Editorial The enigma of patient centredness, the therapeutic relationship and outcomes of the clinical encounter A Niroshan Siriwardena MMedSci PhD FRCGP Editor, Quality in Primary Care; Visiting Professor of Primary Care, School of Health and Social Care, University of Lincoln, UK Tim Norfolk Independent Occupational Psychologist, UK The increasingly ubiquitous notion of ‘patient centred- ness’ often causes confusion; indeed instruction received onthissubjectoftenlefttraineeswithonlythevaguest notionofhowitcouldbeputintopractice,sometimes leading to bizarre interpretations of this idea. For example, one colleague described how he, in an attempt at ‘real’ patient centredness, had attempted a whole surgery without saying anything at all for as long as possible,presumablyjustnoddingandgesticulatingto compensate. Although we readily agree that non-verbal expression accounts for a considerable content of com- munication, this is perhaps taking things just too far. Patient centredness remains a central plank of clinical learning, teaching and assessment and nowadays is also central of policy development in the health service. But what do we mean by patient centredness? Is it really important? How important is it compared to other aspects of the consultation? Does it make a difference? Oneproblemwiththesequestionsisthatthenotion of patient centredness has developed over several decades before and since the pioneering work of Michael Balint 1 and others; in doing so it now means different things to different people. Just as ideas of evolution and creationism have changed and adapted to new scientific discoveries 2 sohaveourideasofpatient centredness. As practitioners and thinkers have mulled over these ideas and as studies have revealed that patient centredness is not always what patients see as most important or what leads to improvements in outcomes the concept has become more enigmatic. Consequently, some clinicians have developed anti- bodies to the very idea of patient centredness. As a result, patient centredness has become as PC and as pejorative a term as ‘political correctness’ in some quarters; patient centrists have become fervent be- lievers whilst positive ‘acentrists’ to coin a term, equally firmly believe that the notion is positively harmful. Most of us lie somewhere between these extreme positions with the result that real life consultations may not in fact have increased in terms of patient centredness over the past 20 years. 3 Patient centredness, at one time thought to mean listening, and then active listening 4,5 has over time evolved into a variety of clinical behavioural (inter- mediate or proxy), 6 patient perceived 7 and health (true) outcomes.Althoughtheconcepthasevenextendedto include administrative and policy issues such as ac- cess, 8 in its purest form it still relates most closely to the clinical consultation. Models of the clinical con- sultation have been traditionally divided into behav- iour orientated and task orientated models, both usually focusing on what the doctor does rather than what the patient perceives within or as a result of the consultation. 9 This includes attending to psychological and social as well as physical aspects of the consul- tation (the biopsychosocial perspective), sharing power and developing a therapeutic relationship. 10 Consul- tationtasksthathavebeenthoughttorelatetopatient centredness include eliciting patients’ health beliefs, ideas, concerns and expectations, exploring the im- pact of presenting problems on physical and social functioning, tailoring explanation to incorporate health beliefs and involving the patient in shared decision making. From the patient’s point of view the experi- enceofpatientcentrednessmayrelatelesstotasksthat the doctor undertakes and more to feelings of empa- thy and trust or effects such as continuity, concord- ance, time and enablement. 11,12 Individual elements have been developed into complex rating scales for self 13 , peer 6,14 and patient 15 evaluation and many of these aspects have been incorporated enthusiastically into teaching and assessment 16 of practitioners. In a recent study of one aspect of patient centred- ness, Saba and colleagues looked in detail, using stim- ulated recall of both patients and doctors experiences Quality in Primary Care 2007;15:1–4 # 2007RadcliffePublishing