The impact of patient-centered care on outcomes.

BACKGROUND: We designed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization. METHODS: We selected 39 family physicians at random, and 315 of their patients participated. Office visits were audiotaped and scored for patient-centered communication. In addition, patients were asked for their perceptions of the patient-centeredness of the visit. The outcomes were: (1) patients' health, assessed by a visual analogue scale on symptom discomfort and concern; (2) self-report of health, using the Medical Outcomes Study Short Form-36; and (3) medical care utilization variables of diagnostic tests, referrals, and visits to the family physician, assessed by chart review. The 2 measures of patient-centeredness were correlated with the outcomes of visits, adjusting for the clustering of patients by physician and controlling for confounding variables. RESULTS: Patient-centered communication was correlated with the patients' perceptions of finding common ground. In addition, positive perceptions (both the total score and the subscore on finding common ground) were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals. CONCLUSIONS: Patient-centered communication influences patients' health through perceptions that their visit was patient centered, and especially through perceptions that common ground was achieved with the physician. Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.

Educating future physicians for Ontario: phase II.

In 1990, a collaborative project was launched to determine what the people of Ontario expect of their physicians and how the programs that prepare future physicians should be changed in response. The project, called Educating Future Physicians for Ontario (EFPO), brought together the five Ontario medical schools, the Council of Ontario Faculties of Medicine (COFM); a nonprofit, charitable organization, Associated Medical Services (AMS); and the Ontario Ministry of Health. The first phase ran for five years and was described in the November 1998 issue of Academic Medicine. After an external review, the project was continued for a second phase (EFPO II) for four more years until December 1998; that second phase is the topic of this article. EFPO II (1) focused more on residents' education; (2) emphasized four of the EFPO I-created physician roles in project activities; (3) maintained the province-wide, inter-institutional medical education framework of phase I, but fostered greater involvement of the seven sites (five medical schools and two regional health centers) in project activities; (4) stressed five project components (e.g., needs assessment and community partnerships) and worked for collaboration among components at all sites; (5) enhanced the original EFPO I Fellowship Program by adding residents and community fellows to the existing fellowships and by initiating leadership development activities, all of which bode well for the future leadership of medical education in Ontario. Students and residents played a vital role in EPFO II. Most of EFPO II's objectives were met, but the overall view of external reviewers was that the project was less successful than EFPO I. For example, the impact on clinical education, especially residency education, was less than anticipated. On the other hand, the project helped encourage the wide adoption of the eight physician roles that originated in EFPO I and advanced faculty development and assessment activities based on these roles. A third phase of EFPO concerning continuing medical education was planned, but support was not available. However, one of the funders will continue to support the successful fellowship and leadership program and the provincial education network for the next three years. Overall, the two phases of EFPO substantially modified medical education in Ontario to make it more responsive to evolving social needs.

Educating future physicians for Ontario.

In 1987, Ontario's physicians conducted a strike, ultimately not successful, over the issue of "extra billing." The fact that the Ontario public did not support this action reflected a major gap between the profession's view of itself and the public's view of the profession. In 1990, the province's five medical schools launched a collaborative project to determine more specifically what the people of Ontario expect of their physicians, and how the programs that prepare future physicians should be changed in response. The authors report on the first five years of that ongoing project. Consumer groups were asked to state their views concerning the current roles of physicians, future trends that would affect these roles, changes in roles they wished to see, and suggestions for changes in medical education. Methods used included focus groups, key informant interviews, an extensive literature review, and surveys, including a survey of health professionals. Concurrently, inter-university working groups prepared tools and strategies for strengthening faculty development, assessing student performance, and preparing future leadership for Ontario's medical education system. Eight specific physician roles were identified: medical expert, communicator, collaborator, health advocate, learner, manager ("gatekeeper"), scholar, and "physician as person." Educational strategies to help medical students learn to assume these eight roles were then incorporated into the curricula of the five participating medical schools. The authors conclude that the project shows that it is feasible to learn specifically what society expects of its physicians, to integrate this knowledge into the process of medical education reform, and to implement major curriculum changes through a collaborative, multi-institutional consortium within a single geopolitical jurisdiction.

Introducing problem-based learning into a traditional undergraduate medical curriculum.

