Three discourses of patient-centeredness have been presented on the basis of an analysis of a sample of scientific articles that discuss the meaning of patient-centeredness in the context of medical encounters. Like earlier research, the present article is rooted in an anti-essentialist approach to patient-centeredness and focuses on the ways in which the concept of patient-centeredness is brought into being through texts and practices (Hughes et al. 2008). Unlike earlier research, however, the focus was on highlighting differences rather then similarities.
As is in line with how Deetz (1996) presented discourses of organization science, the discourses of patient-centeredness need not be seen as ‘mutually exclusive’. Relational processes, such as conversations and texts like these, often involve a coming together of different discourses, which can lead to re-constructions and enrichments of discourses, and to the emergence of new discourses. Discourses can, for instance, “steal each other’s insights” (Deetz 1996). Consequently, the presented discourses are assumed to be fluid and open to change. At the same time, each discourse articulates a different set of arguments and practices that seem to be promoted when actors use the language of patient-centeredness. Or to put it differently, each discourse can be seen as a possible orientation to patient-centered encounters, and as a possible way of constructing the patients and healthcare professionals that participate in them.
Deetz (1996) argues that an important way to evaluate the results of a Discourse Analysis is by looking at how discourses pose problems for one another and hereby invite us to reflect on “differences that matter”. Indeed, I think that the discourses raise important moral questions for each other (Table 2).
One fundamental question that seems to underlie the questions in the table above is whether healthcare professionals should explore and then accept a patient’s wishes and abilities with respect to the content of medical encounters and his/her involvement in decision-making, or whether healthcare professionals should persuade patients into a certain direction. Let me say a bit more about how the discourses pose questions for each other and hereby help us to develop “critical insights” (Alvesson and Deetz 2000).
Moral questions: conversations between the discourses
When patient-centeredness is constructed as a process of caring for patients, the focus tends to be on how the biopsychosocial model can be adopted (“discussing psychosocial issues, unless…”). After all, it is assumed that when the focus is purely on the patient’s disease, this could lead to wrong diagnoses, and treatments run the risk of being ineffective (see e.g. Mishler 1984; Bensing 2000). In addition, from a caring discourse it makes sense to argue that healthcare professionals should not refrain from their medical responsibilities. Salmon and Hall, for instance, argue that a discourse of empowerment mainly serves doctors (not patients), since it allows them “to withdraw from responsibilities for areas of patient need that are problematic for medicine” (Salmon and Hall 2003, p. 1969). Likewise, a recent article ‘subverts’ the popular assumption that the patient’s involvement in medical decision-making is particularly important in those cases in which there is great uncertainty surrounding the medical options and the “right” choice. In this text, the author argues that if patients are faced with complex considerations regarding unclear benefits and harms, they may benefit most from a recommendation from their healthcare professional (Fried 2016). Texts like these show how the arguments that are central in a discourse of caring raise relevant questions about patient-centeredness as empowering. It invites us to carefully consider the ‘when’ and ‘how’ of empowerment in relation to a patient’s need for good medical care.
When patient-centeredness is constructed as a process of “empowering patients”, the focus tends to be on how patients can be empowered – even if patients feel they lack the skills or do not seem up for it (“empowering patients, unless….”). Rather then taking the patient’s skills and values with respect to medical decision-making for granted, healthcare professionals are invited to explore how patients can be trained or coached (“empowered”) to make medical decisions and/or to manage their own health. See, for example, how Légaré and Witteman respond to arguments of vulnerable patients that cannot or should not be empowerment:
Although health care providers hold strong views regarding which patients want to, should, or even can engage in shared decision making, those views may be flawed. Surveys consistently indicate that patients want more engagement than they get. […] patients can learn communication skills and become increasingly confident in their ability to engage in decisions about their health. […] ethical and moral principles require that we not withhold it from vulnerable patients just because it may be more difficult to deliver it to them. Rather, we must find ways to deliver such care across the board (Légaré and Witteman 2013, p. 279).
Empowerment is often promoted because “it can lead to significant patient and clinician benefits, ultimately leading to better outcomes for individuals and societies” (Hannan and Webber 2007, p. 108). Moreover, patients that are involved in their care are expected to visit their doctor less frequently, which is often considered timely because of the increase of healthcare costs (Hughes et al. 2008). This argument illustrates how the discourses are linked to political interests and macro-level discourses, in this case empowerment is linked to a discourse of efficiency and related to the interests of the healthcare system as a whole.
When patient-centeredness is discoursed as a challenge of responsive communication, ‘values’ such as empowerment and holistic caring are more or less presented as food for negotiation or for ‘shared reflection’. In other words, the focus is shifted to the medical encounter itself as an arena of negotiation. During their conversations, patients and healthcare professionals need to work out whether and how to discuss psychosocial issues and whether and how the patient is involved in medical decision-making (Illingworth 2010; Ishikawa et al. 2013). The local specifics of the encounter, including the skills and values of the participants at that particular moment, are thus centered over a more general ethical notion of ‘what is good’. The discourses of caring and empowerment raise questions about whether this isn’t a relativist approach, and suggest that patients could be persuaded to do what seems best for them (see e.g. Pulvirenti et al. 2014).
