Street Jr (2001). Active patients as powerful communicators – Article summary

The way in which care providers and patients talk with one another influences an array of post-consultation outcomes (e.g. adherence to treatment). Provider-centric bias refers to the fact that the health-care provider is treated as the communicator of primary importance. However, the patient-centred approach may be more useful.

Participation refers to action, involvement and influence within the health care environment. Patient participation consists of seeking health-related information (1), being involved in medical decision making (2) and interacting with providers in a way that narrows the knowledge and power gap between provider and patient (3) The care-provider’s communication style influences post-consultation outcomes.

In order to participate in medical consultations, patients must be able to express their needs (1), concerns (2), preferences (3), ideas about health (4) and expectation for care (5).

There are four types of speech that influence the events of consultation and the provider’s behaviour:

1. Asking questions
   This is a method of gathering information and clarification.
2. Expression of concern
   This includes statements in which the patient expresses worry, anxiety, fear, anger, negative affect or emotions.
3. Assertiveness
   This includes verbal actions that express one’s rights, feelings, beliefs and interests (e.g. offering opinions).
4. Health narratives
   This includes health experiences related to everyday activities, relationships, situations and problems that unfold over time.

Assertive patients are seen as better communicators. The health narratives provide important contextual information about the patient’s health status (1), needs (2), behaviour (3), beliefs (4) and values (5).

Patient participation (e.g. four types of speech) provide an opportunity for the clinician because it can be used to tailor explanations and recommendations to take into account the patient’s personal preference and circumstances. In addition to this, it can point at what is important for the patient.

It also provides a constraint for the clinician because the patient’s participation should be taken into account, even when it is, according to the clinician, not relevant for the topic at hand.

Quality of care refers to the process (e.g. how the consultation is conducted). Outcomes of care refers to the consequences of care (e.g. health improvement). The patient’s understanding of health issues and satisfaction are indicators of quality of care.

The patient’s participation in a medical encounter can enhance quality of care in several ways:

1. Patients who ask more questions receive more information.
2. Expression of concern elicits more patient-centred responses of support and reassurance.
3. Patients who actively participate can better recall the clinician’s recommendations.

Assertiveness might lead to better quality or worse quality of care. It is possible that more assertive patients are more likely to express frustration with medical care and assertive patients are more likely to struggle for control of the interaction, which influences quality of care perception.

Patient participation contributes to improved health and healthier behaviour. This means that patient participation leads to better outcomes of care. Commitment of treatment is associated with the degree to which patients were able to introduce issues of concern about their health (1), their perception of having actively participated (2), the degree to which they openly expressed negative feelings (3) and the degree to which they asked questions, offered opinions and provided information (4).

Active patient participation may be linked to treatment outcomes because patients receive care tailored to their unique needs (1), it may enhance adherence to treatment programmes (2) and it may enhance a patient’s perception of control over health (3).

Predisposing factors refer to social, psychological and cultural forces that predispose people to communicate in certain ways. There are four relevant predisposing factors:

• A belief in the legitimacy of patient participation.
• The salience of perceived health needs.
• Personality factors
• Perception of rapport with one’s health care provider.

Patient participation is influenced by the belief of advantages of patient participation (i.e. more formal education) (1), they believe they have important health needs and concerns (2), personality and cognitive factors (3) and the quality of the relationship with the health care provider (4).

Enabling factors refer to the communicative resources and skills needed to effectively participate in the consultation. The most important enabling factors are knowledge about the health issue (1) and a readily accessible repertoire of verbal responses and routines (2).

The provider’s communication will have a strong effect on the patient because clinicians typically assume considerable control over the events of the consultation. A provider who uses a patient-centred approach (e.g. partnership building) encourages greater patient involvement in the encounter and legitimizes the patient’s perspective. This leads to greater patient-involvement.

Educational interventions for both patients and clinicians can be used to improve patient participation. Patient activation programmes typically employ a combination of presenting information about the health condition (1), encouraging the patient to be actively involved in care (2), teaching specific communication strategies (3) or showing role models of actively involved patients (4). Behaviourally focused interventions are more effective than simply providing health information or encouragement alone.

Changing the clinician’s behaviour is more complex because the clinician has multiple objectives during the consultation (1), they do not want the consultation to be too long (2) and have a routine for consultations (3). This means that clinician behaviour is more difficult to change. Furthermore, more patient-participation does not necessarily lengthen the consultation as the clinician speaks less when the patient speaks more (1) and inhibition of patient participation may add time to the closing of the encounter where patients often introduce new concerns (2).