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STUDY QUESTION What outcomes should be reported in all studies investigating uterus-sparing interventions for treating uterine adenomyosis? SUMMARY ANSWER We identified 24 specific and 26 generic core outcomes in nine domains. WHAT IS KNOWN ALREADY Research reporting adenomyosis treatment is not patient-centred and shows wide variation in outcome selection, definition, reporting and measurement of quality. STUDY DESIGN, SIZE, DURATION An international consensus development process was performed between March and December 2021. Participants in round one were 150 healthcare professionals, 17 researchers and 334 individuals or partners with lived experience of adenomyosis from 48 high-, middle- and low-income countries. There were 291 participants in the second round. PARTICIPANTS/MATERIALS, SETTING, METHODS Stakeholders included active researchers in the field, healthcare professionals involved in diagnosis and treatment, and people and their partners with lived experience of adenomyosis. The core component of the process was a 2-step modified Delphi electronic survey. The Steering Committee analysed the results and created the final core outcome set (COS) in a semi-structured meeting. MAIN RESULTS AND THE ROLE OF CHANCE A total of 241 outcomes was identified and distilled into a ‘long list’ of 71 potential outcomes. The final COS comprises 24 specific and 26 generic core outcomes across nine domains, including pain, uterine bleeding, reproductive outcomes, haematology, urinary system, life impact, delivery of care, adverse events and reporting items, all with definitions provided by the Steering Committee. Nineteen of these outcomes will apply only to certain study types. Although not included in the COS, the Steering Committee recommended that three health economic outcomes should be recorded. LIMITATIONS, REASONS FOR CAUTION Patients from continents other than Europe were under-represented in this survey. A lack of translation of the survey might have limited the active participation of people in non-English speaking countries. Only 58% of participants returned to round two, but analysis did not indicate attrition bias. There is a significant lack of scientific evidence regarding which symptoms are caused by adenomyosis and when they are related to other co-existent disorders such as endometriosis. As future research provides more clarity, the appropriate review and revision of the COS will be necessary. WIDER IMPLICATIONS OF THE FINDINGS Implementing this COS in future studies on the treatment of adenomyosis will improve the quality of reporting and aid evidence synthesis. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was received for this work. T.T. received a grant (grant number 2020083) from the South Eastern Norwegian Health Authority during the course of this work. T.T. receives personal fees from General Electrics and Medtronic for lectures on ultrasound. E.R.L. is the chairman of the Norwegian Endometriosis Association. M.G.M. is a consultant for Abbvie Inc and Myovant, receives research funding from AbbVie and is Chair of the Women’s Health Research Collaborative. S.-W.G. is a board member of the Asian Society of Endometriosis and Adenomyosis, on the scientific advisory board of the endometriosis foundation of America, previous congress chair for the World Endometriosis Society, for none of which he received personal fees. E.S. received outside of this work grants for two multicentre trials on endometriosis from the National Institute for Health Research UK, the Rosetrees Trust, and the Barts and the London Charity, he is a member of the Medicines and Healthcare Products Regulatory Agency (MHRA), Medicines for Women’s Health Expert Advisory Group, he is an ambassador for the World Endometriosis Society, and he received personal fees for lectures from Hologic, Olympus, Medtronic, Johnson & Johnson, Intuitive and Karl Storz. M.H. is member of the British Society for Gynaecological Endoscopy subcommittee. No other conflict of interest was declared. TRIAL REGISTRATION NUMBER N/A.

OBJECTIVE: To validate and refine typologies of consultation performance from previous research to identify learning needs associated with each typology.METHODS: We performed a qualitative study in a General Practice Specialty Training programme, using a two-stage design. First, we selected four exemplars from 80 videotaped consultations of 7 first-year and 6 third-year trainees that reflected the four typologies. We subsequently held individual interviews with clinical supervisors (N = 20) who observed these consultations to identify recurrent trainee behaviours.RESULTS: The 'doctor-patient interaction' dimension from previous research was specified to encompass relationship-building, exploring, structuring, and shared decision-making competencies. Medical expertise was a moderating factor. The attitude and consultation behaviours included in the typologies were validated and we formulated directions for learning based on learning needs identified per typology.CONCLUSION: Supervisors have a shared frame of reference for the behaviours reflecting proficient consultation performance. Serving as a developmental road map, all learning needs emphasised contextual adaptation, calling for an improved balance between patient-centred relationship building and application of medical expertise.PRACTICE IMPLICATIONS: By providing rich and tailored feedback on consultation performance, the refined typologies - albeit subject to additional refinement in future research - may promote the monitoring of individual competence development over time.

ObjectivesInterdisciplinary bedside rounds is gaining ground as a method to improve patient centredness and involvement, quality of care and team collaboration. An exploratory study was conducted in Flemish hospitals to (1) map and (2) examine the current form of rounds and the extent to which these were bedside, patient and family participatory and interdisciplinary.MethodsIn February 2020, a quantitative cross-sectional self-reporting web-based survey was conducted in 23 hospitals in Flanders, 213 head nurses of 213 wards completed the survey. A self-reporting 19-item questionnaire was developed in Lime Survey®. The questionnaire contained a mix of closed-ended questions an open-ended questions. The data were analysed using SPSS 26.0.ResultsMost of the wards in Flanders organise a form of daily rounds at the bedside. In only half of the wards these rounds are organised at a fixed time. The rounds most often include a physician and a nurse. Other disciplines are rarely actively involved. Only a minority of wards uses checklists, structures or protocols to standardise the rounds. The majority of the wards reports that patients (and family) get sufficient time to ask questions and say they are actively stimulated to do so.ConclusionIn current practice, most rounds are (partially) bedside, open for patient and family participatory and often include only a physician and a nurse. However, these elements of interdisciplinary rounds are not yet well integrated and vary strongly amongst ward. Most rounds should be considered as an extended form of physician rounds, rather than being interdisciplinary.

