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.