Patient-centred care (PCC) is typically framed as a moral imperative, necessary to prevent a return to the outmoded medical paternalism of the past. Critical engagement with the concept is difficult, partly because of its moral dimension, and partly because there is no universally agreed definition. It is generally accepted that the term was introduced by the psychotherapist Michael Balint, in his work with UK GPs in the 1950s. However, Balint (1957) described it largely in terms of what it was not, as a contrast to a reductionist biological approach. It was subsequently used by Byrne and Long (1976) to describe specific interactional behaviours on the part of doctors, before being developed into a wider approach (Levenstein et al, 1986). Since its original specification, large numbers of definitions, models and measurement tools have been developed; in 2014 the UK charity The Health Foundation identified over 160. They overlap to varying degrees and researchers have shown they can produce different results even when applied to the same consultation (Landmark et al, 2017). However, they generally share an emphasis on the importance of the transfer of control from doctor to patient, through support of patient autonomy and choice.
Given the ubiquity of the term in UK health policy and service standards, it might be assumed that there is a strong evidence base. There are many studies evaluating individual interventions in specific settings, but three significant larger scale reviews. A Cochrane systematic review of PCC interventions found some evidence for improvement in patient satisfaction, but none for health behaviour or health outcomes (Lewin et al, 2001). A subsequent update showed positive effects on how patients rated the consultation, but mixed results on overall satisfaction, behaviour and outcomes (Dwamena et al, 2012). A review of Shared Decision-Making interventions (included here because some conceptualisations of PCC characterise presence of SDM as the defining characteristic) found no impact on behavioural or health outcomes (Shay and Lafata, 2015). Evidence for positive impact, then, is mixed to non-existent. The only consistent finding is that PCC interventions improve the practice of PCC as measured by that specific intervention, which is an unhelpful circularity. Nevertheless, these results are largely considered as evidence of professional failings, to be remediated through more or ‘better’ training in PCC. This suggests a mismatch between the aspects of communication that patients orient to as problematic, and the policy initiatives that have been designed to fix them.
Sociologists have long demonstrated that there can be ‘good’ organisational reasons for what may look like ‘bad’ healthcare practice, for example where safety, or wider public health issues, must be given priority. But to stretch the title of Garfinkel and Bittner’s famous paper a little further, there can also be good interactional reasons for this. With a British Academy Senior Research Fellowship, I examined audio and video-recorded data of healthcare interactions collected from a variety of settings, over a 25-year period (Pilnick, 2022). This analysis supported two conclusions: firstly, that practices that in the abstract appear inclusive may not function that way in healthcare; and secondly, that PCC, through the use of specific discursive practices, constitutes an ideal patient with particular kinds of intellectual and interactional attributes (see also Armstrong 1983; Silverman and Bloor 1997). Where that ideal isn’t realised, the empowerment promised by PCC isn’t easily achieved.
Specifically, practices designed as patient-centred can become problematic because of how they impact on expertise. Assuming the only alternative to PCC is medical paternalism conflates two distinct issues: authority and expertise. But from a philosophy of language perspective, there is an important distinction to be made between epistemic authority (in simple terms, the right to knowledge in a particular area) and deontic authority (the right to decide what should happen based on that knowledge) (Bochenski, 1974). PCC’s focus on patient choice and control has rightly problematised deontic authority, and successive medical scandals have shown us where this unquestioned authority can lead. But at the same time, it has problematised epistemic authority and so medical expertise. This is despite the fact that analyses of how healthcare interactions unfold in practice have shown us that we cannot begin by treating aspects of social context (e.g. power, status, knowledge) as exogenous and immutable factors that will always govern patient behaviour in particular and predictable ways. Boundaries of expertise and knowledge and the right to determine what should happen next are negotiated and determined in the moment as part of these interactions. PCC places an emphasis on the ‘epistemics of experience’, but if this is given absolute primacy, healthcare issues become recast as private concerns. The logical endpoint of this is either in practices of affirmative care which may not meet care standards (see the interim report of the Cass review (February 2022) for an example of the issues this raises), or in placing patients in a situation where they cannot easily access expertise they want or need. By framing medical decisions as entirely personal we set them outside of medical expertise, and potentially abandon patients to the rhetoric of consumer choice.
