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Patient-Centred Medicine: transforming the clinical method

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Patient-centred care is now one of the orthodoxies of modern healthcare practice. Healthcare professionals, including many doctors, profess that they deliver such care
Moira Stewart, Judith Belle Brown, W Wayne Weston, Ian R McWhinney, Carol L McWilliam and Thomas R Freeman

Radcli¡e Medical Press: Oxford, ISBN: 1-85775-981-8, 2003 (2e), 376 pp, £24.95

Patient-centred care is now one of the orthodoxies of modern healthcare practice. Healthcare professionals, including many doctors, profess that they deliver such care. The six key elements of such care are that the practitioner should: explore the patients’ main reason for the consultation; seek an integrated understanding of the patients’ world; find common ground on what the problem is and mutually agree on management; enhance prevention and health promotion; enhance the continuing relationship between the patient and the doctor; and ‘be realistic’.

The development of the notion of ‘patient-centredness’ has been the subject of several socio-logical studies and it can correctly be seen as a ‘reformist’ approach to medicine that attempts to address both the sociological critique of ‘biomedicine’ and the consumerist proposition that the patient ‘knows best’. There have been concerns as to the extent to which medicine, in particular, can term itself ‘patient-centred’ and it has also been noted that few general practitioners actually practice patient-centred medicine, at least in their seven minute consultations.

Stewart and colleagues, however, do not concern themselves with the sociological critique of the con-cept of ‘patient centredness’, and trace the linear development of the concept from the seminal work of Michael Balint in the 1950s. Their work is part of a growing body of theoretical and empirical research that attempts to define the key components of a ‘patient-centred approach’ and to establish whether or not it has a positive e¡ect on health outcomes. The authors are well placed to review the literature on patient-centred care as they have had a research and development programme in this field at the Univer-sity of Western Ontario since the late 1960s, initiated by Ian McWhinney, and the first edition of this book has been acknowledged as an important text in the field.

The book has three main sections, prefaced by an overview of the method. In part one, the six com-ponents of the patient-centred clinical method are discussed in turn. Each chapter o¡ers a clear defin-ition of each component, and the case studies are a useful way of bringing the components ‘to life’ for healthcare practitioners. It was interesting to see the second edition being brought up to date with discus-sion of how illness narratives may be used by practi-tioners. In part two, the authors show how the method can be taught and o¡er suggestions for developing a patient-centred medical curriculum. In part three, they summarise research relevant to the method and show how both qualitative and quanti-tative methodologies can be used to explore patient-centred care.

Radcli¡e Medical Press is to be congratulated in making this key text on patient-centred medicine easily available to a UK audience. It o¡ers much for the practitioner who wishes to learn about and teach patient-centred medicine.

Dr Tim Stokes

Senior Clinical Lecturer,

Clinical Governance Research & Development Unit,

University of Leicester

Mapping Health on the Internet: strategies for learning in an information age

Ross Scrivener

Radcli¡e Medical Press: Oxford, ISBN: 1-85775-593-6, 2002, 160 pp, £19.95

Ross Scrivener starts the book with an illuminating fact: ‘more information has been produced in the last 30 years than in the previous 500 years’. He then describes the types of information overload and the associated signs and symptoms. The web is likened to a maze more complex than any ever built. This book aims to give health professionals the skills and com-petencies to navigate the web and to develop search-ing and information mapping skills.

The concepts of focusing and framing questions, di¡erent types of evidence and their strengths and weaknesses, and di¡erent information sources are presented. These ideas are nothing new to anyone with any experience in searching for information, but some practical suggestions are o¡ered which may be useful both to those more experienced in information retrieval and novices alike. Three types of maps: smart, conceptual, and mind maps are described. Mind maps are then used in four areas of clinical practice: care of older people, mental health, child health, and primary care. It is this aspect of the book that is novel. Mapping, using any of the three types proposed, seems to o¡er a systematic, useable method of improving searches for information. In addition to the practical strategies for navigating the web, the addresses of many websites have been provided. However, although they are undoubtedly useful, the information may well have proved more user-friendly if provided on an accompanying CD or even a dedicated website.

This book is primarily aimed at enabling healthcare professionals to use the Internet when trying to keep their practice current and based on the best available evidence. This aim has been achieved with a readable, practical guide to the maze that is the Internet.

Ms Elizabeth Shaw

Systematic Reviewer,

Clinical Governance Research & Development Unit,

University of Leicester

Medication Errors

Robert Naylor

Radcli¡e Medical Press: Oxford, ISBN: 1-85775-956-7, 2002, 344 pp, £29.95

Initially I was horrified after learning the incidence and causes of medical errors but after in-depth read-ing of this book I was relieved to learn how these errors can be prevented and reduced, leading to improved patient care at all levels of its delivery.

In his first chapter the author introduces the aims of this book, which are to contribute to the global debate on the reduction of adverse reactions; to give a concise account of the serious nature this public health problem and to identify possible solutions to reduce adverse events and medication errors.

The second chapter highlights the size of this prob-lem. Studies from the developed world show that injury or mortality induced by medical management is a leading cause of impairment, disability and death. This is equivalent to eight and four deaths per hour in USA and UK respectively. Iatrogenic injury due to drug-related adverse events is the most common and 50% of these injuries are preventable. In the sub-sequent chapters these findings are further supported by meta-analysis of studies already published from both secondary care and primary care. The author highlights the problem of lack of studies on medical errors from primary care where most of the consulta-tions take place.

Chapter 4 explains the stages at which drug-induced events/reactions occur. Most of these occur at ordering/prescribing (56%), drug administration (34%) or during transcription (6%) and dispensing (4%). Chapter 5 highlights the causes behind these medication errors. Lack of knowledge is the single most important error in 36% of cases. The other causes of errors are slips, memory lapses, fatigue, stress, and sta¡ inexperience. Twenty-four per cent of errors occur due to a lack of information about the patient. In this chapter the author has produced an excellent table of categories and incidence of specific types of errors in a weighted sample.

In the next chapter the author reveals the heavy cost of medication errors in terms of physical and psycho-logical injury to patients and also great distress to healthcare professionals with heavy legal and financial implications. He emphasises that medication errors are a major cause of concern and yet they are under-reported. The following chapters are devoted in implementing robust strategies at all levels including undergraduate education, postgraduate training and continuing professional development of medical per-sonnel to reduce medication errors.

At the end of the book there are appendices, which explain commonly used definitions in relation to adverse reactions to medication and classification of potential severity of the errors with examples, profes-sional ethical duties and References.

The only criticism I have is the large size of this book and the time needed to read the whole book. The summary at the start of each chapter does stimulate the reader to gain in-depth knowledge by reading the whole chapter. I recommend this book to all health-care professionals working in the hope of reducing medication errors and improving patient care.

Dr Karl Sher

GP and CPD Tutor,

University of Leicester

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