Patient centered method and self directed behaviour change
By Eivind Meland

The concept of patient centeredness is attributed to the work of Michael Balint (1), who used the concept as related to illness-centeredness. The concept and it's ethical foundations are, however, closely related to humanistic psychology and the person-centered therapy originally developed by Carl Rogers in the 1940s (2). Balint's emphasis on the doctor as drug also contained, however, criticism and caution against dependence and regression (3).

Tuckett (4) summarizes the importance of the patient centered approach by emphasizing that:

• Reassurance and understanding are intrinsic and important parts of therapy.
  
• It might prevent noncompliance, especially when intervention embrace life habits and environment.
  
• When medical interventions has been extended to treatment of asymptomatic "problems" sometimes by intrusive means (e.g. dietary and drug treatment of elevated blood pressure), the treatment must rely on a contract between care-giver and care- receiver.
  
• The consultation is a short event in a long process of "making sense". Consultations must therefore be seen as meetings between systems of belief and ideas.
  
• As society changes the paternalistic role must change in accordance with the lay consumer and patient movement.

Even though Tuckett and coworkers' study was insufficient in demonstrating any outcome benefit, the necessity of treating patients as competent can be evaluated according to other criteria. They conclude that patients are experts on their own personal and cultural background and their own story of the illness.

When Ian R McWhinney give the grounds for the patient centered clinical method, his reasons seem first and foremost based on philosophical and ethical conciderations (5, 6). The one-dimensional biomedical paradigm is insufficient for the comprehension of current medical knowledge, and more important, it is based on an inadequate and impoverished view of reality. A reciprocal bio-psycho-social paradigm is advocated, where the understanding of the patients perspectives and subjective meaning of health problems is a basic task for the clinician (5-8).

Based on qualitative data Inga M Lunde also emphasize the importance of the patients' perspective, advocating that all therapeutic desicions should be made within the framework of their perceptions (9). Similar results emerge from the Cardiff study by Stott and coworkers (10). They call for humility and patient centeredness in health care personnel, comparing change of a cherished or habitual life-style with the physiological response to loss and grief.

Byrne and Long (11) are more specific in their evaluation of doctor-patient interaction. According to their definition patient centeredness refers to the doctors verbal behavior in the consultation: seeking and accepting patient ideas, seeking and giving recognition and encouragement are among the patient-centered doctors' behavioral skills.

Weston and coworkers have proceeded with the work on patient-centered method established by McWhinney. According to their opinion (12) this clinical method should enable doctors to diagnose the illness perspective of disease. Four dimensions are focused: Patients' ideas about what is wrong with them; their feeling about their illnesses; the impact of their problems on functioning; and their expectations about what should be done. Finding common ground while viewing patients as autonomous individuals with the right to have a voice in deciding among treatments is also mandatory according to Weston and coworkers (13).

Current information on doctor-patient interaction is mostly concerned with the early phases of the interview; the diagnostic efforts. Less is known about therapeutic strategy and methods supporting behavior change. Observational studies support the relevance of the patient centered clinical method (14-21), although some of the studies show weak associations or inconsistencies. A few studies are, however, unable to demonstrate any outcome effects (22, 23). Experimental evidence is sparse. In two studies, improving patients' information-seeking skills, led to improved blood sugar control and fewer functional limitations in diabetics (24), and fewer functional and role related limitations in patients with peptic ulcer disease (25). In another study, improving the verbal behavior of physicians had a beneficial outcome effect on blood pressure treatment compliance and regulation (26). A randomized clinical trial among smokers (27, 28) showed improved cessation rates in the patient centred counseling group as compared to the advice only group (11.9% vs 9.1%).

Based on correlational evidence in reviewed papers Kaplan et al (29) conclude that the physician-patient relationship is a primary bond that may act as a form of social support to influence patients' health status. In their experimental study (29) a similar relationship was demonstrated. Their intervention improved patient control during consultations, but statistical methods seem improper to evaluate if the communication intervention improved health status.

According to Ley (30) comprehension is a primary prerequisite for satisfaction and compliance with doctor's advice. Although observational data show rather low correlation coefficients, the clinical relevance of these correlations are significant according to Ley. A one-way causal relation between comprehension, satisfaction and compliance seems, however, unlikely. In a study by Wartman and coworkers a positive correlation between comprehension of drug instructions and compliance was found, but compliance correlated negatively with satisfaction with doctor-patient interaction (31).

What the clinicians say will always be interpreted in terms of the patients' own framework of ideas. Improvement of the communication should therefore imply exploring the ideas or health beliefs of the patient. Interventions based on the Health Belief Model (HBM) may enable physicians to communicate patient-centered and patients to comply better and improve their blood pressure control (26, 30). The mere receiving of instructions from the clinician seems however, irrelevant for the explanation of outcome differences (32).

A meta-analysis of 36 controlled studies (33) where health professionals aimed at improving compliance and/or health behavior, revealed that didactic instructions were effective. Behavioral interventions with emphasis on the patient's unique circumstances and daily routine were even more effective.

Zimbardo et al. (34) also review relevant social psychological knowledge for the understanding of how attitudes are influenced and behavior changed. Credibility of the persuader is important, but observational data indicate that large differences in credibility are needed to produce rather small differences of attitude or behavior change.

The HBM also gives a rationale why fear arousal seems to increase behavior change provided recommendations are specific, possible and are perceived as effective in averting the danger referred to in the message (30, 35). The persuasive ability of preventive efforts may however be vanished by a counterproductive effect called "psychological reactance" (36, 37). A more patient centered approach presumably preserves the expectancy of freedom and control, wich is crucial in preventing psychological reactance (37).

Another conceptual framework related to the patient centred method is social learning theory and cognitive behavior modification theory. According to Cameron and Best (35) goal setting, self-monitoring and development of self- efficacy are important strategies in acquiring desired behaviors or avoiding undesired behaviors. Meichenbaum and Turk (38) claim a modest connection between health beliefs and behavior. Correlation is strengthened with the incorporation of other determinants such as physician-patient relationship, perceived susceptibility and belief in personal self-efficacy. Self-monitoring alone are not effective, but must be employed together with negotiated, individualized, self-determined treatment goals (38). Offering choice of treatment alternatives, goal setting and behavioral contracting are also advocated.

Albert Bandura explains comprehensively how self cognitive elements are important in regulation of human behavior (39). His contribution to social learning theory underlines that people act as active agents in their own self-motivation, a view that contrasts unidirectional behaviorism. Self-directive influence wherein individuals observe their own behavior, set goals and reinforce their performances are major elements in human motivation. Perceived efficacy is a more proximal determinant of behavior than outcome expectation, and motivation for behavior change should start with revealing individual efficacy expectation (39).

Comments & questions are welcome: Eivind.Meland@isf.uib.no

References

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