect measures of patient-centeredness? Do certain situations, such as a discussion of an emotionally charged topic, evoke less patient-centered responses from physicians? It appeared that patient perceptions and physician measures of reaching common ground had the most robust associations with outcomes. Is shared decision making the final common pathway of diverse actions that comprise patient-centeredness?

Interpreting the results

The study by Stewart and coworkers should not be overinterpreted by claiming that the patient’s perceptions are all that matter, that teaching physicians to explore the meaning of the illness with a patient does not make a difference, or that measures of patient-centered communication are meaningless because they are not directly linked to outcomes; it should also not be underinterpreted by claiming that it is flawed because it used the patient as the unit of analysis. They have shown that thoughtful studies of the science of the art of medicine can make a difference and that the questions raised open new worlds of possibilities for further exploration.

Patient-centered care expands on the disease-oriented model by incorporating the patient’s experience of illness, the psychosocial context, and shared decision making.¹ This type of care has been adopted as a model of medical practice by many primary care physicians, medical educators, and specialists. Elements of patient-centered care have been described since antiquity. Although different authors have used different nomenclature, the fundamental idea is that the process of healing depends on knowing the patient as a person, in addition to accurately diagnosing their disease. Evidence that elements of a patient-centered approach improve important outcomes of care is abundant.² However, many myths about this type of care persist. For example, some clinicians conflate patient-centered and psychosocial. However, patient-centered care can apply equally to deciding which antibiotic to prescribe for a urinary tract infection and to an evaluation of domestic violence. Another myth is that being patient centered means giving patients what they ask for.

Patient-centered communication, a cluster of physician behaviors presumed to help the physician achieve the goals of this type of care, includes clearly defined components: (1) identifying and responding to patients’ ideas and emotions regarding their illness, and (2) reaching common ground about the illness, its treatment, and the roles that the physician and the patient will assume.¹ These components seem both obvious and radical. For example, asking the patient why he has come to the physician and eliciting his feelings, ideas, and expectations about the illness make perfect sense, but are done in less than half of medical visits, including those not constrained by the pressures of time imposed by managed care and governmental health systems.

The study by Stewart and colleagues³ in this issue of the Journal is a landmark in research about the patient-centered clinical method. Using a stratified sample of 39 family physicians and 315 of their patients, they conducted an observational cohort study in which they examined the interrelationships between 3 elements: patient perceptions of patient-centeredness, observed communication behaviors, and subsequent health and resource utilization. When patients perceived the visit to be patient centered they experienced better recovery, better emotional health, and dramatically fewer diagnostic tests and referrals 2 months later. The patient-centered communication measure (a validated coding scheme using audiotapes of physician-patient visits) correlated only with patients’ perceptions, but not directly with any health care outcome. Thus, this study further affirms that the patient is the ultimate arbiter of patient-centeredness. Because only the patient can report whether she has felt understood or if or has been adequately involved in developing a treatment plan, it is no surprise that the inside perspective is more highly correlated with outcomes than any objective measure of verbal content.

Improving physician training

What conclusions can be drawn about how physicians can be trained to be more patient centered? One might think that patients can be our best teachers when it comes to communication. After all, their perceptions correlate most strongly with outcomes. However, although patients can report how they feel, they often cannot comment with sufficient detail on the physician’s specific communication behaviors. Their effect can be indirect, though. Patients can learn to communicate more effectively with their physicians with brief training interventions.⁴ In the process, they can take an observer’s perspective on the encounter and guide the physician to engage in shared decision making.

Training is effective in producing measurable changes in physicians’ communication skills even 5 years later;⁵ physician training also improves relevant patient outcomes.⁶ However, we may be teaching only a few of the skills necessary to improve patient-centered care, and it is not clear whether these are the most important ones. For example, even in a technically oriented profession such as medicine, relationship building is largely related to nonverbal communication. A recent study⁷ showed that nonverbal communication predicted likelihood of malpractice litigation to a greater degree than either qualitative or quantitative analysis of verbal content of interviews. Physicians often regard communication as the art of medicine. With that realization, however, should come the obligation to refine that art using known tools and to develop new tools that will expand their own potential as healers.

Linguistic correctness in communication skills training is important but is no substitute for genuine human expression. The goal is not the politically correct interview that contains a requisite number of open-ended questions and empathic-sounding responses. Instead Stewart and colleagues suggest that arriving at a deeper level of connection is essential, and they propose 2 methods designed to promote mindful reflection: small group discussions with patients and videotape review with standardized patients. In my experience, videotape provides a powerful means for self-critique. Other methods include standardized patients trained to give immediate feedback,⁸ self-awareness groups,^9,10 modeling thinking out loud, and reflective questioning.¹¹ The goal of such exercises is to appreciate the biological and psychological uniqueness of each individual. Medical decisions can then be better informed by the evidence that the patient presents; healing relationships can be cultivated on the basis of who the patient is rather than who the physician would have him be.

Stewart and coworkers used the patient as the unit of analysis and controlled for clustering of patients by physician. Their analysis raises questions about the extent to which individual physician differences accounted for the differences in outcomes. More plainly, they could not determine whether some physicians are more patient centered than others. Instead their discussion suggests that individual physicians show a range of patient-centered scores, test ordering, and referrals. Why might a physician be more patient centered with some patients and not others? Perhaps patients can induce patient-centeredness from physicians .¹² If so, patient-centeredness would be a quality of the patient as well as the physician. The same physician might be perceived as more patient centered by one patient than by another, perhaps because of previous experiences, biases, and expectations.

Patient-centeredness may also be more important to some patients than others. Some patients may gravitate to physicians who are more patient centered; thus, patient-centeredness is also a quality of their relationship. Finally, the context of the visits may determine the degree of patient-centeredness; physicians may appear to be less patient centered during some types of visits or in certain practice environments. In that regard, it would be interesting to study the effect of time constraints on the physician’s patient-centered care.

Understanding patient-centeredness

Good research generates more questions than it answers. It is clear, however, that future studies of patient-centered care will require more than just the application of quantitative ratings to observational data. To understand patients’ constructs of patient-centeredness, we need to understand the patient as a person rather than as a cluster of attributes. Given the diversity of patient needs and personalities, our conceptualization of what it means to be patient centered may not have adequately incorporated diverse patients’ perspectives. Our current understanding of patient-centeredness should be a complex web of physician, patient, and interactional factors, rather than one simple coherent construct. We may not have adequately characterized many of the relevant elements. I have wondered: Do physicians who have a rigid style (regardless of whether it is patient centered) do less consistently well with their patients? If so, does flexibility become an important component to measure? Do demographics, such as the age of the patient and physician-patient race or sex concordance, affect measures of patient-centeredness? Do certain situations, such as a discussion of an emotionally charged topic, evoke less patient-centered responses from physicians? It appeared that patient perceptions and physician measures of reaching common ground had the most robust associations with outcomes. Is shared decision making the final common pathway of diverse actions that comprise patient-centeredness?

Interpreting the results

The study by Stewart and coworkers should not be overinterpreted by claiming that the patient’s perceptions are all that matter, that teaching physicians to explore the meaning of the illness with a patient does not make a difference, or that measures of patient-centered communication are meaningless because they are not directly linked to outcomes; it should also not be underinterpreted by claiming that it is flawed because it used the patient as the unit of analysis. They have shown that thoughtful studies of the science of the art of medicine can make a difference and that the questions raised open new worlds of possibilities for further exploration.