Problem-based learning (PBL) has been introduced into the undergraduate curricula in most Canadian medical schools. In the University of Western Ontario model, we set aside 20% of time to PBL in the first two years of the programme and the rest for didactic methods. The objective of this article is to discuss 6 years of our experience with the model and the process and problems of introducing PBL into a traditional curriculum. The importance, and methods for developing good cases which are multidisciplinary and 'three-dimensional' (biological, behavioural/ psychosocial and population issues) are emphasized. The challenges have been to: integrate the underlying teaching/learning values of two different methods, develop a valid and reliable examination/evaluation procedure, and keep the faculty interested and continually improving their skills. Students have welcomed the break from lectures and the challenge to explore in-depth areas of special interest. The most positive outcomes of this curricular change have been an increased interest in medical education reform in general, and enhanced recognition of teaching in relation to appointments and promotions.

Self-assessed competence: before and after residency.

This study measures changes in clinical confidence experienced by 42 family practice residents as they progressed through a 2-year residency program. At the beginning, 20% or more of respondents reported they lacked confidence in 47 of the 177 topics. Self-assessed competence increased substantially in many areas. However, during the residency, new areas of concern emerged.

[Problem-based learning--a cautious approach]. / Problembasert laering--en forsiktig tilnaerming.

Most medical schools in Canada have, over the last few years, introduced Problem Based Learning (PBL) into their undergraduate curricula. In contrast to some other schools which have radically transformed their entire curricula, the University of Western Ontario approach has been more cautious, setting aside 20 per cent of the time during the first two years of the curriculum to PBL, more traditional, didactic methods being used otherwise. The main challenges have been to integrate the underlying values of the two different approaches to teaching and learning to develop valid and reliable examination and evaluation procedures, and to sustain the enthusiasm and interest of a large, mostly voluntary, group of faculty members, continually improving their skills as tutors. The most beneficial results of this curricular change have been an increased interest in medical education reform in general, and an increased recognition of the importance of teaching in relation to appointments and promotions. Students have appreciated the break from a never ending stream of lectures, and many have welcomed the challenged to explore in depth areas of special interest.

Changes in residents' self-assessed competences during a two-year family practice program.

PURPOSE: To compare changes in self-assessed clinical confidence over a two-year residency between two groups of family practice residents, one starting in a family practice center and the other starting in a hospital. METHOD: All 44 entering residents at the University of Western Ontario in either 1984 or 1985 were eligible. Forty-two participated at baseline, and 24 (57%) provided completed responses after two years. Confidence regarding 177 topics in 19 general topic areas was assessed using self-completed questionnaires administered at baseline and after six, 12, and 24 months. The residents rotated every six months between sites, with approximately half starting in each site. Nonrandom assignment to starting site included consideration of the residents' stated preferences; hence self-selection bias was possible. Mean differences were evaluated using t-tests, and trends over time were assessed using repeated-measures analysis of variance. RESULTS: There was no difference between the groups' grand means at any time. In the 19 areas, five statistically significant differences were seen, four at six months and one at 12 months; four involved greater confidence by the center-start group. No difference was seen after two years, and both groups displayed substantial increases in confidence over two years. CONCLUSIONS: The few significant differences in confidence between the two groups suggest that their training might have been deficient if it had omitted one of the settings. However, because these differences had disappeared after the groups had each experienced 12 months in each setting, the initial site of training appears not to affect learning.

A survey of residency-trained family physicians and their referral of psychosocial problems.

BACKGROUND: Communication between family physicians and other specialists has been identified as a central component of the referral process. This survey examines the referral process between family physicians and psychiatrists. METHODS: A questionnaire was mailed to all 167 graduates of a family practice residency program in Ontario; 154 (92.2%) responded. The questionnaire requested information from the family physicians about the frequency of, reason for, and satisfaction with referrals they made to psychiatrists. RESULTS: In the previous year, 41 percent of family physicians had regularly referred patients to a psychiatrist. The main reasons for referral were for assessment and advice on patient management and/or for ongoing psychiatric care. Family physicians referred to one of several psychiatrists, depending on the patient's problem. The primary method of interphysician communication was a personal conversation between the family physician and the psychiatrist. Only 50% of family physicians were satisfied with the assistance provided by psychiatrists to whom they referred patients, and only 40% were satisfied with feedback they received from these consultants. CONCLUSIONS: The high degree of dissatisfaction suggests that improvement is needed in the interactions between family physicians and psychiatrists.

Training in Psychosocial Issues: Survey of family medicine graduates.