Summary The provision of high-quality health care involves many different aspects, including safety, effectiveness, efficiency, and patient centredness. In order for care to be truly patient centred requires patients’ views being sought and considered, and this may be achieved through patient-centred research. Patient-centred research is fundamentally important in contemporary health care and has many benefits; for example, it ensures that research is relevant, identifies those aspects of care that are important to patients, provides information that is important to current and future patients, and allows the integration of patients’ views regarding how services may be enhanced in the future. This paper provides an overview of how we currently involve patients in orthodontic research, what this means to the specialty and how we can enhance patient involvement in the future.

Background and purpose Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff. Methods A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned. Results Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures. Conclusions In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

Introduction Regular physical activity (PA) is recommended by all type 2 diabetes mellitus (T2DM) management guidelines. The OPADIA study aimed to determine whether using a specific patient questionnaire (Optima-PA©) could help T2DM patients increase their PA by leading to better physician-patient communication and improved levels of shared decision making concerning Specific, Measurable, Acceptable, Realistic, Timely (SMART)-PA micro-objectives. Methods Physicians participating in this multicentre, prospective, randomised, real-life study were allocated to a standard group (T2DM patients managed according to usual clinical practice, n = 24) or the OPTIMA-PA group (additional use of the questionnaire, n = 30). The main outcome was the percentage of inclusion visits ending with the setting up of at least one SMART-PA micro-objective. Other outcomes were the impact of the OPTIMA-PA questionnaire on patient perceptions of shared decision making (ENTRED questionnaire) and the impact of the OPTIMA-PA questionnaire and establishing SMART-PA micro-objectives as well as patient-perceived physician empathy (ENTRED questionnaire) and GP aptitude for patient-centredness (SEPCQ scores) on patient PA levels over a 3-month period (IPAQ-SF scores). Results One hundred twenty-two patients were included in the standard group and 134 in the OPTIMA-PA group. Unexpectedly, more inclusion visits ended with SMART-PA micro-objectives being set up in the standard group (p

Background: Patients’ perspectives on standardised, multimodal prehabilitation programmes showed barriers to adherence. Further investigation of patients’ ability to prepare is needed. Aim: To investigate what patients with cancer who were due to undergo major abdominal surgery actually were able to do when provided with preoperative, home-based, multimodal recommendations presented in a leaflet. Methods: Patients from the colorectal- or ovarian cancer centre, who were scheduled for major abdominal surgery, received a leaflet with preoperative recommendations. On a daily basis, the patients filled in what they had completed in relation to these recommendations, so that adherence could be investigated. Additionally, face-to-face interviews were conducted to evaluate patients’ experiences of using the leaflet. Malterud’s principles of systematic text condensation were used to analyse the interviews. A convergent design was used to merge the quantitative and qualitative data into a combined interpretation presented in the discussion. Results: A total of 53 patients returned a completed leaflet, and five patients were interviewed. In the combined interpretation, patients’ ability to prepare was presented through four major domains. The domains were adherence and the importance of support, manageable actions leading to change, preparation in a broader perspective and impediments to preparation and to symptom relief. Conclusions: Patients prepared themselves in various ways, which were not limited to recommendations inspired by multimodal prehabilitation. Patients from the ovarian cancer centre increased their weekly exercise during the preoperative period, which indicates that the leaflet not only functioned as a data collection tool, but also motivated and supported the patients in prehabilitation-related actions. Patients’ perspectives on prehabilitation need to be taken into account, when aiming to enhance patient-centredness and adherence.

The publication of To Err is Human 1 by the US Institute of Medicine (IOM) helped launch not just the field of patient safety but the broader interest in healthcare quality. The report’s estimates of 44 000–98 000 annual deaths from medical error in US hospitals—eye-catchingly equated to a jumbo jet crashing every day and a half—captured headlines and widespread attention. The IOM (now the National Academy of Medicine, NAM) followed up this success with Crossing the Quality Chasm ,2 which notably defined quality in terms of six distinct dimensions, including not just safety, but also effectiveness, patient centredness, efficiency, timeliness and equity. Many might have feared that the interest generated by these two reports would represent passing fads rather than enduring fields. Thankfully, that has not occurred. Patient safety and broader quality improvement efforts remain active areas of research and operational activities in healthcare organisations around the world. In addition, some funding agencies focus on healthcare quality, as do an increasing number of journals, such as BMJ Quality and Safety , and many public interest advocacy groups have been spawned. It thus feels fitting that a new book, Making Healthcare Safe: The Story of the Patient Safety Movement, 3 should recount the birth and subsequent development of patient safety as a field. The author, Lucian Leape, played a leading role in launching the field—not just as one of the authors of To Err is Human, but also through numerous prior and subsequent contributions. Leape helped lead the seminal Harvard Medical Practice Study4—one of the two large studies that generated the widely quoted estimates of deaths due to medical error. A few years later, Leape’s groundbreaking article on Error in Medicine5 outlined many ideas that remain paradigmatic. Fast forward a quarter century and we now have this …

Background/purpose Although much has been written about the medical learning environment, the patient, who is the focus of care, is rarely the focus in this literature. The purpose of this study was to explore the role of the patient as an active participant with agency in the medical learning environment from the standpoint of the learner, the attending physician, and most importantly, the patient. We hoped to gain insights into the mechanisms that can reinforce professional values such as patient-centred and respectful behaviours in a patient-present learning environment. Methods We conducted this study in an ambulatory internal medicine clinic using "patient-present" clinic visits. All case presentations occurred in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semi-structured interviews after each clinic visit to explore the impact of the patient-present learning environment. We recruited 34 participants in the study; 10 attending physicians, 12 learners, 10 patients and 2 family members. We analyzed the data deductively using a conceptual framework of agency. Summary/results We identified three major insights: 1. Patients felt engaged and valued opportunities to be heard; 2. Attending physicians and learners reported a more respectful learning environment and a positive though challenging teaching and learning experience; and 3. A hidden curriculum emerged in a performance-based view of professional behaviour. Conclusions Patient-present teaching engaged patients and enhanced their agency by recasting the patient as the central focus within the healthcare encounter. We identified a tension between performing and learning. This study adds new insights to the concept of patient centredness and professionalism from the perspectives of all participants in the medical teaching and learning environment.

