BACKGROUND: We designed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization.
METHODS: We selected 39 family physicians at random, and 315 of their patients participated. Office visits were audiotaped and scored for patient-centered communication. In addition, patients were asked for their perceptions of the patient-centeredness of the visit. The outcomes were: (1) patients’ health, assessed by a visual analogue scale on symptom discomfort and concern; (2) self-report of health, using the Medical Outcomes Study Short Form-36; and (3) medical care utilization variables of diagnostic tests, referrals, and visits to the family physician, assessed by chart review. The 2 measures of patient-centeredness were correlated with the outcomes of visits, adjusting for the clustering of patients by physician and controlling for confounding variables.
RESULTS: Patient-centered communication was correlated with the patients’ perceptions of finding common ground. In addition, positive perceptions (both the total score and the subscore on finding common ground) were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals.
CONCLUSIONS: Patient-centered communication influences patients’ health through perceptions that their visit was patient centered, and especially through perceptions that common ground was achieved with the physician. Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.
Being patient centered is a core value of medicine for many physicians. The principles of patient-centered medicine date back to the ancient Greek school of Cos, which was interested in the particulars of each patient.1 More recently similar concepts have arisen in a variety of fields of human endeavor: the concept of physical diagnosis and deeper diagnosis of Balint,2 the client-centered therapy of Rogers,3 the total-person approach to patient problems in nursing of Neuman and Young,4 the biopsychosocial model of Engel,5 and the disease- versus patient-centered medical practice of Byrne and Long.6 In the past decade the patient-centered concepts of Gerteis and colleagues7 have been applied to the hospital setting.
In the setting of primary care, and specifically family practice, patient-centered concepts incorporate 6 interactive components. The first component is the physician’s exploration of both the patients’ disease and 4 dimensions of the illness experience including: their feelings about being ill, their ideas about what is wrong with them, the impact of the problem on their daily functioning, and their expectations of what should be done. The second component is the physician’s understanding of the whole person. The third component is the patient and physician finding common ground regarding management. In the fourth component the physician incorporates prevention and health promotion into the visit. The fifth component is the enhancement of the patient-physician relationship. Finally, the sixth component requires that patient-centered practice be realistic. Our study addresses the first 3 of these components. Being patient centered does not mean that physicians abdicate control to the patient8 but rather that they find common ground in understanding the patients and more fully respond to their unique needs.9
What are the benefits of being patient centered? Previous research of specific communication variables indicates that patient-centered encounters result in: (1) the duration of the office visit remaining the same10,11 (2) better patient satisfaction,12 (3) higher physician satisfaction,10 and (4) fewer malpractice complaints.13 We focus on 2 other outcomes: patients’ health and efficiency of care.
Methods
Our study was designed to test the hypothesis that adult patients whose first visit in an episode of illness is patient centered will, by 2 months after the first visit: (1) more frequently demonstrate recovery from the symptom (and recovery from the concern about the symptom); (2) demonstrate better self-reported health; and (3) experience less subsequent medical care (ie, fewer visits, diagnostic tests, and referrals), compared with patients whose visit is not patient centered.
Data Collection and Participants
For our observational cohort study data were collected at 5 points: (1) the research assistant identified eligible patients in the physician’s office before the visit; (2) the office encounter was audiotaped and scored for patient-centered communication; (3) the research assistant held a postencounter interview with the patient; (4) we assessed, by chart review, the use of medical care during the 2-month follow-up; and (5) we conducted a follow up telephone interview with patients 2-months after the encounter.
Physician Selection. Physicians were recruited from the 250 family physicians practicing in London, Ontario, Canada, and the surrounding area. They were randomized within strata to ensure a representative sample in terms of year of graduation and geographic location and were selected using a modified version of the method of Borgiel and colleagues.14