Chapter 7 Clinical reasoning and patient-centred care
Developing effective patient care requires making improvements to the way health professionals relate both to patients and to each other, in an effort to make better healthcare decisions. Clinical reasoning refers to the ‘thinking and decision making processes which are integral to clinical practice’ (Higgs & Jones, 1995, p. xiv). Fundamental questions may be asked about the part the patient should or can play in these processes and how this may be achieved. It is widely assumed that many patients want and benefit from an active role. Concepts of patient choice, autonomy, empowerment and partnership are being widely examined, advocated and challenged within consumer and professional literature as a means of enhancing patient-centred care (Coulter 2002, Edwards & Elwyn 2001, Mead & Bower 2000). Patient-centred decision making is being promoted by government policy initiatives such as the UK government’s National Health Service (NHS) plan (Department of Health 2000) and ‘expert patient’ initiatives in the UK (Department of Health 2000, 2004). Evidence suggests that a level of participation in clinical reasoning appropriate for the individual contributes to the patient’s sense of control. This may positively affect psychological well-being, physical recovery and satisfaction and lead to patients accepting greater responsibility for their health (Michie et al 2003).
It may appear self-evident that clinical decision making would always be formulated in the best interests of the patient. However, there are times when organizational or professional objectives can take precedence over effective decisions that take sufficient account of patients’ interests, in terms of both objective clinical facts and patients’ experiences and values. Professionals’ varying levels of skill when relating to patients may also lead to insufficient account being taken of their concerns and preferences. This in turn can have adverse consequences, such as patient anxiety and dissatisfaction, or sub-optimal clinical outcomes.
This chapter reviews the significance of a patient-centred approach to clinical reasoning. Relevant concepts and theories are introduced to orient the reader to a range of different sociocultural, psychological, ethical and professional perspectives on patient-centred care. Practical strategies that contribute to patient-centred decision making are examined. Finally, a case is made for the promotion of clinical reasoning that is patient-centred to achieve more clinically effective, ethical and humane health care.
Patient-centred care is a complex and difficult concept to define. However, there is an emerging consensus about its key features, particularly in the primary care and general practice literature (Fulford 1996, Mead & Bower 2000, Stewart et al 2003). In a review of the conceptual and empirical literature, Mead & Bower identified five dimensions of patient-centredness which distinguish it from the conventional biomedical model of practice:
It has been argued that the health outcomes associated with greater patient involvement in decision making need to be evaluated (Entwistle et al 1998). However, we contend that patient-centredness is fundamentally about the process of care. When patients are enabled to participate in clinical reasoning, the views of professional and patient may be at variance and a decision taken may not necessarily lead to the best clinical outcome. An example would be a patient with cancer or severe chronic psoriasis who expresses reluctance to engage in cytotoxic therapy due to awareness of the risks of major side-effects with such treatment, despite the prospect of therapeutic gain.
Concepts of health and illness behaviour and professional and patient roles are fundamental to understanding the way in which social factors may shape the way professionals adopt a patient-centred approach to decision making. In particular, a number of different theoretical approaches have been used to analyse the role and function of power relations in doctor–patient relationships (Lupton 2003). These approaches acknowledge that a power differential and ‘competence gap’ exist between patients and professionals, which may influence or limit patients’ involvement in clinical decision making.
Functionalist theory has classically portrayed the patient as a passive recipient of medical expertise. Parsons’ (1951) concept of the sick role considers patients as exempt from normal social obligations and from accepting responsibility for the management of their illness. Patients are viewed as having a psychological need to leave decision making to the doctor, but with the requirement to cooperate with treatment. There is duty upon the doctor to take control and to be solely guided by the patient’s welfare, applying the highest standards of professional competence and scientific knowledge. The sick role may be circumscribed by patients who are unable to fulfil the obligations and expectations that it entails; this applies to the chronically ill. However, it may still be the case that some patients, especially those with life-threatening conditions, prefer to hand over responsibility for managing their illness to professionals.
Political economy theory highlights how professions control knowledge and expertise to secure a position of power in society (Freidson 1970). Whether intentional or not, there is a risk of professionals withholding information from patients about their condition and treatment, thereby limiting patients’ scope for participation in decision making. From this perspective, it is argued that the imbalance of power between professionals and patients leads to inequalities in health care, with people from poorer or ethnic minority backgrounds being disadvantaged. A more patient-centred approach therefore requires a review of the professional role and of the impact of professionalization on power use. Self-help and community-led healthcare initiatives are also advocated to improve power balance.
Contemporary approaches to examining social aspects of medical practice, for example social constructionism, have been influenced by the writings of the French philosopher Michel Foucault. Medical knowledge is regarded as a series of relative constructions that are dependent on the sociohistorical settings in which they occur (Lupton 2003). Power relations are viewed as subtle and dynamic. They are constantly negotiated and renegotiated between patient and professional in medical consultations, with patients sometimes taking more control. Medical dominance is considered potentially positive and at times necessary to fulfil patients’ expectations and needs for health professionals to exercise medical expertise. Patients who choose to relinquish decision making to health professionals may be regarded positively as engaging in a practice they consider essential to their emotional and physical well-being.
Overall, these sociological perspectives acknowledge that some imbalance of knowledge and power between patients and professionals may be necessary to achieve patient-centred care, and that there are limits to the extent to which patients may participate in clinical reasoning.