Bringing therapeutic innovation and the latest science to routine patient care, while safeguarding principles of affordability and equality, is a challenging mission in the current complex multi-stakeholder environment. Precision oncology and new approaches to clinical trials (methods and clinical setting) have dramatically changed clinical research and the clinical development of new treatments. Improved understanding of molecular biology and immunology paves the way for innovative pharmacological approaches. However, we argue that the evidence generated during the clinical development of these new products for the purpose of obtaining marketing authorisations often does not address fundamental questions concerning the impact of these new interventions on the most relevant clinical outcomes: namely, quality of life and patient survival. Similarly, patient populations (for example defined by biomarkers), treatment duration, and sequence and combination of treatments within current treatment pathways are often poorly defined by clinical developments for regulatory purposes. Finally, the lack of integrated translational research within the pathway of development is a major limiting factor to delivering cost-effective and affordable, evidence-based care to clinical practice. This leaves many gaps in the knowledge on the efficacy and therapeutic use of medicines, which can impose a significant financial burden on healthcare systems, possibly to the detriment of more cost-effective interventions. We argue that policy changes are required to integrate clinical research and healthcare to inform clinical practice. New routes toward optimising the integration of drug development and care are being proposed to achieve this ultimate goal.

There is no consensus among health professionals on how to structure medical records to serve clinical decision-making. Three approaches co-exist (source-oriented, problem-oriented, goal-oriented), each suiting a different subset of patients. In primary care, the problem-oriented approach is dominant, but for patients with multiple conditions (multimorbidity) the goal-oriented approach seems more appropriate. There is a need to combine different approaches in one medical-record system. In this article, we explain some misconceptions about ‘problems’ and ‘goals’ that hinder the way to consensus. When putting the approaches into historical perspective, it becomes evident that each relates to a different definition of health. Each approach has its specific merits that should be preserved even when health definitions change. Hence, we combine the merits of each approach into one overarching model, as to show the way to a new generation of electronic medical-record systems that can serve all patients. This model has three levels: a level of problems, diseases, and patient goals, a level of (shared) objectives, and a level of action plans and results.

n this article, we examine three cases of e-health solutions for patients in Norway. For the analysis of the three cases, we focused on friction forces that come into play when different established arrangements need to change to accommodate novelty. We argue that the design of new technologies was shaped by friction related to institutionalised practices, regulatory regimes and entrenched patient roles. These friction forces connect the past with the present, come into action when aiming for novelty and result to the perpetuation of constituents of the past during change processes. Specifically, the e-health solutions under study were strongly influenced by established healthcare provision logics. All three initiatives expanded the healthcare information infrastructure towards the patients with as little disruption to established arrangements as possible. nivå1

Longitudinal evaluation of interprofessional programming is necessary to understand the impact of interprofessional education (IPE) for collaborative practice. Attitude is one measure of intended behavior. The Interprofessional Attitude Scale (IPAS) was developed as an improved measure to examine the readiness for interprofessional education and collaborative practice. As a means to pilot a protocol for a longitudinal comprehensive evaluation of an interprofessional program with 13 health professional programs in 6 health science faculties, the IPAS was administered over a 3-year period to three cohorts of students. The results of the IPAS indicated no significant differences detected across the 3 years. Although there was a significant difference on the Patient Centredness subscale for Cohorts 2 and 3 the effect size was small. Previous experience in an interprofessional course was a predictor of more positive patient centeredness attitudes, but other IPE experience and years of education were not predictors of any interprofessional attitudes. Students from the Medicine & Dentistry (M&D) faculty ranked significantly lower on the teamwork roles and responsibilities subscale compared to the other faculties, except Rehabilitation Medicine (RM). However, once the outliers in RM were removed, there was a significant difference on this subscale between RM and M&D. This paper outlines the challenges with using the IPAS as part of a comprehensive program evaluation and identifies issues with longitudinal data collection for evaluation with large student cohorts.

Background Patient-centredness is considered a core competency for health professionals. To support faculty in designing courses focused on patient-centredness, an understanding of how educational interventions lead to patient-centredness is required. This study aims to show how learning mechanisms, which potentially contribute to patient-centredness, are triggered. Methods Thirty-five third-year medical students at the UMC Utrecht followed four different patients for two years. The intervention took place in an out-of-hospital setting. Students visited patients in their home circumstances and accompanied them to clinical events. Twelve students were interviewed. The realist approach was used to construct configurations which relate components of the intervention to the context and learning mechanisms. Results Following patients in their home circumstances for a prolonged period supported the development of meaningful relationships between students and patients and provided continuity. In the context of a meaningful relationship and continuity, mechanisms contributing to learning patient-centredness were triggered. The most important learning mechanisms found in this study were: reflecting, contextualising disease in a real persons’ life, broadening perspectives and engaging with the patients. Conclusions Learning mechanisms are triggered by continuity and by meaningful student-patient relationships. These can be enhanced by an out-of-hospital setting and longitudinal contact. Thus, a relationship between students and patients is an important enabler for the development of patient-centredness.

