2. INTRODUCTION
• Patient-centred care was introduced in the
1970s within family medicine to describe an
approach to patient care that went beyond
the traditional disease-centred or doctor-
centred method that was expected to be
followed by medical school graduates.
3. • The traditional ‘’history taking” did not seem to
be adequate alone to provide successful primary,
continuing, coordinated and comprehensive
care to a defined group of patients within a
community.
• Various conceptual frameworks have been
elaborated since then culminating in the “patient-
centred clinical method” by a group within the
Department of Family Medicine at the University
of Western Ontario, Canada.
4. INTRODUCTION
• PCCM is a guide to exploring patient problems
that allows physicians and patients to define
problems and decide on the management
together.
• It considers the agenda of both the physician
and the patient and finds common ground.
5. • Doctors generally build a biomedical construct
around the symptoms.
• In Family Medicine, the physician builds a bio-
medico -psychosocial construct that weaves all
symptoms together to find aetiology.
6. • The key to the patient-centred method is to allow
as much as possible to flow from the patient,
including the expression of feeling.
• The clinician should possess the vital skill of
attentive listening and responsiveness to verbal
and non-verbal cues through which the patients
express themselves.
• Failure to take up the patient's cues is a missed
opportunity to gain insight into the illness.
8. PCCM
• In the patient-centred clinical method, both
agendas are addressed by the physician and
any conflict between them is dealt with by
negotiation.
• This is contrasted with the disease-centred
method in which only the doctor's agenda is
addressed.
9. • Every patient who seeks help has
expectations, based on his understanding of
the illness. Every patient has some feelings
about his problem. Some fear is nearly always
present in the medical encounter, even when
the illness may seem to be minor: fear of the
unknown, fear of death, fear of insanity, fear
of disability, fear of rejection.
10. Family Medicine model of Care- Patient
Centred/Model
– It is biopsychosocial
Patient’s Complaints of Unwellness
Parallel Search of 2 framework
Disease Illness
History Patient’s feelings
Physical Examination Ideas
Lab & Radio & Others Functional loss
Diagnostic technique Expectations
Differential diagnoses and Understanding the
the patient’s
Definitive Diagnoses Illness Experience – ARC
Integrated
Understanding
11. Identifying Patients’ Actual Reasons for Coming
(ARC) vs. Presenting Complaint
• Why should a patient present with a simple coryza when
many others with same problem wouldn’t ? This may be
due to needs unexpressed.
1. Needs to get urgent resolution of the catarrh so he can move on quickly
with his other businesses.
2. Fears from past experience, progression to LRTI.
3. Fears sinister diagnosis – since he is a chain smoker.
4. Even unrelated psycho-social problem.
12. Why delve into patient’s ARC or
Illness Experience?
1. It will ensure patient’s satisfaction.
2. It will reduce doctor/clinician
shopping/hopping.
3. It will reduce legal suits by angry patients.
4. Reassurance
5. Better patient’s adherence
6. Greater levels of doctor’s satisfaction
13. COMPONENTS OF THE PATIENT
CENTRED PROCESS
• Exploring both the disease and the illness
experience.
• Understanding the whole person
• Finding common ground
14. COMPONENTS OF THE PATIENT
CENTRED PROCESS
• Incorporating prevention and health
promotion
• Enhancing the doctor-patient relationship
• Being realistic
15. 1st component
Exploring both the disease and the illness
Disease, is an abstraction, the “thing” that is wrong
with the body as a “machine”. ( history-taking,
physical examination and investigations)
Illness, is the patient’s personal experience of sickness
– the thoughts; feeling and altered behavior of
someone who feels sick.
16. Some distinctions between disease and illness
Illness Disease
1. Patients’ personal experience of
ill health
Explains patients’ problem in
terms of abnormalities of
structure and body function.
2. It is unique and subjective It is generalized and
objective.
It is what everyone has in
common
3. It includes social, psychological,
biological and spiritual dimensions
Is mainly biological and
psychological
4. Focuses on both the body and
the person including ideas,
feelings, and impact on function
and expectations.