This is not to suggest that either communication, or patient expertise, are unimportant. They are of fundamental importance, but the current paradigm does both a disservice. Healthcare communication needs to be studied not only as a way of judging the success or otherwise of policy implementation, but in its own right, so that we can use it to inform healthcare policymaking from the outset. And patient experience needs to be recognised and incorporated through co-production of resources and co-design of services, rather than evaluation of individual consultations. The current situation has arisen because sociology has been co-opted in an attempt to bring about PCC: using Straus’ (1957) distinction it is an example of sociology in medicine rather than sociology of medicine. If sociologists think only from inside the perspective of medicine, we run the risk of losing the original purpose of sociological inquiry, and failing to ask more fundamental questions about what we think the purpose of medicine in modern society is or ought to be.
Note from Katy Mathers, Senior Commissioning Editor, Emerald Publishing:
Alison’s book, Reconsidering Patient Centred Care: Between Autonomy and Abandonment is available now, with discount detailed below. Winner of the Foundation for the Sociology of Health and Illness Book Prize 2023, the book is a major contribution to the sociology of medicine, showcasing ground-breaking shifts in the terms of the debate around patient centred care (PCC). At Emerald, we understand the importance of a world that recognises and protects the most vulnerable and we aim to help research influence real world change in people’s health and wellbeing via our commitment to Healthier Lives. Alison’s writing on how healthcare policies need to be grounded in a solid understanding of how healthcare interaction works in practice is a shining example of how research can affect real world change.
- Armstrong, D. (1983). The political anatomy of the body. Cambridge: Cambridge University Press.
- Balint, M. (1957/1964). The doctor, his patient and the illness. Edinburgh: Churchill Livingstone.
- Bochenski, J. M. (1974). An analysis of authority. In J. A. Frederick (Ed.), Authority (pp. 56–85). The Hague: Martinus Nijhoff.
- Byrne, P. S., & Long, B. E. L. (1976). Doctors talking to patients: A study of the verbal behaviours of doctors in the consultation. London: Her Majesty’s Stationery Office.
- Dwamena, F., Holmes-Rovner, M., Gaulden, C. M., Jorgenson, S., Sadigh, G., Sikorskii, A., … Olomu, A. (2012). Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews, 12, CD003267. doi:10.1002/14651858.CD003267.pub2
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- Health Foundation (2014). Helping measure person-centred care. Retrieved from https://www.health.org.uk/publications/helping-measure-person-centred-care
- Independent Review of Gender Identity Services for Children and Young People (The Cass Review). Interim Report February 2022. Retrieved from: https://cass.independent-review.uk/publications/interim-report/
- Landmark, A. M. D., Ofstad, E. H., & Svennevig, J. (2017). Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements. Patient Education and Counseling, 100(11), 2081–2087.
- Levenstein, J. H., McCracken, E. C., McWhinney, I. R., Stewart, M. A., & Brown, J. B. (1986). The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine. Family Practice, 3(1), 24–30
- Lewin, S. A., Skea, Z. C., Entwistle, V., Zwarenstein, M., & Dick, J. (2001). Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews, 4, CD003267.
- Pilnick, A. (2022) Reconsidering patient centred care: between autonomy and abandonment. Bingley: Emerald Publishing Group.
- Shay, L. A., & Lafata, J. E. (2015). Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical Decision Making, 35(1), 114–131. doi:10.1177/0272989X14551638
- Silverman, D., & Bloor, M. (1997). Patient-centred medicine: Some sociological observations on its constitution, penetration, and cultural assonance. In M. Bloor (Ed.), Selected writings in medical sociological research. Aldershot: Ashgate
- Straus, R. (1957) The nature and status of medical sociology. American Sociological Review, 22 (2): 200-204.
Alison Pilnick is Professor of Language, Health and Society in the Faculty of Health and Education, Manchester Metropolitan University. Her research examines communication between healthcare professionals and their patients in order to better understand and improve healthcare delivery. Twitter: @AlisonPilnick