In the face of warnings about total institutions and growing concern about the quality of care, healthcare professionals in Western Europe and North America have increasingly been exhorted to tailor their services to individuals in their care. In this article, we invite our readers to become more interested in the kinds of differences care is being tailored to, and with what effects. Focusing on food provision for residents with dementia, we present three repertoires through which care workers attend to, and enact different sets of differences between individuals: providing choice allows residents to express fleeting preferences; knowing residents places emphasis on care providers' familiarity with a person; and catering to identities brings to the fore the tastes which make up part of who someone is. The analysis brings attending to difference to the fore as a practical process and suggests that tailoring care requires sensitivity to the different kinds of individuals enacted when attending to difference.

OBJECTIVES Physician and patient/parent communication is of utmost importance in consultations to improve the shared decision-making (SDM) processes. This study investigated SDM-related outcomes through turn analysis and an assessment of patient-centred dialogue. DESIGN Multi-centre prospective cohort study analysing audio- and video-recorded patient/parent-physician interactions. SETTING Two tertiary paediatric hospitals in Halifax, Nova Scotia and Salt Lake City, Utah. PARTICIPANTS Paediatric otolaryngologists, patients and parents during consultation for adenotonsillectomy. MAIN OUTCOME MEASURES Medical dialogue measures (turn analysis, patient-centredness scores via the Roter Interaction Analysis System) and SDM questionnaires (SDM-Q-9). RESULTS Turn density was significantly higher for physicians than patients/parents (P

Background We designed this observational study to investigate the level of patients’ and doctors’ ratings of patient-centred aspects of the primary care consultation. Methods Questionnaire study with patients and doctors. Consecutive patients in a primary care setting and 16 doctors responding post visit. Results are presented as proportions with 95% confidence intervals. Results 411 questionnaires, 223 from patients and 188 from doctors, covered 251 consultations. Both patients and doctors gave the highest possible estimations on the aspects of patient-centred communication and satisfaction less frequently when the patient had other reasons for visit than purely somatic. Unlike the doctors’ estimations, the frequency of highest possible estimations in patient responses dropped if the patients had two to six reasons for visit rather than one. Among the six patient-centred aspects, both patients and doctors gave the highest possible estimation least frequently on the aspect of shared decision-making. Conclusion The results suggest that the nature of the reason, as well as the number of reasons for visit, interferes with the doctors’ level of patient-centred communication. Our results furthermore confirm the findings of previous studies that doctors insufficiently involve patients in their care. Electronic supplementary material The online version of this article (10.1186/s12875-019-0959-y) contains supplementary material, which is available to authorized users.

Objective Patient-centredness is often linked to high-quality patient care, but the concept is not well-defined. This study aims to provide an overview of how patient-centredness has been defined in the literature since Mead and Bower’s review in 2000, and to provide an updated definition of the concept. Method & design We performed a systematic literature search in PubMed to identify original articles with a sufficient definition of patient-centredness. We analysed extracted data defining patient-centredness. Results Eighty articles were included. The dimensions “biopsychosocial”, “patient-as-person”, “sharing power and responsibility” and “therapeutic alliance” corresponded to four of five dimensions described by Mead and Bower. “Coordinated care” was a new dimension. Conclusion The identified dimensions are encompassed by three elements: the patient, the doctor-patient relationship and the framework of care i.e. the health care system. The additional focus on coordinated care could reflect increasing complexity of the health care system. Practice implications Narrowing down the understanding of patient-centredness to these three focus areas, viz. 1) understanding of the patients’ experience of the illness in their life situation, 2) the professional’s relationship with the patient, and 3) coordination of care in the system, could make the operationalisation and implementation of a patient-centred approach more manageable.

Digital storytelling ('digistories') offers a way of sharing the personal impact of a condition, if students have limited direct contact. Autistic spectrum disorder (ASD) exemplifies a common condition, where there is need to improve practise in primary care. Hence, we chose this condition to develop and evaluate a digistory. We considered stigmatising attitudes to ASD and wider educational effects.In the digistory, a mother of a boy with severe ASD describes her autobiographical experiences, illustrated by customised cartoons. Participants completed, pre-post, a validated attitude questionnaire and word association exercise. Views on educational value were gathered through free text and focus group.Questionnaire scores indicated positive attitudes, with no significant change. In contrast, content analysis of word association responses showed prevalent negative associations. Thematic analysis identified increased empathy of students with the family, enabled by the resource design. The digistory helped students challenge stereotypes associated with the condition and encouraged greater confidence to engage in future clinical encounters.The digistory is an accessible and authentic patient analogue that gives additional insight into living with autistic spectrum disorder, with potential benefits for patient-centred learning.

Objectives: The aim of this study was to investigate the link between perceived dimensions of patient centred care and the satisfaction of adolescents and young adults within the UK, USA, Australian, Italian, and Chinese healthcare systems. Methods: One thousand and thirty-four participants (212 from China,206 from Australia,208 from UK, 202 from USA, and 206 from Italy) answered a self-report questionnaire assessing the perceived dimensions of patient centred care. Factor analysis (PFA) was conducted on the data to identify relevant dimensions. One-way ANOVAs were run to identify differences between country samples related to perceived dimensions of patient centredness, and a multi-level multiple regression model was computed to assess the link between satisfaction and dimensions of patient centred care. Results: Countries’ mean scores on ‘Satisfaction with Care’ (PF1) and on ‘Psychosocial Context’ (PF2) were statistically significant by inspecting the ANOVAs (p

In this paper we contrast two concepts that permeate political rhetoric concerning healthcare in the UK and elsewhere: patient centred care and consumerism. We outline their parallel histories and note that they appear to have different philosophical origins. Both concepts, however, are founded in the value or rights of the patient, whether as a person or as a buyer of services. As these concepts are variously defined or even misinterpreted, we note that this creates opportunities for their rhetorical use in ways that appear insincere. We outline the main problems with conflating patient centred care and consumerism, arguing that these rest on conceptually messy argument and incorrect or insincere definitions of consumerism. We further argue that consumerism is not compatible with a rationed healthcare service but patient-centred care arguably is.

