Does the achievement of medical identity limit the ability of primary care practitioners to be patient-centred?: A qualitative study
Introduction
Primary care practitioners are increasingly encouraged to deliver patient-centred care and in particular to conduct patient-centred consultations [1], [2]. Mead and Bower have described five distinct dimensions of ‘patient-centred’ care [3]. These are a biopsychosocial perspective; ‘patient-as-person’; sharing power and responsibility; the therapeutic alliance and ‘doctor-as-person’. The sharing of power and responsibility in relation to decision-making has been the focus of most recent research [4], [5], [6], [7]. Elwyn et al. [8] argued, however, that patient involvement and empowerment in decision-making in primary care consultations was a distant fantasy. They argued that practitioners had learnt to explore biomedical and personal agendas but lacked the skills to provide patients with information and to share decisions with them. The framework of required competencies proposed by Elwyn and colleagues include: (1) problem definition, (2) explaining that legitimate choices exist, (3) portraying options and communicating risk and (4) conducting the decision process [9]. While shared decision-making (SDM) has been studied mainly in relation to decisions about treatment Elwyn and colleagues argue that there are opportunities for patients to be involved across the spectrum of decisions made in consultations. They argue that patients have legitimate perspectives on all decisions taken including screening, testing and treatment. The authors developed a scale based on the competencies described and assessed SDM in routine primary care consultations. They found that practitioners did not involve patients to any great extent. Low rates of competency in involving the patient in decisions have also been found in the assessment of consultation skills using videoed consultations in the examination required for membership of the UK Royal College of General Practitioners [10].
The low level of SDM found in clinical practice contrasts with the emphasis given to this in education and policy. In addition to lack of skill, lack of adequate time and lack of an adequate evidence base with which to inform patients have been suggested as impediments to practitioners’ facilitating increased patient involvement in decisions [8]. Stevenson [11] also reported that practitioners suggested that patients varied both in their ability and their desire for SDM and expressed concern about how a practitioner could ensure decisions were really shared.
The assessment of practitioners’ skills in enhancing patient involvement is an example of consultation research within the clinical-observational domain [12]. Research is focussed on the activities of the participants in the consultation. These activities are understood as part of the doctor's clinical method, and the doctor's skills can be improved or changed by training. Bower et al. [12] conceptualised primary care consultation research as falling into four domains—clinical-observational, psychodynamic, social-psychological and sociological. These domains are described as perspectives on the consultation that have developed more or less independently, each using differing theoretical perspectives. The authors suggest that each domain can only provide a partial view of the consultation and consideration of other domains may provide alternative hypotheses. In the sociological domain, the consultation is conceived in terms of broad social processes such as power, rather than as a skills based interaction. The sociological domain is concerned with how the identities of the participants in the consultation are constructed. The construction of these identities involves self-presentation and negotiation and is generated via interaction [13]. In this domain, identity is not given but has to be claimed and demonstrated by the participants in their interaction. People are concerned to give the impression of themselves they want others to see [13]. The emphasis is not on how an activity is done but on what participants achieve through their activities.
This paper reports on an interview study of primary health care practitioners about their approach to the management of menstrual disorders. The aim of the study was to explore practitioners’ management of these common disorders in primary care settings. Menstrual disorders are a common presentation in primary care but widespread variation in practice has been described. Menorrhagia, or heavy bleeding, is the most common reason for referral to gynaecologists and is considered a condition where patient-centred care is particularly appropriate. Serious pathology is rare and legitimate choices exist regarding management. The condition does however significantly impair quality of life [14]. The diagnosis is largely based on clinical history and the choices of treatment lie between doing nothing, taking medication or a number of surgical options. Guidelines for the initial treatment of heavy bleeding have been developed which suggest that unless there are symptoms suggestive of pathology investigations are not required, and that investigation and management should proceed according to individual patient need and request [15]. In the UK, referral to a gynaecologist at secondary care is required for surgical treatments but most investigations and oral treatments are available in primary care settings. Practitioners’ accounts indicated that many of the activities of the consultation could be understood as being important to the achievement of professional identity. The potential existed for the achievement of identity to conflict with sharing of power and responsibility in the consultation.
Section snippets
Method
The study was conducted in one inner city health authority area in the UK in 2000/2001. We used an iterative approach to recruitment and analysis, which was informed by grounded theory.
The aim of the study was to increase understanding of primary care practitioners’ approach to menstrual disorders. A purposeful sampling strategy was used to identify interviewees. Initial characteristics used for recruitment were gender, length of time qualified, qualification and type of practice. Nurses were
Results
The analysis developed a number of core categories. The nature of menstrual problems and the importance of gender in the interaction have been described in another paper [20]. Practitioners had two main approaches to women with menstrual disorders; a biomedical approach and an approach that we have called patient-as-person, which emphasised patient individuality. These categories are described here under the label of the clinical task. Practitioners’ assertion of their medical identity to their
Discussion
The clinical task identified by this group of medically qualified practitioners encompasses both a biomedical and a patient-orientated approach. While a minority expressed either lack of interest or inappropriate skill in eliciting women's concerns and views, all practitioners referred to communication in their account of how they managed women with menstrual complaints. Despite the stated importance of patients’ perspectives, some clinicians were however making assumptions about patients’
Acknowledgements
The authors would like to thank the primary care practitioners who agreed to be interviewed.
NO’F was funded throughout the study by an NHS R&D National Primary Care Researcher Development Award. Both authors worked at the Department of General Practice at GKT Medical School, London at the time of the study. We would like to acknowledge helpful discussions with Dr. Joseph Gafaranga about the analysis of the study.
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