JOURNAL REVIEW

Journal Review

Journal Review

Primary Care for Patient Complexity

Increasing the patient's voice has often been considered one of the main sources of potential threat to professional autonomy. The trends discussed in this chapter may appear to imply similar predictions. However, such analyses often require subscribing to a rather simplistic zero-sum game to account for patient-professional relations, where increasing the voice of the patient diminishes the authority of the doctor. Many of the analyses reviewed in this chapter, perhaps optimistically, anticipate mutually advantageous consequences of shared decision making.

The evidence presented in this chapter suggests that there is a substantial momentum behind calls to increase the responsiveness of health care systems to patients' preferences and concerns.

Despite the substantial body of evidence produced by research into patient satisfaction, work in this field is frequently criticized for failing fully to capture the patient's perspective with regard to health care.

One line of criticism has been that patterns of views about health care obtained in survey research reflect normative values surrounding health care. Patients are reluctant to criticize their health care, at least in part because they risk appearing ungrateful or unappreciative (Fitzpatrick and Hopkins 1983). This is particularly seen as a problem in surveys of patients' views in which respondents are asked fairly simplistic standardized questions about their views regarding aspects of health care experience with minimal opportunity to go beyond basic levels of 'satisfaction' or 'dissatisfaction.' A variant of this critique argues that patient satisfaction research is substantially flawed because of its reliance on insensitive methods of survey research to produce artificially inflated rates of positive satisfaction (Williams 1994). In contrast, it is argued that in-depth qualitative methods are necessary to obtain more valid evidence.

A related criticism is that the evidence obtained via standardized surveys is skewed towards favourable views by the majority of respondents, with the result that uniformly positive data do not permit investigators, managers, and planners to identify sources of poor or substandard care (Carr-Hill 1992). This is especially the case when the variation that is obtained by such methods can be substantially related to patients' demographic characteristics (Fitzpatrick 1997). Thus, older respondents report more positive views about their health care. To the extent that such favourable views are due to diminished expectations, normative values or different response sets in relation to attitudinal questionnaires, the use of information about patients' views to manage and plan patterns of services may be undermined.

At the heart of many critiques of patient satisfaction research is the view that it has given patients only a marginal role in relation to their own health care. To be consulted as a respondent in a survey is to have a very vicarious method of providing feedback to health professionals about the value and appropriateness of care received. The sense of limited involvement would be greater if there were greater awareness of the modest impact such evidence often has on decisions about future provision. More obviously, it is a form of involving patients that can only operate at an aggregate level of ...