Student awareness of and insight into patient experiences are essential to the development of competent, patient-centred medical and allied health students. However, early learning opportunities with actual patients can be limited and it can be challenging to standardise learning experiences across multiple health conditions within resource limitations.

Purpose – The purpose of this paper is to evaluate an organizationally oriented, patient-focused care (PFC) model's effects on care quality and work climate. Design/methodology/approach – The study has a before-after (PFC implementation) design. The sample included 1,474 patients and 458 healthcare providers in six participating wards before and after PFC implementation, plus five additional randomly chosen wards, which only featured in the post-assessment. Findings – No pre-post differences were found regarding care perceptions or provider work climate evaluations. Statistically significant improvements were noted among provider care evaluations. Using aggregate-level ward data, multiple regression analyses showed that high adherence to PFC principles and a positive work climate contributed significantly to variance among care quality ratings. Research limitations/implications – Among healthcare providers, questions related to specific PFC aspects during evenings, nights and weekends had to be dropped owing to a low response rate. Practical implications – An important requirement for both practice and research is to tailor PFC to various health and social care contexts. Originality/value – The study is large-scale before-after PFC model review, where patient and provider data were collected using well-established measurements.

Concordance between general practitioners (GPs) and patients is an essential requirement for treatment success and patient satisfaction in general practice. The objectives of this were to estimate the total amount of discordance with respect to reason for encounter (RFE) during consultation in German general practices, and to explore the influence of psychosomatic co-morbidity of the patients in case of discordance.1101 consecutive patients completed a questionnaire, including questions about the RFE and the Patient Health Questionnaire (PHQ). RFEs, as stated by the patients and diagnosed by the GPs were matched according to a predefined index. Factors that may influence the level of discordance between patients' RFE and GPs' RFE were analysed.Amount of concordance was 74.9%, incomplete concordance 11.2%, discordance in different physical RFEs was 9.1%, and discordance when GPs diagnosed psychosomatic illness while patients presented physical complaints was found in 2.5%. The number of RFE (OR 3.03; 95%CI 2.48-3.69; P.001), depression (OR 2.27; 95%CI 1.51-3.41), anxiety (OR 1.78; 95%CI 1.03-3.10) and somatisation syndrome (OR 2.20; 95%CI 1.50-3.22) significantly predicted incomplete concordance and discordance, respectively. The number of RFE was significantly associated with depression (OR 1.32; 95%CI 1.09-1.61) and somatoform syndrome (OR 1.45; 95%CI 1.21-1.74).The considerable amount of discordance and incomplete concordance can partly be explained by the psychosomatic co-morbidity of the patients. If it is seen as a fundamental right of patients to be adequately understood, more efforts are necessary to improve patient centredness. Further studies have to evaluate if improvement of identification of psychosomatic co-morbidity might reduce discordance.

CITATION: Mash, R. 2016. Whole person medicine : psychosocial issues in primary care. African Journal of Primary Health Care & Family Medicine, 8(1):1-3, doi:10.4102/phcfm.v8i1.1328.

Quality Problem. Patient-centred care is increasingly being acknowledged as an integral part of evaluating health care. Yet, from a quality improvement perspective the rationale, measurement and implementation of strategies to improve patientcentred care is often subject to debate. Objective. The aim of this paper is to review why quality improvement efforts should embrace patient-centredness, to examine some of the measurement issues and to assess conceptual underpinnings that should inform both measurement and actions to improve patient-centred care. Lessons. The causal pathway through which quality improvement affects and/or is associated with patient centredness is complex and goes beyond patients’ rights and assessing patient views. Interventions to improve patient-centred care should reflect on key rationale, measurement strategy and underlying theory.

Objective To determine patients’ perspectives of components of patient-centred physiotherapy and its essential elements. Design Qualitative study using semi-structured interviews to explore patients’ judgements of patient-centred physiotherapy. Grounded theory was used to determine common themes among the interviews and develop theory iteratively from the data. Setting Musculoskeletal outpatient physiotherapy at a provincial city hospital. Participants Eight individuals who had recently received physiotherapy. Results Five categories of characteristics relating to patient-centred physiotherapy were generated from the data: the ability to communicate; confidence; knowledge and professionalism; an understanding of people and an ability to relate; and transparency of progress and outcome. These categories did not tend to occur in isolation, but formed a composite picture of patient-centred physiotherapy from the patient’s perspective. Conclusions and practice implications This research elucidates and reinforces the importance of patient-centredness in physiotherapy, and suggests that patients may be the best judges of the affective, non-technical aspects of a given healthcare episode. © 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Objective To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness. Methods Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System. Results Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness. Conclusion Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations. Practice implications It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.

ObjectivesThe objective of this exploratory study was to see how the Patient-Reported Apnea Questionnaire (PRAQ) may impact the daily clinical practice of sleep centres, and why it may or may not work as expected. The hypotheses were tested that this patient-reported outcome measure makes patients more aware of which of their health complaints may be related to obstructive sleep apnoea (OSA), and that it improves patient-centredness of care by shifting the focus of care away from (only) medical problems towards the individual burden of disease and quality of life.DesignMixed methods. The quantitative study (surveys, patient records) was a before-and-after study.SettingThree sleep centres in The Netherlands (secondary care).Participants27 patients and 14 healthcare professionals were interviewed. 487 patients completed surveys pre-implementation, and 377 patients completed surveys post-implementation of the PRAQ. For the health records, 125 patients were included in the pre-implementation group, and 124 other patients in the post-implementation group.InterventionsThe PRAQ was used in clinical practice for six successive months.Outcome measuresScores on individual survey items, number of patients receiving non-medical treatment, adjustment of treatment at first follow-up, compliance with treatment.ResultsPatients were generally positive about the usefulness of the PRAQ before and during the consultation, as they felt more informed. Healthcare providers did not consider the PRAQ very useful, and they reported minor impact on their consultations. The surveys and health record study did not show an impact of the PRAQ on clinical practice.ConclusionsImplementing the PRAQ may be beneficial to patients, but this study does not show much impact with regard to patient-centredness of care. New Dutch guidelines for OSA care may lead to a greater emphasis on quality of life and value of care for patients, making its integration in clinical care potentially more useful.

