An alternative interpretation is that patients’ perceptions may influence resource use in several ways. For example, increased participation during the visit may reduce patients’ anxiety and their perceived need for investigations and referrals. Alternatively, patients’ perception that the physician has not understood their problem may provoke insecurities resulting in a request for further medical interventions. Also, if patients openly express their discontent with the encounter there may be an increase in physicians’ anxiety and a lowering of their threshold for diagnostic uncertainty, resulting in further investigations and referrals.
Certainly the finding that the failure to be patient centered (as perceived by the patient) was related to higher rates of referral and diagnostic tests should be a concern for medical education and health care policy. Perhaps of most importance is that the patients’ experience of being a participating member in the discussion of the problem and the treatment process may translate into the patients’ reduced need for further investigation or referral—simultaneously reducing the physicians’ need as well.
These findings counter a common misconception: that being patient centered means responding to every whim of the patient, thereby increasing expenses to the health care system.
Approximately 30% of the patients refused to participate, and although the participants represented the age distribution of eligible patients, men were overrepresented in the study. Nonetheless, sex was not identified as a confounding variable for the associations studied.
Although no measure of severity was possible, the variables representing concurrent health problems and concurrent life problems were considered in the analysis strategy. They were not related to the outcome variables and were therefore not entered into the multivariable analyses.
One interpretation of the lack of association between patient-centered scores on the audiotaped interviews and subsequent health outcomes may be that the audiotape measure has failed to capture the important essence of the dynamic interaction between physicians and patients. The measure had a number of strengths, however; it had been tested for reliability and validity (compared with a global rating), and it was based on a theoretical framework. Also, it was correlated with one component of the patient perception measure of a patient-centered interview, a finding which indicates that future research should be directed toward determining physicians’ skills and behaviors that correlate with the patients’ positive perceptions, especially the perception that common ground has been reached. Such behaviors could then be emphasized in clinical teaching.
It should be noted that the utilization data were available only from the participating practices and not from care received elsewhere. Although this is a limitation, it would be expected that this lack of data would minimize the current relationship between patient-centered practice and utilization, because patients with less favorable perceptions would be potentially more likely to seek care elsewhere. Also, drug costs and hospital costs were not included and require further study. Future research could also build on these results about resource utilization and assess the specific kinds and actual costs of the diagnostic tests and referrals.
It could be argued that the results of our study demonstrated simply that people with positive perceptions and less severe problems achieved better health and more efficient services. We counter this interpretation with 2 thoughts. First, the preliminary step in our analysis included confounding variables to control for a variety of relevant variables (ie, personality and concomitant health problems). Only 2 confounding variables were influential enough to remain in the final analysis: marital status and diagnostic code of the main presenting problem. Second, patient perceptions were not independent of the physician-patient visit. They were influenced significantly by the communication score based on the audiotaped encounter, implying that the measure of perceptions was tapping not merely the patients’ general outlook on life, but also an important interactive component of visits between patients and physicians.
Patient-centered practice was associated with improved health status (less discomfort, less concern, and better mental health) and increased efficiency of care (fewer diagnostic tests and referrals).
Patients’ perceptions of the patient centeredness of the visit, but not the measure of audiotaped interactions, were directly associated with the positive outcomes. The subscore on patients’ perception of finding common ground was more strongly associated with the positive outcomes than the subscore on patients’ perception about exploring the illness experience.
Medical education should go beyond skills training to encourage physicians’ responsiveness to the patients’ unique experience. Therefore, involving real patients and standardized patients in teaching programs is recommended.
Health service organizations must recognize that efficiencies accrue from patient-centered practice and encourage such practice through structures that enhance continuity of the patient-physician relationship and through meaningful education programs.