DEFINITION OF PATIENT-CENTREDNESS

In recent decades, patient-centredness has become firmly established as an important component within practical healthcare. It denotes a certain ideal doctor/healthcare system-patient relationship with its primary focus on the individual patient. Its implementation is an essential element of high-quality medical care [1, 2].

To date, many clinical, organizational and research initiatives have been initiated and implemented around the world to promote and provide patient-centred care. There are thousands of publications devoted to the topic. However, despite the impressive extent of these initiatives, there is still no clearly formulated and unified opinion on what patient-centred care is [3].

So, Olson et al. recognize that ‘patient-centredness’ is a complex theoretical structure consisting of a combination of various concepts and practices that have been developed by representatives of various professional groups in the field of healthcare such as doctors, psychotherapists, care professionals, health care organizers, and specialists in the field of medical ethics. They all share a common ideal, though every person looks at the problem from different perspectives [4].

Psychologist Rogers and psychotherapist Balint were the first to propose the idea of person-centred therapy. In 1951, Rogers formulated the idea that people are able to solve their problems independently using their own resources, provided that they have necessary supportive conditions [5]. In turn,

Balint proposed to consider person-centredness’ as a way of medical thinking, when a doctor perceives his patient as a unique human being, and this vision should precede the clinical diagnosis [6].

Later, the idea of patient-centredness applies to other sectors of medicine and healthcare, with different experts defining it in different ways. In 2000, Mead and Bauer conducted a review of the published literature on patient-centredness [7]. They concluded that patient-centredness is a multidimensional concept with five dimensions that includes as follows:

1. a biopsychosocial approach that expanded the view on the patient’s disease from a strictly biomedical framework to a biopsychosocial perspective;
2. considering the patient as a multifaceted personality who may have a variety of experiences about his illness. Mead and Bauer described it as follows: “A compound leg fracture will not be perceived equally by two different patients; it can cause much less suffering to an office worker than to a professional athlete” [p. 1089];
3. separation of power and responsibility, depending on proper patient information and participation in medical decision-making. An obvious obstacle to complete egalitarianism in the doctor-patient relationship is the “competence gap”, asymmetry of knowledge between the patient and the doctor, which nevertheless should not interfere with the transition from the paternalistic model of “leadership-subordination” to the model of mutual participation and division of responsibility (p. 1989 onwards);
4. therapeutic alliance in the doctor-patient relationship. Mutual benevolent relationships can improve treatment outcomes, whereas negative relationships, on the contrary, can reduce the chances of successful treatment;
5. perception of a doctor as a person. As in any relationship, both sides influence each other through interaction. This dimension highlights the importance of realizing that the doctor’s personality, way of thinking, mood and well-being affect the current relationship with the patient and choices made during the consultation.

The presented definition of Mead and Bauer, according to Langberg et al, is still one of the most cited ones [8].

An interesting approach to the definition of patient-centred care was used by Duggan et al. They suggested going from the opposite, describing what it is not. So, it is not a doctor-centred help. Patient-centredness can be opposed to medical paternalism, when a patient’s needs and opinions are ignored by a doctor. Being patient-centred, it can be opposed to disease-centred medicine. Finally, patient-centred approach differs from the technical or biomedical model of rendering aid, when a doctor is considered as a technician who makes interventions and performs procedures. According to Dagan et al., patient-centredness can be considered as a strategy that allows simultaneous correction of all these negative trends in medicine [9].

In 2019, Langberg et al. have prepared a scientific review on patient-centredness, in which the definitions given by various authors since 2010 were provided. According to them, there is still no uniformity in defining the concept, but the authors identify the same components of patient-centredness. Separation of powers and responsibilities, including informed consent and joint decision-making, as well as a therapeutic alliance are mentioned in articles devoted to patient-centredness. Less often, but quite often, there are references to the biosocial perspective when looking at the patients and the topic “the doctor as a person” is covered in some articles only. According to the analysis of Langberg et al., one more aspect represented by coordinated care that meets the patient’s needs has appeared in the literature on patient-centredness [8].

PATIENT-CENTREDNESS AS A MORAL STANDARD

Despite the absence of a single strict definition, patient-centredness is considered as a form of doctor-patient relationship, which is the standard of high-quality interaction between a doctor and a patient while providing medical care and is recommended for widespread implementation in medical practice. [2]. Its proponents believe that it should be pursued as an ideal, and in its absence, the relationship between the doctor and the patient should be assessed as not entirely satisfactory. Thus, patient-centredness becomes prescriptive or normative [9]. It can be said that it is becoming a new moral norm for medical practice. In this regard, moral justification of patient-centredness, which was given by Duggan et al., is of interest. They examined patient-centredness from the perspective of three groups of ethical theories.