Rationale Current medical student perceptions of patient centredness and the priorities of students for a change in medical care were investigated. Methods We conducted an observational study using questionnaires at the University of Leipzig in Germany. In total, 188 consecutive medical students attending the Department of General Medicine participated in this study. We investigated students’ priorities for an improvement in medical care related to aspects of the patient–doctor relationship and to aspects of organization. Results Receiving more information and undergoing the process of shared decision making was the most important choice; selected by 43.2% as their first priority. The second choice was found to be consultation time (16.2%) which also refers to the patient–doctor relationship. Shorter queues for tests, also considered important for more patient autonomy, were ranked third (14.6%). Medical students participating in this study were least interested in access to specialists, cost of medications and continuity of care. Conclusion For the first time, it is shown that shared decision making, in addition to its many benefits, is not only a patients’, but also a prospective doctors’ top priority. Consequently, medical student training programmes might incorporate shared decision-making training as an important element of patient centredness.

Objective. To evaluate the association of characteristics of patients and general practices with patient assessment of quality of care. Design. Cross-sectional multi-practice study using the general practice assessment survey. Settings. General practices in Australia. Participants. Ninety-six general practices and 7505 chronic illness patients aged 18 years. Main outcome measures. Access of care and patient-centredness. Results. Two factors were identified in factor analysis: ‘Access of care’ and ‘Patient-centredness’. Multilevel regression analysis showed significant associations between patients’ assessments and patient and practice characteristics. Patients from smaller practices (one to three general practitioners) reported better access to care compared with larger practices. Patients from urban areas were more satisfied with patient-centredness than those from rural areas. Self-reported health status and age had a positive and home ownership, employment and education, and patients from non-English-speaking countries a negative relationship with both scores. Females were more satisfied with patient-centredness. Conclusions. Patient assessments of quality of care and patient-centredness were strongly associated with practice and patient characteristics. This has important implications for interpreting assessments of the quality of primary care, and for policy and practice measures designed to improve this.

Quality standards play an increasingly important role in primary care through their inscription in various technologies for improving professional practice. While ‘hard’ biomedical standards have been the most common and debated, current quality development initiatives increasingly seek to include standards for the ‘softer’ aspects of care. This article explores the consequences of both kinds of quality standards for chronic care consultations. The article presents findings from an explorative qualitative field study in Danish general practice where a standardized technology for quality development has been introduced. Data from semi-structured interviews and observations among 17 general practitioners were analysed using an iterative analytical approach, which served to identify important variations in the uses and impacts of the technology. The most pronounced impact of the technology was observed among general practitioners who strictly adhered to the procedural standards on the interactional aspects of care. Thus, when allowed to function as an overall frame for consultations, those standards supported adherence to general recommendations regarding which elements to be included in chronic disease consultations. However, at the same time, adherence to those standards was observed to narrow the focus of doctor–patient dialogues and to divert general practitioners’ attention from patients’ personal concerns. Similar consequences of quality standards have previously been framed as manifestations of an inherent conflict between principles of patient-centredness and formal biomedical quality standards. However, this study suggests that standards on the ‘softer’ aspects of care may just as well interfere with a clinical approach relying on situated and attentive interactions with patients.

Aim : To create sustained improvements in medical students’ critical thinking skills through short teaching interventions in pharmacology. Method : The ability to make professional decisions was assessed by providing year-4 medical students at a UK medical school with a novel medical scenario (antenatal pertussis vaccination). Forty-seven students in the 2012 cohort acted as a pretest group, answering a questionnaire on this novel scenario. To improve professional decision-making skills, 48 students from the 2013 cohort were introduced to three commonly used medications, through tutor-led 40-min teaching interventions, among six small groups using a structured presentation of evidence-based medicine and ethical considerations. Student members then volunteered to peer-teach on a further three medications. After a gap of 8 weeks, this cohort (post-test group) was assessed for professional decision-making skills using the pretest questionnaire, and differences in the 2-year groups analysed. Results : Students enjoyed presenting on medications to their peers but had difficulty interpreting studies and discussing ethical dimensions; this was improved by contextualising information via patient scenarios. After 8 weeks, most students did not show enhanced clinical curiosity, a desire to understand evidence, or ethical questioning when presented with a novel medical scenario compared to the previous year group who had not had the intervention. Students expressed a high degree of trust in guidelines and expert tutors and felt that responsibility for their own actions lay with these bodies. Conclusion : Short teaching interventions in pharmacology did not lead to sustained improvements in their critical thinking skills in enhancing professional practice. It appears that students require earlier and more frequent exposure to these skills in their medical training. Keywords: critical thinking; professionalism; prescribing; antenatal pertussis vaccination; patient centredness; medical education (Published: 5 June 2015) Citation: Med Educ Online 2015, 20: 27097 - http://dx.doi.org/10.3402/meo.v20.27097