Focuses on the body not the
person
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17. • FIFE
• Feelings – “What is the patient most concerned
about? their greatest fear, concerns, worry?”
• Ideas – “What does the patient think is happening?”
• Function – “what has this kept you from doing?”
– “what do you have to do, now that….”
• Expectation – ‘’What does the patient expect of the
visit, the health care system?’’
18. 2nd component- Understanding the
whole person
• The patient encounter considers:
the personality, culture, religion, family life cycle
(stages)-cradle to grave(generational medicine), life
history, spirituality, family dynamics, response to current
health status.
• These determine how the person views the disease and
its causes, behaviours and reactions to illness,
perspectives on treatment
19. The doctor needs to know his patient’s
cultural background that may block
meaningful understanding
• Tools used in understanding the whole person
include the family life cycle, family genogram,
family circle
20. 3rd component-Finding common ground with the
patient
• Working with the patient to define the problem and establish
goals of treatment and/or management.
• Identify roles to be assumed by the patient and clinician.
• Address the patients’ questions and concern in an empathic
manner so he/she feels heard and understood
• Involves on- going dialogue with the patient on merits and
demerits of the different mgt approaches. There may be a
need for family involvement.
• Lack of information incapacitates the patient psychologically.
21. problem priority Doctor’s role Patient’s role
Strong family
history of heart
disease- father died
of MI
Minimize patient’s
risk of heart attack-
Doctor and patient
both want a better
outcome
Carry out
investigations,
recommend
medications and
lifestyle changes.
Offer
encouragement and
support
Eat vegetables at
every meal, take
medications,
exercise regularly,
keep appointments,
Be honest with
doctor about
progress
22. 4th component-Incorporating health promotion and
disease prevention
• Health promotion is defined as the process of
enabling people to increase control over and to
improve their health.
• Disease prevention –reducing the risk of acquiring a
disease.
• Risk avoidance
• Risk reduction
• Early identification
• Complication reduction
23. • Physicians and patients together monitor
areas in patients’ lives that need
strengthening in the interest of long-term
emotional and physical health
• Physicians monitor recognised problem and
screen for unrecognised ones
24. 5th component- Enhancing doctor- patient
relationship
• This involves conscious effort to enhance doctor-
patient relationship
• A relationship is the bedrock or basis for all
interchanges between two people.
• When doctors see the same patients time after
time with a variety of problems, they acquire
considerable personal knowledge of them that
may be helpful in managing subsequent problems
• In a patient-doctor relationship, the purpose is to
help the patient i.e. for the relationship to be
therapeutic and foster healing.
25. • Each contact with the patient should be used
to build on the patient –physician relationship,
including empathy, trust, caring and healing.
• This relationship is unique to each patient
seen (different patients require different
approaches), with varying degrees of control
exerted by the doctor.
• Requires good communication skills on the
part of the physician.
26. 6th component- Being realistic
Involves the physician being realistic about time,
availability of resources and amount of emotional or
physical energy needed
Physicians must develop skill of priority setting,
resource allocation and team work
27. • The physician must realize that he/she is first a
person before being a physician.
• The key to success of time management is the
balance between practice time and personal
time.
28. CASE STUDY TO ILLUSTRATE PCCM
The following example will serve to illustrate the method:
A 68-year-old male patient, who had recently been operated on for a benign
stricture of the sigmoid colon presented for a routine follow-up office visit. The
patient, a retired Roman Catholic priest, had very recently taken up residence in a
retirement home for ageing clergy. All these facts were known to the doctor. The
interaction has been reconstructed in two ways to illustrate the disease- and
patient-centred methods.
The Disease-Centred Method
Doctor Hello Father Smith, how are you today?
Patient Fine—except for my headaches . . .
Doctor . . . and your operation, how's that going?
Patient Fine.
Doctor Bowels working?
Patient Yes.
Doctor Appetite?
Father A bit poorly.
Doctor Have you lost any weight?
Patient No.
Doctor Well, obviously your loss of appetite hasn't affected anything, so it can't be
too bad? Any nausea or vomiting?