Thus, from the point of view of utilitarianism, patient-centred medical care will be recognized as ethical, since it can be proved that it provides better results compared to the doctor-centred model of care. In the review by Duggan et al, a number of studies have been presented in which a positive relationship between the patient-centred model, treatment outcomes and quality of medical care, assessed by a variety of indicators, has been found. For example, Safran et al. have shown that elements of patient-centred care have a positive effect on patient satisfaction [10]. Kaplan et al. found a positive relationship between the nature of doctor-patient interaction and functional parameters in chronic diseases [11]. Hall et al. found a connection between patient-centredness and commitment to treatment: rejected dominance in communication with the patient, nonviolent communication on the part of the doctor is associated with increased adherence to therapy [12], etc.

Substantiating the morality of patient-centredness from the point of view of deontological ethical theories, Duggan et al. ask whether patient-centredness has some internal feature of “correctness”, which should be sought as a due. And answering it, the authors refer to Balint’s definition of patient-centredness when each person is taken as a unique human being. It coincides with Kant’s categorical imperative who recognized that every person has an unconditional moral value and dignity [13].

The third group of ethical theories requires an answer to the question of whether patient-centredness is a virtue. Unlike utilitarian ethical theories, the theory of virtue does not consider the consequences of actions as an important characteristic for distinguishing between good and evil. It does not insist on following pre-existing rules out of a sense of duty, as in deontological theories. The theory of virtue rather focuses on the education of correct attitudes and character traits that determine further moral actions. A person learns to act correctly by following the example of a teacher or mentor. Duggan et al. note that considering patient-centredness we understand that it is impossible to be truly attentive to the patient if there are no attitudes and beliefs that form the basis of patient-centricity. In the absence of these attitudes, it is impossible to act in a patient-centred way. These attitudes of respect and interest in the patient’s personality are virtuous in themselves. They constitute a moral standard. A person acts in accordance with them willingly, with joy and enthusiasm, because he knows that being virtuous is the best thing he can do for himself as well. Virtues promote beneficial relationships with others, make it possible to avoid judicial and social conflicts, and enhance self-esteem.

A STUDY OF THE ATTITUDE OF YOUNG DOCTORS TOPATIENT-CENTREDNESS

The conclusion that patient-centredness can be considered as a new moral norm of medical practice, allows us to raise the question of the attitude of the younger generation of doctors towards it, which will determine our medicine for years to come. To answer this question, we conducted a study participated by postgraduate doctors (Pirogov Russian National Research Medical University) and medical residents (RUDN). They were offered a questionnaire consisting of 21 questions on different aspects of patient-centred communication. 155 completed questionnaires were received from 24 surgeons, 90 therapists, and 41 representatives of other specialties. There were 48 men and 107 women among the respondents. 125, 19 and 11 respondents had employment history of up to 3 years, from 3 to 5 years, and more than 5 years respectively. The questionnaire consisted of several blocks and contained questions about the doctor-patient relationship, communication skills, attitude to informed voluntary consent, and caring skills used.

Study outcomes

The question “Have you ever encountered ethical problems when communicating with patients?” was addressed to young doctors in order to find out how sensitive they are to ethical issues while dealing with patients. The answer “yes” was provided by 67% of the respondents. We believed that a group of young surgeons would show less sensitivity to ethical issues than a group of therapists, as numerous surveys indicate a relatively lower level of empathy among surgical professionals. The hypothesis was not confirmed: no surgeon provided a negative response. On the contrary, in the group of therapists, the proportion of those who faced ethical problems reached 31% (23% and 48% for female and male therapists respectively). However, in this survey, the unexpected difference in the sensitivity level can be explained by the fact that a group of surgeons were interviewed at the end of a one-year postgraduate course in bioethics. The majority of therapists (70% of the respondents) were residents with less than three years of medical experience, who had not studied bioethics in residency. This allows us to draw a cautious conclusion that bioethics training increases sensitivity of young doctors to ethical issues.