Summary Objective To document differences in provider behaviour between private and public providers in hospital outpatient departments, health centres and clinics in Bangkok, Thailand. Method Analysis of the characteristics of 211 taped consultations with simulated patients. Results Private hospitals and clinics were significantly more responsive. Private clinics but not private hospitals were also significantly more patient-centred. All doctors, but particularly those in private hospitals, prescribed unnecessary and potentially harmful technical investigations and drugs. The direct cost to the patient varied between 1.5 (in public health centres) and 12 (in private hospitals) times the minimum daily wage. The combined cost – to the patient and to the state – in public hospitals and health centres exceeded the cost of consultations in private clinics. Conclusion Market incentives favour responsiveness and a patient-centred approach, but not more appropriate therapeutic decisions. Excessive use of pharmaceuticals is observed among public as well as private providers, but is most pronounced in private hospitals. If patients in Bangkok want to maximize responsiveness and degree of patient-centred care and yet minimize costs and iatrogenesis, they would benefit from avoiding hospitals, both public and private, and, to a lesser extent, specialists. Choosing to use primary facilities, health centres and clinics, particularly when consultations are carried out by general practitioners (GPs), is more beneficial than choosing between public and private providers. Objectif Documenter les differences de comportement chez les praticiens entre secteur prive et public, dans les services de patients ambulants des hopitaux, des centres de sante et des cliniques de Bangkok, Thailande. Methode Analyse des caracteristiques de 211 consultations enregistrees avec des patients simules. Resultats Les hopitaux et cliniques prives repondaient de facon plus significative. Les cliniques privees mais pas les hopitaux prives, avaient une approche plus centree sur le patient. Tous les medecins et en particulier ceux des hopitaux prives, prescrivaient des examinations techniques et des medicaments non necessaires et potentiellement dangereux. Le cout directe pour le patient variait entre 1.5 (dans les centres de sante publique) et 12 (dans les hopitaux prives) fois le revenu minimal journalier. Le cout combine, pour le patient et l’etat, dans les hopitaux publics et les centres de sante depassait le cout des consultations dans les cliniques privees. Conclusion Les incitations du marche favorisent la reponse et l'approche centree sur le patient, mais pas plus de decisions therapeutiques appropriees. L'utilisation excessive de medicaments est observee autant chez les praticiens du secteur public que du secteur prive. Mais, elle est plus accentuee dans les hopitaux prives. Si les patients a Bangkok veulent maximiser la reponse et le degre d'approche centree sur le patient en minimisant les couts et les effets iatrogenes, ils beneficieraient en evitant autant les hopitaux publics que prives et, dans une moindre mesure les specialistes. Choisir l'utilisation des secteurs de soin primaire, des centres de sante et des cliniques - en particulier lorsque les consultations sont menees par un medecin generaliste - est plus benefique que choisir entre dispensateurs publics et prives. Mots cles Reponse, approche centree sur le patient, medication, de patients ambulants, cout, patients simules, prescription, public–prive, protection des consommateurs Objetivo Documentar las diferencias en comportamiento del proveedor entre hospitales privados y publicos en consultas externas, centros de salud y clinicas en Bangkok, Tailandia. Metodo Analisis de las caracteristicas de 211 consultas grabadas con pacientes simulados. Resultados Los hospitales privados y las clinicas tuvieron una respuesta significativamente mejor. Las clinicas privadas, mas no los hospitales privados, tambien tenian una mayor dedicacion al paciente. Todos los medicos, pero particularmente aquellos de hospitales privados, prescribieron medicamentos innecesarios asi como tecnicas o medicamentos bajo investigacion potencialmente peligrosos. El coste directo al paciente variaba entre 1.5 (en centros de salud publicos) y 12 (en hospitales privados) veces la salario diario minimo. El costo combinado – al paciente y al estado – en hospitales publicos y centros de salud excedio el costo de las consultas en clinicas privadas. Conclusion Los incentivos del mercado favorecen el interes y la dedicacion al paciente, pero no la toma de decisiones terapeuticas apropiadas. Se observo un uso excesivo de farmacos tanto el los hospitales publicos como privados, pero de forma mas pronunciada en los hospitales privados. Si los pacientes de Bangkok desean maximizar el interes y el grado de dedicacion en la atencion y ademas minimizar los costos y la iatrogenia, deberian evitar los hospitales, tanto publicos como privados, y en menor extension a los especialistas. Escoger el usar servicios primarios, centros de salud y clinicas, particularmente cuando las consultas son realizadas por medicos generales, es mas benefico que escoger entre proveedores publicos y privados. Palabras clave interes, dedicacion en el cuidado del paciente, medicacion, consultas externas, pacientes simulados, prescripcion, publico-privado, proteccion al consumidor

The evidence for physiotherapeutic procedures is growing fast. Databases are required which keep up which all new research developments and which house emerging evidence for the clinician as well as for the researcher. As, many procedures have not been investigated yet and remain a matter of experience and clinical reasoning, a case report is a primary way to focus on the efficacy of a technique, test or procedure. An uncommonly applied soft-tissue technique has been taken to demonstrate a false positive magnetic resonance imaging diagnosis in a muscle injury as well as its clinical efficacy. Moreover, the management of this simple, monostructural impairment will serve as an example to discuss the characteristics of patient-centredness. Patient-centredness is considered to be the practical application of the multidimensional biopsychosocial illness model. The shift in paradigm in medicine has led to the development of, and discussion on, domains of patient-centredness (Stewart et al., 1995). In an analogy to patient-centredness in medicine, such domains have recently been proposed (Langendoen, 2002). Analysis of these characteristics seems relevant as patient-centredness builds one of the three cornerstones of evidence-based practice: (1. evidence, 2. experience, clinical reasoning, 3. practical, patientcentred application).

The aim of this study is to analyse the way in which orthopaedic physicians manage consultations, and to identify those factors associated with patient-experienced satisfaction/dissatisfaction. This was explored both using a descriptive method and by analysing comments from patients. Consultations were videotaped; 18 physicians and 18 patients participated. Approximately 1 week after the consultation, the patient was shown the video recording and asked for his/her points of view and spontaneous reactions. Each time, the patient wished to say something, the video was stopped and the comments recorded. According to the patients' comments of the videotaped consultations four consultations were mainly positive, seven negative and seven neither completely positive nor completely negative. We analysed the positive and negative consultations using the Consultation Map (CM) method. The pattern in the positive consultations shows a greater flexibility. Statements regarding initial history and aetiology often move to and fro between other items, and the consultation as a whole was often characterised by this rapid change between items. The pattern in the negative consultations seems to indicate a slower motion; with longer time spent with few items and fewer items covered. The positive consultations were characterised by a greater prevalence of the items 'Sharing Understanding' and 'Involving the Patient in Management'. On the other hand, the negative consultations were characterised by more time spent with the items 'History of problems', and 'Patient Ideas'. This might be due to the patient having tried to express him/herself in order to present his/her views but the physician not following them up. In this study, the CM has been helpful in clarifying the difference between encounters experienced as satisfactory or dissatisfactory.

