4.3.2 70-80

In the seventies and eighties the patient-physician relationship changed dramatically due to several developments. First, in the late sixties and early seventies many protest movements and emancipatory organisations struggled for equality on various terrains. Patients' rights advocates and organisations were established including patient self-help groups and self-care movements. Patients claimed their place as active participant in the consultation and fought for self-determination and legal rights. These social changes eventually resulted in legislation regarding the provision of information, informed consent, privacy protection and the right to complain about the received care. Also in the late seventies and early eighties social active general practitioners founded healhcare centers and addressed not only psychosocial issues but also health determining societal conditions and inequalities. They regarded patient education as an important means to engage their patients in illness prevention, living conditions improvement and community based health care. One of the Dutch left wing political parties stems from such a politically engaged health care center. Second, medico-technical developments complicated treatment decisions. Diagnostic and treatment options expanded rapidly. For several diseases equivalent treatments became available and other diseases which were untreatable before or lethal on the short term, became chronic conditions and patients' life span could be prolongued substantially. Thus, physicians had to take into account patients' wishes and quality of life considerations. Third, patient education is embedded in the wider field of health promotion, which flourished in the seventies due to the rise of behavioral and lifestyle related diseases. The Lalonde rapport from 1974 acknowledged for the first time that not only biomedical aspects are important to define health, but that citizens in general and patients in particular could improve on their health through behavioral factors related to their lifestyle [Lalonde 1974]. At first, health promotion activities mainly used knowledge transfer as influencing technique, but gradually other behavior modification techniques, originating from social psychology and educational research, were used in health promotion interventions. Fourth, political and economic factors also supported the promotion of health education, self-determination, patient participation and health responsibility, since health care costs increased substantially in the eighties and the economic climate urged for reductions in governmental costs.

All these developments forced physicians to pay more attention to patient-centred communication and patient education in their consultations. The concept of patient-centred communication originated from the power shift model in which the patient-centred exchange of information opposes the doctor-centred exchange of information especially in the diagnostic phase of a consultation [Byrne & Long 1976]. Gradually, the concept of patient-centredness was extended to all phases of the consultation and became a moral philosophy with core values such as considering patients' ideas, wishes and perspectives, encouraging patients to provide input into and participate in their care, and enhancing partnership and understanding in the patient-physician relationship [Stewart 2001, Mead 2002, Epstein 2005]. Thus, patient education became an inseparable part of patient-centredness and physicians were supposed to promote patient participation and shared-decision making [Taylor 2009]. However, only general practitioners embraced these ideas and research on patient-physician communication that blossomed in the early nineties, mainly concerned primary care consultations. In primary care which is by definition more connected to societal movements than hospital care, patient education directed at behavior modification and lifestyle change, became part of illness prevention and treatment. In medical specialist consultations patient education was not yet taken very seriously [Webber 1990, Wouda 1993].