The relationship of patients’ perceptions of patient centeredness with their health and efficiency of care was both statistically and clinically significant. Specifically, recovery was improved by 6 points on a 100-point scale; diagnostic tests and referrals were half as frequent if the visit was perceived to be patient centered.
The associations we found may imply a potentially important pathway (which could be tested in future trials), such as the one shown in the [Figure]. The pathway suggests a process through which patient-physician communication influences patients’ health, by first influencing the patients’ perceptions of being a full participant in the discussions during the encounter. Such a pathway has been noted by Sobel, whose review suggested a pathway to explain the lack of a direct relationship between patient education programs and patient health where there was a relationship between patient perceptions about their health and health outcomes. Sobel called this pathway “a biology of self-confidence.”31 He and others32 stress the critical role of patient perceptions in the healing process, which highlight that a person’s subjective experience influences biology.
How do we understand the results that show the ratings of the audiotape were not directly related to the outcomes, but the patient-centered perception measure was related to outcomes? One interpretation is that observable skills are not as important as patient perceptions. Although there is some evidence that skills training can improve both physicians’ behavior and patients’ health,33 our findings and those of Bensing and Sluijs34 indicate that differences in interviewing skills may not be associated with patient responses. Physicians may learn to go through the motions of patient-centered interviewing without understanding what it means to be a truly attentive and responsive listener. The implications of the current findings for educators are that education about communication should go well beyond skills training to a deeper understanding of what it means to be a responsive partner for the patient, during both that phase of the visit in which the problem is discussed and when the discussion of treatment options occurs. Two examples of such education approaches are: small group discussions between patients and physicians to illustrate the patients’ experiences and needs, and reviews of videotaped interviews with standardized patients participating in the review. Placing prime importance on the patients’ perceptions recognizes the influence of these perceptions on the patients’ subsequent health and epitomizes being truly patient centered.
Views that the visit was patient centered included perceptions about the discussion of the problem (exploring the illness experience) as well as discussion and agreement about treatment options (finding common ground). There is a substantial body of research supporting the importance of these discussions. The Headache Study found that patients’ perceptions that a full discussion of the problem had taken place predicted resolution of headaches after 1 year.34 In keeping with our results, which found that finding common ground was more strongly associated with outcomes than exploring the illness experience, Riccardi and Kurtz36 stressed that the physicians’ explanation to the patients was the crucial phase of the visit. Also, a key outcome study has found that patient agreement with the physician about the nature of the treatment and the need for follow-up were strongly associated with their recovery.37
Efficiency of Medical Care
We found that patient-centered practice (assessed by patients’ perceptions) was associated with the efficiency of care by reducing subsequent diagnostic tests and referrals by half, after controlling for key confounding variables. These results were both statistically significant and clinically significant. Also, the number of subsequent visits to the family physician was lower (although not significantly) when the patient perceived the study visit to be patient centered. Efficiency in health service delivery was also found in a randomized trial of compassionate care in the emergency department setting with homeless patients.38 In their study of continuity of care in Norwegian general practice, Hjortdahl and Borchgrevink39 found that diagnostic tests were 10 times more likely to be ordered for patients about whom physicians reported the least previous knowledge compared with patients in whom they had reported fullest knowledge. Also, patients had only half the chance of being referred if their physicians knew them and their history.38
One possible interpretation of the results of our study is that patient-centered physicians order fewer tests and refer less often. However, countering this interpretation is the fact that individual physicians in our study showed a range of patient-centered scores, as well as a range in test ordering and referral. In addition, the statistical analysis took account of the clustering of patients within a physician’s practice.