Using the general precepts of integration, Lean thinking, and patient centredness, this article highlights the potential for dramatic dehospitalization of health services as a prerequisite for a sustainable and effective health system.

Much research has explored the interaction between doctor and patient in the consultation and patient centredness has generally emerged as the preferred mode of consultation style. The present study aimed to examine and compare general practitioners' (GPs) and patients' beliefs about the importance of the different aspects of patient centred behaviour in a consultation. Matched questionnaires were completed by 410 patients (response rate = 76.5%) and 64 GPs (response rate = 85.3%) from practices around London concerning aspects of patient centredness operationalised in terms of doctor receptiveness, patient involvement, the affective content of the relationship and information giving. The results showed that GPs and patients showed similar beliefs about involving the patient in decision making, aspects of doctor receptiveness and the importance of the patient's own feelings in the consultation. However, GPs believed that it was less important to focus only on the patient's main problem, and more important to acknowledge their own feelings and avoid medical language. Further, GPs rated doctor receptiveness and the affective content of the relationship overall as more important for a good consultation than the patients. The patients also consistently rated information giving as more important than the GPs. To conclude, GPs rated the doctor receptiveness and affective components of patient centredness as more important than patients whereas patients showed greater endorsement of information indicating that although patient centredness may currently be the preferred style of consultation, doctors and patients prefer different aspects of this behaviour. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

The definitive version is available at www3.interscience.wiley.com, OBJECTIVE To show that low-cost attitudinal, structural and procedural changes aimed at improving responsiveness to patients have the potential to increase uptake of family planning (FP) even among populations considered reluctant to do so by health personnel. METHODS Intervention study with before–after comparison of contraceptive acceptance, couple-years of protection (CYP) and an `index of contraceptive uptake' (IUC) in rural health centres in Niger. The intervention consists of a package of instructions to actively propose family planning, integrated within curative and under-fives consultations, coupled with measures to increase the health centres' responsiveness to their clients. RESULTS Implementation of the intervention package was followed by marked increases in family planning uptake. CONCLUSION Health services in Niger present an untapped potential for improving family planning through low-cost supply-side measures.

Background Patient centred communication can improve pharmaceutical care, but is not well described for pharmacists. Aim of the review To provide a comprehensive and accessible overview of the concept of patient centred communication for the pharmacy practice. Method A scoping review and thematic analysis was undertaken to synthesize the extracted data and present it in a model. Results Literature search and selection resulted in eighteen articles. Thematic analysis of the extracted data led to five categories regarding patient centred communication. Two categories refer to phases of a pharmaceutical consultation: (1) shared problem defining and (2) shared decision making; three refer to underlying concepts and assumptions about patient centredness regarding (3) the patient, (4) the pharmacist and (5) the therapeutic relation. The categories were modelled in the so called Utrecht’s Model for Patient centred communication in the Pharmacy. Conclusion Although there might be barriers to implement patient centred communication in the pharmacy, the concept of patient centred communication as described in the literature is relevant for the pharmacy practice.

ObjectivePatient-centredness has become an important aspect of health service delivery; however, there are a limited number of studies that focus on this concept in the domain of hearing healthcare. The objective of this study was to examine and compare audiologists’ preferences for patient-centredness in Portugal, India and Iran.DesignThe study used a cross-sectional survey design with audiologists recruited from three different countries.ParticipantsA total of 191 fully-completed responses were included in the analysis (55 from Portugal, 78 from India and 58 from Iran).Main outcome measureThe Patient–Practitioner Orientation Scale (PPOS).ResultsPPOS mean scores suggest that audiologists have a preference for patient-centredness (ie, mean of 3.6 in a 5-point scale). However, marked differences were observed between specific PPOS items suggesting these preferences vary across clinical situations. A significant level of difference (pConclusionsThere are differences and similarities in audiologists’ preferences for patient-centredness among countries. These findings may have implications for the training of professionals and also for clinical practice in terms of optimising hearing healthcare across countries.

SummaryObjective – To assess the reliability and to describe the categories and the procedure to apply the VRMICS/P (Verona-Medical Interview Classification System/Patient). Setting – The interviews used for the reliability study were audio taped. Five general practitioners (GPs) working in two general practices in South-Verona recorded their consultations. Sample – 50 interviews selected randomly from 120, 10 for each GP. The selection criterion for the participating patients was a GHQ-12 score of 3 and the consultation for a new illness episode. Main outcome measures -The VR-MICS/P classifies patients' verbal behaviours into 21 categories, 15 of them are defined by form (cue or statement) and content. Procedure – Two trained raters classified 50 interviews. Before applying the classification system each interview is divided into units which are numbered to define doctor's and patient's sequence of speech. Results – The reliability of VR-MICS/P was satisfactory (Kappa 0.85). Similarity Index (Dice, 1945) for categories varied between 0.71 and 0.94. Reliability for form and content classification was satisfactory too (Similarity Index between 0.81 and 0.89 and between 0.84 and 0.94, respectively). Conclusions – The VR-MICS/P is a reliable measure for describing patients' verbal behaviours during medical interviews. It can be used together with the VR-MICS/D (Verona-Medical Interview Classification System/Doctor; Saltini et al., 1998) to describe the medical interview, the quality of doctor-patient interview and can be used as a measure of patient centredness.