Patient None.
29. Doctor Any pain at the operation site?
Patient Not really.
Doctor Are you eating the bran we recommended?
Patient No.
Doctor You must please stick to our recommendations. We don't want
any recurrences.
Patient (sighing) Yes.
Doctor Good, well the operation seems to have been a success and
there don't seem to be any complications. Have you any other
complaints?
Patient I have this headache.
Doctor Is your vision affected?
Patient No.
Doctor Any weakness or paralysis of your limbs?
Patient No.
Doctor Where are your headaches?
Patient At the back of my head.
Doctor Do they throb?
Patient Yes.
30. Doctor How long do they last?
Patient About four hours.
Doctor What takes them away?
Patient I just lie down.
Doctor How often do they come?
Patient About twice a week.
Doctor How long have they been there for?
Patient Ever since I've been at the home.
Doctor Good, well you needn't worry—it can't have anything to do
with your operation. They are tension headaches. Perhaps we
can give you some paracetamol for it. The home you have just
moved into seems to have beautifulgardens.
Patient Yes.
Doctor It really is good of the church to care for its elderly and it must
be comforting to have company.
Patient Yes.
Doctor Well good. Come and see me in a month's time and we'll see
how things are going. Take care.
31. The Patient-Centred Method
Doctor Hello Father Smith, how are you today?
Patient Fine, except for my headaches.
Doctor What about your headaches?
Patient Well, I've been getting them about twice a week at the back of my
head and they bother me so I can't do anything, and I have to lie down.
Doctor You can't do anything? What's that like for you?
Patient It's frustrating, they're interfering with the writing I want to get done
and nobody seems to understand . .
Doctor Understand?
Patient All the other priests are so old and decrepit in that place. All they can
talk about is their aches and pains. I'm ashamed to say they make me
sick.
Doctor Why are you ashamed?
Patient Well, I shouldn't really talk that way about them, they mean no harm
. . . I feel so guilty about it.
32. Doctor What do you mean guilty?
Patient I feel that my anger is unjustified, I'm so frustrated that no
one understands that I wish to write.
Doctor It must be frustrating . . .
Patient Yes, it is and my headaches—my headaches make it worse.
Doctor When did they first start?
Patient Ever since I've been at the home.
Doctor Why do you think that is?
Patient I . . . don't know, I haven't really thought about it . . . do you
think it's tension? . . . 1 mean the people at the home . . . is it
possible?
Doctor What do you think?
Patient Well the whole situation at the home does trouble me.
33. Doctor Would you like to talk about it more?
Patient No, not now, perhaps later.
Doctor Well, feel free to discuss it anytime you like.
Patient Mmm, mmm, I will.
Doctor Well, how are things going after your operation?
Patient It seems okay.
Doctor What do you mean, it seems okay?
Patient Well I don't seem to be eating well and I can't stand that bran. In fact
I have no appetite for food.
Doctor What do you think that could be due to?
Patient I wonder if it's due to the tension I'm feeling?
Doctor Mmm, mmm.
Patient I will really think about what we've said and come back to see you
again.
34. Doctor Fine, anything else today?
Patient Fine, everything is fine, except I get a funny feeling on my scar.
Doctor A funny feeling?
Patient Yes, it seems a bit numb . . . I hope it's not serious.
Doctor It's probably a little nerve that supplies the skin that was cut during
the operation. Nothing to be concerned about.
Patient I'm glad it's only that. I was quite worried.
Doctor Anything else you'd like to discuss?
Patient No, everything else is fine.
Doctor Good, would you like something for your headaches?
Patient Thank you, but I don't think it's necessary.
Doctor I'd like to see your wound in a month's time, but we can get
together earlier if you'd like to.
Patient Fine, I'll be in touch, Doctor.
35. Conclusion
• PCCM is vital in clinical decision making and
needs to be practised to ensure overall well
being to both patient and doctor.
• Although the six components of PCCM have
been presented as separate and discrete, in
reality they are intricately woven
• The skilled clinician moves effortlessly back
and forth among the six components,
following the patient’s cues
