Medical care is by definition patient-centered. And while caring for their patients, physicians should listen to them and take them seriously. No doctor or any other healthcare professional would disagree with this statement and they are educated in this manner. At the University Medical Center (UMC) Utrecht, medical students receive extensive training in communication and have to study the impact of diseases on patients' daily lives.
In the first year of the GP vocational training programme at UMC Utrecht, half a day per week is devoted solely to communicating with patients, informing them, and enhancing their coping behaviour. But, as always with principles and training, daily practice gives a diverse picture. There are many doctors who stand by their Hippocratic oath, discuss diagnostic and therapeutic options as well as prognosis, and take decisions with the consent of their patients.
Primary care physicians (and nurses) in general have a reputation for being patient-centered and having a very good relationship with most of their patients. Many surveys on patients' opinions about their GP have confirmed this. But of course there are also many examples where patients' preferences are ignored, where they are patronised and ill informed, and where the organisation of primary care is not always as patient-centered as it could be.
In the Netherlands a recent assessment of the Health Care Inspectorate showed that in 40% of all practices a patient could not get through on the telephone within 2 minutes, and that in 25% of the practices the emergency line kept people waiting for more than 30 seconds. Few practices met the patients' wishes to have evening surgeries or to provide web-based facilities to contact the doctor. As in the UK, in the Netherlands there are also many complaints about the way in which out-of-hours services work.
Will increasing the input of patients help to improve all this? Yes, absolutely, but there are caveats. Research funds and guideline committees have mixed experiences with patient involvement. In the fields of diabetes and asthma, Dutch patient organisations are well organised and have an important contribution to research and health care that really makes a difference. But regarding guidelines on Lyme Disease and the implementation of vaccination against HPV, there have been discussions in the Netherlands that have made it clear that putting patients' opinions and preferences at the centre of health care can be complicated.
Giving patients decisive influence in the policy of primary care practices, as Chuter suggests in this issue of the BJGP,1 could endanger the quality of medical care, for instance by putting patients' wishes for more readily available tests like MRI and treatments like antibiotics or antidepressants above scientific insights on the effectiveness of these tests and treatments. The challenge is, and will be, to balance patients' preferences and expectations against our professional and scientific knowledge and beliefs. Several studies have shown that GPs' judgment in balancing these factors really works and is appreciated by both patients and their doctors.2,3 Stimulating doctors to perform better in this respect by educating them and giving them feedback on their performance has also shown to improve quality of care.4
Feedback from patients should be an essential part of care, and surveys and patients' advisory boards could be very helpful. However, imposing penalties and down-side risks on practices that do not comply with certain criteria for patient-centered care, as seems to be the plan in the US,5 bears the same risks as the Quality and Outcomes Framework in the UK: some aspects of care that are directly related to selected targets seem to improve, while the effects on overall quality remain uncertain to say the least.6–8 Doctors and patients are alike: improvement of performance and cooperation with others is better stimulated and supported than forced by a top down approach.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice, January 2011
