Patient-centred care

As a profession we are aware that the days of ‘Doctor knows best’ in healthcare are over. More than 40 years ago George Engel, in a critique of the biomedical model of care, stated that “physicians are lacking in interest and understanding, are preoccupied with procedures, and are insensitive to the personal problems of patients” (1) – as an alternative he proposed the biopsychosocial model of care.

From this work the concept of patient-centred care (PCC) was formalised and later defined as “care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions” (2). According to Rathert et al “there is a growing body of evidence that providing patient-centred care can lead to positive clinical outcomes for patients, as well as increasing their satisfaction” (3).

There are also other forces at work pushing modern healthcare in this direction – the advent of the internet (reducing the professional-patient knowledge deficit), consumerism (expectations of choice, convenience and options) and a patient base less understanding when there is a negative gap between their expectation and the outcome of care.

So, what does this mean for Dentistry and how to do we incorporate this healthcare worldview into our practice?

For a start the concept is written into our conditions of registration – Dental Board of Australia (DBA) Code of conduct states that “practitioners have a duty to make care of patients or clients their first concern” and that “good practice is centred on patients or clients” (4). This wording seems to be a very deliberate endorsement of the PCC concept.

We are explicitly directed by our regulator to practice Dentistry in a manner that is centred on our patients, and the expectations of our patient base coincides with this, yet we may have little or no teaching or guidance of what this entails in the real world.

This has been highlighted recently as a significant issue – “references to patient-centred care and its principles are becoming more prevalent both in dental literature and in policy documents. Despite increasing prominence of the concept, however, there is a lack of a universally agreed definition in dentistry as to what the term means or how it can be translated into practice” (5).

Taking a step back from the semantics, we see every day with our patients that disease presentation and management does not necessarily correlate directly with the patient’s experience of illness.

Contrast the patient who presents with obvious infection, broken teeth, pain and who just wants minimal work done, to the patient who demands to be seen as an emergency only to present with the tiniest enamel fracture on a lower incisor.

We often see patients with significant but asymptomatic periodontal disease who indicate, despite our earnest attempts to educate, that treatment is not a priority for them right now. Patients may decline treatment on the basis of cost only to nonchalantly mention, in the next sentence, their impending overseas holiday.

Examples like this can be very frustrating when we are trained and primed to diagnose and treat disease – if we are to practice PCC, the patient’s values should guide the clinical decision-making process in conjunction with our professional input. This will hopefully lead to the patient making an informed (and carefully documented!) decision on treatment/ intervention or non-treatment, based on the information to hand at the time.

In day-to-day Dentistry how can we ensure that we are translating the concept of PCC into our practice? Scambler et al say that PCC is about care that considers the following four basic factors (6):

  1. “The illness in its widest context” – for example a PCC discussion about the need for an extraction would “explore not just the technical aspect of the extraction but the impact that the extraction is going to have on the person’s overall life” (6) – from potential implications of the patient’s medical history to options for replacement of the tooth (including costs and time-frames). Even something a simple as need for child-care while a parent is having the procedure and recovering may be relevant.
  2. “The patient as a whole person: this is about the Dentist focusing not just on the mouth but the patient behind it” (6). In the example above of the reluctant patient with periodontitis we tend to focus on the disease, however there may be many factors outside of the mouth influencing the patient’s attitude such as anxiety/ phobia, financial constraints, other priorities (such as a family illness) or even embarrassment and shame. If we uncover and address these issues, along with the disease, then we are more likely to achieve realistic outcomes.
  3. “The ethos behind the relationship with your patient” – the development of “a relationship based on trust, compassion, empathy and shared humanity” is “key to developing a long-term relationship that is going to be conducive to appropriate decision-making about possible treatments and their outcomes” (6). When we endeavour to empathise with and understand the reluctant periodontal patient rather than judge and preach to them we are more likely to achieve the next aspiration of PCC.
  4. “Finding common ground with a view of sharing responsibility”. The “aim is to achieve a common understanding of the health issue in question and, where there is disagreement or divergence, to reach consensus” (6). This is crucial – with the rights of each party comes a responsibility to communicate and understand each other’s attitudes, decisions and potential outcomes/ implications.

In my view each of these points centres on effective communication – where patient and Dentist have a relationship in which understanding the perspective and attitudes of the other is key.

Before we pick up a scaler, drill, forceps or implement any of the Hard Skills we are itching to get to consideration should be given to allocating time, resources (and training if necessary) for these key, learnable communication skills;

  • building rapport,
  • listening effectively,
  • demonstrating empathy,
  • diagnosis (using your mental database of knowledge and experience),
  • discussion of options,
  • achieving informed consent,
  • providing information,
  • influencing and educating,
  • identifying and managing behaviours,
  • reassuring,
  • addressing anxiety,
  • seeing the patient’s perspective,
  • showing that you care and understand.

We must maintain a broad view of what Dental practice is  – this will enable us to take our role beyond that of a ‘tooth mechanic’ managing Dental disease, to practitioners of PCC seeing the patient and their illness experience as a whole.

Our position as professionals is a privileged one, and with that comes responsibility to look after our patient’s best interest. This will ensure a win-win for patient and Dentist – our patients will feel a level of trust and assurance that we are attending to their concerns and we are much more likely to form resilient relationships, especially in these times of increased competition and over-supply of practitioners.

In conclusion, we perform PCC by keeping at the forefront of our minds the need to practice key communication skills alongside the diagnostic and technical skills we are taught and evaluated on in Dental school.

Scambler et al go so far as to say that we should be proactive in this – their “recommendation would be that the theory and skills of PCC are developed as part of Continuing Professional Development (CPD) for dentists who are already practicing but have not received training in this area” (7).

All of my courses are based on the underlying principles of PCC – this in turn aligns with the DBA Code of conduct which states that “relationships based on openness, trust and good communication will enable practitioners to work in partnership with their patients” and that “an important part of the practitioner-patient/client relationship is effective communication in all forms” (8).

 

References;

  1. Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977.
  2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press. 2001
  3. Rathert et al. Patient-centred care and outcomes: a systematic review of the literature. Medical Care Research and Review. 2012
  4. Dental Board of Australia. Code of conduct. 1.2.
  5. Scambler et al. Defining patient-centred care in dentistry? A systematic review of the dental literature. British Dental Journal. 2016
  6. Scambler S, Scott S, Asimakopoulou K. Sociology & Psychology for the Dental Team. Polity. 2016.
  7. Scambler et al. Patient-centred care – what is it and how is it practiced in the dental surgery? Health Expectations. 2015
  8. Dental Board of Australia. Code of conduct. Overview.

 

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