The majority of respondent provided positive replies (82.6%, 67%, 67.8% respectively) to the following questions “Have you ever been dissatisfied with unsuccessful communication with a patient?”, “Have you ever felt that you did not want to go to the ward because it was difficult for you to communicate with a patient or consult such a patient on an outpatient basis?” and “Has it happened that after communicating with a patient you felt unusual fatigue, emptiness, anxiety, etc.?”. It indicates that young doctors are aware of the intersubjective nature of their communication with a patient and their vulnerability during this communication. The answers of young doctors allow us to raise a question whether they need training of their communication skills in difficult situations, and psychological support to prevent emotional burnout.

Asking the questions about communication skills, researchers wanted to know how important patient-centred communication skills are for young doctors, how they assess their mastery of the skills and the communication training they received during the training process.

74.8% of the patients gave a negative answer to the question “Do you agree with the statement that if a doctor is good at diagnosis and treatment, his/her communication skills do not matter while interacting with a patient?”, indicating that the ability to communicate is very important for the respondents. Nevertheless, it should be noted that almost a quarter of doctors gave a positive answer to the question, which means that the ability to communicate is not important in the presence of good clinical skills and abilities. It should be noted that 28% of those who agree with the proposed statement nevertheless believe that their training in the field of communication is insufficient, which indirectly indicates that they do not take such skills as superfluous.

58.3% and 36.5% rated their communications skills as “good” and “satisfactory” respectively. Only a few considered their communication skills to be poor. It is obvious that awareness of insufficiency of one’s communication skills can play a positive motivational role in learning effective communication.

The answers to the questions “Are you familiar with the term “patient-centred consultation?” and “Have you seen examples of patient-centred communication in your practice?” showed that the majority of respondents are familiar with the term (80.9%) and have seen such examples in their practice (76.5%), i.e. they imagine what it should look like. It can be assumed that this knowledge is the result of university education, when teachers of clinical disciplines passed on to students not only medical knowledge, but also cultural norms of communication with patients [14].

Probably, this can also explain the paternalistic attitudes of the respondents, which were revealed while answering the questions about how young doctors imagine an ideal patient and a relationship with him. 67% of respondents agreed that the ideal patient is laconic, ready to discuss the topic set by the doctor, and complies to treatment. This indicates that already during university studies, paternalism has penetrated into their ideas about what is proper in relationships with patients, and this will certainly hamper transition to patient-centred communication as a new norm.

Since an important aspect of patient-centred interaction includes rejection of gross paternalism, respect for patient autonomy and desire for joint decision-making, some of the questions were devoted to this topic. 83.5% of respondents i.e. the vast majority, gave a positive answer to the question “Does discussion with the patient help to choose the best option for an examination and treatment plan?”. Interestingly, that this percentage almost coincides with the proportion of doctors who, when asked what they would have spent extra time on during medical consultations, replied that they would have spent it on communicating with the patient. Based on the answers, it becomes clear that young doctors are aware of the lack of communication with the patient and consider it useful to increase the time that should be spent on it.

A patient-centred attitude includes caring for the patient, and therefore questions related to this aspect are included in the questionnaire. They allow us to judge whether young doctors practice patient care skills. So, in response to a question whether they touch patients while establishing contact, 79% of respondents provided a positive reply. However, in the male group, the proportion of practitioners with trusting touching is much lower and constitutes 22%. 64.3% gave a positive answer to the question “Have you ever sought the help of family, nurse, colleagues in situations where a patient is experiencing stress or anxiety?”. The proportion of men who answered “yes” was lower (32%) in this case as well.

CONCLUSIONS

A survey of young doctors showed that most of them are familiar with the concept of patient-centredness, have an idea of patient-centred relationships, respect their autonomy, and practice such communication, including the use of patient-centred communication and caring skills. At the same time, many people feel vulnerable while communicating with the patient and unprepared for communication. Thus, it can be concluded that they are motivated to learn patient-centred communication skills.

At the same time, the answers to the questions revealed the presence of paternalistic attitudes among young doctors towards patients, most likely formed at the stage of university education, which may interfere with the spread of patient-centred practice. The introduction of patient centredness will require not only technical training in communication skills, but also the study of the moral foundations of patient-centred care in the framework of bioethics courses, as well as in the form of “hidden” curricula of clinical disciplines, when studying clinical issues, teachers form ideas among students and residents/graduate students about a proper, patient-centred attitude to the patient, which is considered as a new the moral norm.

Authors of the study realize that in order to get a better understanding of the attitude of young doctors towards patient-centredness, the group of respondents should be expanded. Also, in the upcoming study, it is necessary to determine the dynamics of formation of patient-centred attitudes among students in the process of university and postgraduate studies. This will make it possible to clarify approaches to the formation of training programs for future doctors.