Implications: the challenge of diversity
What to make of these different discourses? How to answer the questions they raise? The present relational constructionist philosophy suggests that we need to let go of the idea that there is a universal ground or “God’s eye view” from which to judge different discourses (Gergen 1999). Moreover, it suggests that discursive differences are both inescapable and can be appreciated. They are inescapable because conversations are likely to involve a coming together of multiple discourses. Different actors are likely to bring in different discourses that make sense in relation to the historical and cultural particularities of both the conversational context and their local “communities”. Discursive diversity needs to be appreciated, because it is vital to our well being (Falzon 1998). After all, a lack of diversity suggests a state of suppression of certain discourses over others, and such domination can stunt opportunities for the development of new insights and processes of innovation (Sampson 2008). Moreover, a lack of diversity often leads to taken-for-granted constructions of the “real and good”, which could mean that potentially interesting alternative constructions are being overlooked. Consequently, relational constructionism invites us to centre the challenge of working with differences in ways that are helpful to the local (groups of) actors involved. This requires that we accept differences, and that we start to critically examine the local realities we are making (or breaking) during conversations (Hosking 2007). This way we can develop “critical insights” into perhaps taken for granted discourses and their ethical and political consequences (Alvesson and Deetz 2000). Who is given certain rights, who are made responsible for different healthcare tasks, who are being silenced by a discourse? Do we feel this makes sense in this particular context, given our local criteria of ethics and the local interests of the actors involved? (Hosking and Pluut 2010). In sum, the present article suggests diversity and conflicts between discourses are both an inevitable and healthy aspect of social life. The challenge is to make conflict a “positive sum game”. The implications of this view are discussed below by using the example of projects that aim to make healthcare more patient-centered through the practice of “Health Information Exchange”.
The case of Health Information Exchange
The greater availability of health information to patients has fuelled discussions on the role of patients in healthcare (Henwood et al. 2003). Consequently, it is not surprising that health information emerged out of the Discourse Analysis as one of the themes that is constructed differently in texts that construct patient-centeredness. Health Information Exchange (henceforth HIE) refers to the process of (electronically) sharing patient-level health data across a network of stakeholders (Vest and Gamm 2010; Shapiro and Kuperman 2011). Those who want to improve the availability of health information are faced with political challenges: who are given the rights and responsibilities to exchange which kind of information, for what reasons, and in what ways? As we have seen, the three discourses of patient-centeredness each provide a different answer to these questions. This explains why the ‘what, why, how, and for whom’ of HIE is often highly contested. Projects that aimed to facilitate HIE on a national scale, for instance, have suffered from unproductive, polarized debates (Garrety et al. 2014). One reason for this is that actors ignored the challenge of working with different discourses. To illustrate, those who evaluated a national HIE project in the Netherlands argued that a shared recognition of the patient’s interests did not bind actors together, but divided them (Twist et al. 2012). There seemed to be a false sense of consensus: all actors stated the HIE project needed to centre patients, but they meant different things by it. As Abma argued, there is a serious risk in using abstract concepts such as patient-centeredness:
When vague and abstract […] concepts […] have to be implemented, the consensus often appears to be a superficial one. Under the outer layer of homogeneity one finds a broad spectrum of meanings, which not infrequently lead to heated discussions and a confusion of tongues (Abma 2000, p. 199-200).
Discussions on whatever sort of patient-centered innovation run the risk of becoming unproductive if they fail to acknowledge that patient-centeredness can be constructed differently by different (groups of) actors, in relation to their varying norms, values, and interests in a local project. Consequently, rather than assuming that we all want what is best for patients, we need to anticipate dissensus and need to explore how we can deal with different discourses of patient-centeredness in relation to the local challenges we are facing.
As Gergen argues, “if dialogue is to proceed successfully, it is critical that the other understands who we are and what we stand for” (Gergen 1999, p. 158). This implies that when particular HIE solutions are being debated, it is vital that actors link different arguments to different discourses, and that they gain insights into how these discourses makes sense in relation to the interests, norms and values of the (groups of) actors that are involved. The discourses that are presented in this article hopefully sensitize practitioners in healthcare to different discourses of patient-centeredness and help them gain an understanding for why different actors promote particular (HIE) practices. Developing such critical insights is an important first step towards making conflicts on patient-centered HIE a “positive sum game” (Abma 2000; Alvesson and Deetz 2000). It means that the different stakeholders are starting to build productive working relations that are rooted in an understanding of the multiple local “rationalities” and a recognition of the communal challenge of working with diversity in fruitful ways.
I do not wish to claim that this article presents all possible or all popular constructions of patient-centeredness. Hopefully it does, however, paint an interesting and colourful picture of how scientific texts that discuss the meaning of patient-centered encounters construct this multi-faced concept differently. Some may feel that additional themes or arguments should have been included in the overview of discourses. Likewise, some perhaps argue that interesting articles on the meaning of patient-centeredness have been overlooked and should have been included in the analysis. In that case, I would invite readers to join and enrich the dialogue on how we can construct patient-centeredness. I prefer to not see this article as the end of an analytical process, but as a potentially useful starting point for dialogues on how to deal with moral dilemmas and conflicts over patient-centered care practices.
Future research could broaden the scope of the present discourse analysis to include other kinds of “centeredness”, such as client-, family- person- and relationship-centeredness (Hughes et al. 2008). Perhaps a focus on different constructions of these concepts highlights other relevant dilemmas and suggests additional themes that can be opened up for reflection. Likewise, future research could explore how actors other than scientists (policy makers, doctors, patients, managers) construct patient-centeredness in different contexts and can hereby bring additional candidates for reflection to the fore.
Second, future research could focus on how the results of the presented analysis can be used in ways that stimulate reflexivity and that help actors to make conflicts over patient-centered practices productive. It could, for instance, explore how reflexive workshops can help practitioners (e.g. healthcare professionals, patients, managers, policymakers, researchers) to reflect on different discourses and the challenge of dissensus, hereby developing “practical theories” as to how to deal with diversity within local working contexts (Cunliffe 2003; Abma 2000).