Patient-centred decision making requires an understanding of patient–professional relationships. Patient-centredness is influenced by the health professional’s beliefs, values and attitudes toward patients in the planning and delivery of care. The whole orientation and comportment of practitioners, in terms of how they view and respond to patients, may have a fundamental bearing on the therapeutic consequences of their interactions (Ersser 1997). Skills are also required, such as the recognition of decisions to be made and the process of facilitating active patient involvement. A patient-centred approach encompasses beliefs about the rights of people and their potential to help themselves, with support. The relationship with the health professional provides the basis for that support. The psychology literature suggests that all therapeutic or helping relationships require qualities of self-awareness, authenticity and empathy (Egan 2002). These ideas have been influenced by humanistic psychology (Schneider et al 2001) and are directly reflected in professional–patient relationships and their effect on decision making.
A process of ethical reasoning underpins the decision making of healthcare professionals. Ethical theory can provide a framework to inform and guide clinical reasoning. The bioethical principles of autonomy, beneficence, non-maleficence and justice are widely used in working through ethical problems and dilemmas and in justifying decisions made (Beauchamp & Childress 2001). Patient-centred decisions require professionals to achieve an appropriate balance between respecting the autonomy of ‘competent’ patients to make their own decisions and meeting the duty of beneficence. Beneficence is the primary obligation of all health professionals to ‘do good’ and act in patients’ best interests. Traditionally, health professionals have been criticized for adopting a paternalistic approach, relying almost exclusively on their own professional knowledge and judgement about patients’ needs, without due regard for patients’ concerns and knowledge (Coulter 2002). Professionals facilitating patient involvement and evidence-based patient choice are required to give a higher priority to patient autonomy. However, it is argued here that beneficence should be reconciled with, and not compete with, respect for patient autonomy. For example, Ashcroft et al (2001) suggested that there may be situations where the professional should challenge a patient’s decision if it appears to conflict with the patient’s own values. While respecting patients’ autonomy and choices, professionals are also obliged to be fair to all patients and uphold the principle of justice when health resources are limited. Despite the value of ethical theory in guiding decision making, clinical reasoning involves more than the application of principles and rules. When conflicts occur between prima facie obligations, it rests with the integrity of the professional to make a judgement in a particular situation.
Models of professional practice convey different views about the respective roles of professional and patient, the goals of specific types of health care, and the beliefs and values that should underpin practice. They may also provide pointers to the desirability of patient involvement in clinical reasoning.
In their classic paper, Szasz and Hollender (1956) examined the way in which different models of the doctor–patient relationship related to the patient’s degree of participation in care, along a continuum from the passive patient to active participation. More recently, Charles et al (1999) discussed a shared-decision-making model, which they saw as the middle ground between the conventional ‘paternalistic’ model at one end of the continuum and an ‘informed choice’ model at the opposite end. Key features of shared decision making are that both professionals and patients share information, build consensus and reach an agreement about the treatment and care to be implemented. The model was developed in relation to cancer care, where there may be several treatment options with different possible side-effects and uncertain outcomes. It emphasizes the importance of professional guidance and support in enabling patients to participate in difficult decision making. In contrast, the informed choice model emphasizes information giving about risks and benefits as the key responsibility of the professional, and that ultimately it is for the patient to take the decision (Charles et al 1999). An example of where this model is likely to be used is in family-planning clinics.
Stewart et al (2003), a group of health and social care professionals working in family medicine in Canada, developed a patient-centred clinical model as a central feature of clinical practice and education. The model identifies six essential and interacting components, encompassing the clinical reasoning process between professional and patient as well as emphasizing the context within which they interact. Steps include exploring both the disease and the illness experience, understanding the whole person, and finding common ground in terms of problems and goals. Attention is also given to incorporating prevention and health promotion measures, enhancing the professional–patient relationship and being realistic about time and resources. The strengths of this model include its comprehensiveness and relevance to different professional and patient contexts, and its practical detail for teaching purposes.
Clearly, a number of factors influence the extent to which patients are involved in clinical reasoning. The attitudes and communication skills of health professionals and the extent to which patients are informed and knowledgeable about their illness are crucial factors. Additionally, there is the issue of patients’ role preferences and how they are assessed. There is evidence that while the majority of patients want to be well informed about their treatment and care, this does not necessarily mean that they desire an active role in clinical decision making (Guadagnoli & Ward 1998).
Surveys of patients’ preferred roles in clinical decision making have been conducted across Western societies and in relation to a range of illnesses, including cancers and chronic diseases. A systematic review by Benbassat et al (1998) indicated a number of significant demographic patterns. Better educated, younger and female patients were more likely to prefer an active role. People from ethnic minority groups were more likely to prefer a passive role. The severity of the illness may also be an issue, with patients facing acute or life-threatening conditions being more likely to prefer a more passive role than patients with chronic illnesses. Nevertheless, demographic and situational factors explained only 20% of the variability and therefore cannot be used as predictors of an individual’s role preferences. Also, some patients’ role preferences may change during the course of their illness. Therefore it is apparent that the only way for health professionals to determine patients’ role preferences is through direct inquiry.
Several tools have been developed to measure patients’ role preferences in clinical consultations and in research studies. The Control Preferences Scale of Degner et al (1997) consists of five cards, each portraying a different role in treatment decision making, using a statement and cartoon. This has been used successfully in busy clinics. However, other authors recommend a more subtle approach. For example, Elwyn et al (2000) considered establishing and reviewing the patient’s role preferences to be a fundamental skill of the medical consultation.