Patient-centered approach can backfire

Aug 13, 2007

Today's doctors are trained to take a more "patient-centered" approach toward healthcare. That means educating patients about their conditions, encouraging questions and collaboration, discussing how the condition affects the patient emotionally, and involving patients in treatment decisions.

Some patients prefer that style and respond very well to it. But new research at the University of Iowa suggests that it doesn't work for everybody. In fact, some patients are significantly less likely to follow doctors' orders and feel satisfied with their care when physicians take the patient-centered approach.

According to the UI study, recently published in the Annals of Behavioral Medicine, patients are most satisfied with care and most likely to follow treatment plans -- like taking medication or making diet changes -- if they see a doctor whose attitudes toward patient-physician roles are in line with their own.

But some patients, especially older patients, prefer a doctor with a more traditional "doctor-centered" or "paternalistic" style, someone who spends less time explaining a condition and seeks little patient input when it comes to treatment decisions. The study showed that when those patients are matched with patient-centered doctors who want them to take a highly active role, they're less likely to follow treatment recommendations or feel satisfied with their care.

"There's really a sizable subset of patients with whom the patient-centered approach is going to backfire," said Alan Christensen, professor of psychology in the UI College of Liberal Arts and Sciences, who collaborated with three colleagues on the study. "There are patients who strongly believe it's the physician's job to make decisions. If those people are matched with a physician who wants patients to be more engaged, the physician could end up putting too much responsibility on the patient's shoulders and not giving them enough direction. So they leave the appointment feeling confused about what they're supposed to do, or with information overload."

Christensen and his team recruited 16 primary care physicians and 146 of their established patients from UI Hospitals and Clinics. Each doctor and patient took two surveys about their attitudes toward patients' and providers' roles in healthcare. Within two weeks of the last doctor's appointment, patients reported their satisfaction with the care and how well they had followed doctors' orders.

Christensen, who also holds appointments in internal medicine in the Roy J. and Lucille A. Carver College of Medicine and is a researcher with the Department of Veterans Affairs (VA) Iowa City Healthcare System and the VA Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), said patients who experience a mismatch between their own expectations and preferences for the medical encounter and what actually transpires during the clinical visit are less likely to follow treatment recommendations because their expectations weren't met at the appointment.

"We know from other research that, in general, when people's expectations aren't met, the psychological reaction can be to try to restore control by doing your own thing, or even doing the opposite of what you're told," Christensen said.

Patients at the other end of the spectrum - highly engaged, patient-centered patients treated by doctor-centered providers who prefer less patient involvement -- fell in the middle in terms of satisfaction with care and following doctor's orders. They did better than doctor-centered patients with patient-centered doctors, but not as well as patients who saw a doctor with attitudes similar to theirs.

"A more passive patient who wants the doctor to take the reins is probably not as adaptable to an unwelcome role," Christensen said. "Patients who are highly keyed-in to their own care and motivated to take on responsibility will likely find other ways to accomplish that, even when confronted with a provider who is reluctant to share control."

The study was statistically adjusted to control for the effects of physicians' and patients' age and gender because past studies have shown that symmetry in those characteristics may also improve satisfaction and treatment plan compliance. Limitations of the study included the small number of participants and the fact that patients self-reported how well they followed doctors' orders. Past studies have shown that patients generally tend to overestimate adherence, Christensen said.

Christensen and other researchers are conducting a similar study on a larger scale at the VA Medical Center in Iowa City and the Jesse Brown VA in Chicago. In the follow-up study, they will have access to additional ways to measure adherence such as prescription refill records, and will be focusing on important clinical outcomes like blood pressure and glucose control in diabetic patients.

They believe the research could be used in two ways. Christensen and colleagues are studying whether doctors could be trained to recognize a patient's style and adapt their own style to match it. Another idea: assess doctors' and patients' attitudes toward healthcare roles and use that information to match caregivers and patients.

"When you see a physician, you are routinely asked a lot of background information already, often including patient preferences such as whether you prefer a male or female doctor," Christensen said. "Our research shows that taking this a step further and considering a few straightforward questions about patient preferences or attitudes could go a long way toward creating a healthy and mutually satisfying patient-physician relationship."

The findings already apply to patients. Christensen said it's a good idea for patients to look for doctors who match their style, either by reputation or word of mouth, or by setting up a "get acquainted" visit and being upfront about their expectations.

"If there's a take-home message for the patient, it's that you shouldn't be shy about finding a doctor with the style you prefer," he said. "Doctors' attitudes and personalities are just as diverse as patients' attitudes and personalities. Finding a good match can be very important in terms of how satisfied you are with the care you receive and, ultimately, whether or not you stay healthy."

Source: University of Iowa

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