Achieving patient-centered care across the spectrum

Providing patient-centered care consistently in clinical practice requires practitioners who are able to recognize that different clinical situations require different approaches and are skilled enough to adapt.

Across the range of health-care problems, patient-centered care has been found to be associated with improved patient outcomes, including improved self-management, patient satisfaction, and medication adherence, and some studies have found evidence for improved clinical outcomes. Data from surveys and research indicate that clinicians often do not take patients' perspectives into account during the decision-making process. This is because clinicians are often challenged by the diversity of situations that arise.

Dr. Glyn Elwyn of the Dartmouth Center for Health Care Delivery Science is the principal investigator of a study in the current issue of Annals of Family Medicine. Elwyn said that practitioners could use or integrate two methods: shared decision making and motivational interviewing when discussing options for treatment with patients.

When patients face tough treatment decisions, shared decision making alone is appropriate. And where clinicians perceive a need to change behavior to improved health outcomes, motivational interviewing can be used. Many clinical consultations may require elements of both approaches.

"Clearly, different situations require different communication approaches," Elwyn said. "Each situation has different psychosocial, cultural and medical implications."

Shared decision making is a method where clinicians and patients make decisions together using the best available evidence. Patients are encouraged to consider available screening, treatment or management options and the likely benefits and harms of each. It is used to support patients in making health care decisions where there is more than one reasonable option.

Motivational interviewing is most often applied in situations that usually require some degree of behavioral change about which a patient feels ambivalent, such as lifestyle choices or adherence to medications. Originally developed for dealing with drug and alcohol addiction, the scope has widened to include how best to motivate behavior change across many domains.

Motivational interviewing recognizes that making behavioral change is difficult and that telling or persuading people to change will often meet with resistance. Clinicians should explore and resolve ambivalence and by doing so elicit and encourage a patient's own motives to change.

For motivational interviewing there is evidence for efficacy in treating addictions and mixed evidence in improving health outcomes of patients with diabetes, asthma, high blood pressure and heart disease.

The researchers acknowledge the challenge of implementing shared decision making and motivational interviewing into routine practice. "We believe, however, that we will see little progress in patient-centered care unless these approaches are valued as core elements of good practice; they should be taught, assessed and integrated into daily practice, then appropriately measured and rewarded."