In a survey of family practice graduates, all provided supportive psychotherapy. Most were satisfied with their abilities to deal with problems such as depression or grief reactions, but many were dissatisfied with their abilities to deal with problems such as chronic pain syndrome and family violence. The most helpful learning experiences were seeing patients in the family medical centers and Balint seminars. Respondents' suggestions have implications for curriculum revision and continuing medical education.

Improving the Rate of Influenza Vaccination: A trial of three outreach methods.

This study examined whether mail, telephone, and direct contact could improve a family practice's immunization rate and how patients would react to the outreach strategies. Influenza immunization rates of 73.4% in patients older than 65 and 57.1% in younger patients with chronic illnesses were achieved. Almost all patients accepting immunization appreciated being notified; most preferred telephone contact.

The teacher-student-patient relationship in family practice: common dilemmas.

When students are included in administering patient care, the doctor-patient relationship changes. Because of frequent turnover of students, continuity of care poses a major dilemma. One key to success is to help students deal with issues of change and loss, both in their own experience and in that of their patients. It is also important for supervisors to maintain direct patient contact, especially with new or complex patients or at a patient's request or at the request of a resident or a nurse, or when the teacher cannot get a good "feel" for the patient's problem at second hand. Supervisors should also recognize the effects of different approaches to supervision on relationships with patients and with students.

Patient-centred interviewing part I: understanding patients' experiences.

Effective patient care requires attending as much to patients' personal experiences of illnesses as to their diseases. Diseases are ferreted out by using the conventional medical model, but understanding illnesses requires a different approach. A patient-centred method focuses on four principal dimensions of patients' experiences: their ideas about what is wrong with them; their feelings about their illnesses, especially their fears; the impact of their problems on functioning; and their expectations about what should be done. The key to this approach is attention to patients' cues related to these dimensions; the goal is to follow patients' leads, to understand patients' experiences from their own point of view. This method improves patient satisfaction, complicance and outcome, and is applicable to the everyday work of family physicians with "ordinary" patients.

Patient-Centred Interviewing Part II: Finding Common Ground.

DEVELOPING AN EFFECTIVE MANAGEMENT PLAN REQUIRES PHYSICIANS AND PATIENTS TO REACH AGREEMENT IN THREE KEY AREAS: the nature of the problems, the goals and priorities of treatment, and the roles of the doctor and patient. Often doctors and patients have widely divergent views in each of these areas. The process of finding a satisfactory resolution is not so much one of bargaining or negotiating but rather of moving towards a meeting of minds or finding common ground. This framework reminds physicians to incorporate patients' ideas, feelings, and expectations into treatment planning.

Patient-Centred Interviewing Part III: Five Provocative Questions.

The literature review of select studies on doctor-patient communication seeks to answer some of the frequently expressed questions and doubts about patient-centred interviewing. Studies from Canada, the United States, Britain and Holland, mostly in family practice, provide us with a rich source of data to ponder. The five questions we ask are: Do patient-centred consultations make a difference to patient outcomes? Are patient-centred doctors medically competent? Are patient-centred visits long? Are physicians consistent in their interview styles from patient to patient? How do students learn the patient-centred approach?

The person: a missing dimension in medical care and medical education.

MEDICAL EDUCATION NEEDS TO MOVE BEYOND THE BIOMEDICAL MODEL TO REDRESS THE BALANCE BETWEEN THE TWO GREAT HISTORICAL TRADITIONS IN MEDICINE: the reductionistic and the whole person approaches. Students need to understand the distinctions between disease as an abstract concept and illness as an experience lived by their patients. They need to approach the study of both the sciences and the humanities with a rigorous, thoughtful, and balanced approach, and learn to integrate these understandings and to apply them to the care of sick persons. Medical education should be more than vocational training: it must be a liberal education. The missing dimension in medical education is the person, both the person of the patient and the person of the student. The experiences of both are the very foundations of learning, growth, and healing.

Screening for dementia in family practice.

The Mini Mental State Examination (MMSE) was performed on 90% of patients over age 65 in a full-time teaching practice associated with the University of Western Ontario during a six-month study period. Before screening, dementia was documented clinically in 5.6% of the patients over age 65. The "iceberg phenomenon" did not occur: all patients with dementia identified by the MMSE had already been recognized by the physician; no new treatable problems were discovered. This study challenges the value of screening with this instrument, since it failed to identify one of the six patients in this practice with clinical dementia.