4.1.4 21th century

In the first decade of this century the electronic information supply by the internet became commonplace and patients with internet access now collect health information away from the traditional patient-physician encounter [McMullan 2006, Lee 2010]. Furthermore, health and health related subjects are nowadays a dominant topic in the societal discourse with ample attention to healthy lifestyles, such as healthy food, slimming down and physical exercise. These societal developments revived the ideas of the eighties about patient participation and self-management. However, patients are now better informed health care consumers which place greater demands on accessability, service and outcomes. Just like in the eighties, idealistic motives as well as political-economic interests underlie these claims for patient involvement, patient empowerment and self-determination and patients are encouraged to take responsibility for their own health and recovery. In the above mentioned memorandum of the Dutch National Board of Public Health in which patient participation is strongly advocated, the training in patient education  of health care professionals and especially of physicians, is emphasized and professional organisations are obliged to include patient education competencies into their registration prerequisites [Raad voor de Volksgezondheid en Zorg 2013].

From the nineties until recent years the concept of patient-centredness dominated the research of physicians' patient education behavior and outcomes. However, patient-centredness appeared to be a complex and elusive concept which does not offer a sound theoretical framework from which the patient education objectives of a consultation and matching communication tasks of the physician can be derived. The evidence about the effects of patient-centred communication on patient outcomes also remained limited [Haes 2008, Veldhuizen 2011Dwammena 2013, Street 2008]. As a consequence, functional models of patient education which clarify the relationships between physicians' patient education goals and communicative behaviors on the one hand, and patients' responses and outcomes on the other, emerged [Haes 2008, Haes 2103, Street 2008]. Some models elucidate the prerequisites and processes which determine the outcomes of patient education activities [Bylund 2012, Cameron 2009]. Patient education elements such as fostering the relationship, listening to patients' concerns and wishes, proper explaining and involving the patient in treatment decisions, have unmistakable positive effects on patient satisfaction, comprehension, recall and adherence [Beck 2002, Silverman 2005]. Interventions which aim to enhance patient participation and shared decision making in consultations, also have positive effects on proximal outcomes such as satisfaction, participation in the consultation, understanding and agreement. However, the effects on intermediate outcomes such as adherence to regimes and self-management, and on health outcomes are less convincing [Griffin 2004, Faber 2013]. On the other hand, more advanced patient education methods, which directly aim to improve decision making or health behavior, such as facilitating regimen adherence [Van Dulmen 2007], risk communication [Edwards 2008], decision aids usage [O'Connor 2003] and motivational interviewing [Britt 2003, Lundahl 2013, Noordman 2012] are quite succesful.

Despite the call for more attention to patient education in clinical practice and in the training of medical specialists, patient education is still undervalued in medical specialist consultations. Research on the quality, determining factors and effects of patient education in medical specialist consultations is also less developed. This lack of interest could be attributed to several factors. First, patient education in medical specialist consultations is not rewarded financially or otherwise. Time constraints and the medical problem-solving culture even discourage patient education efforts. Second, patient education in hospitals, especially for patients with chronic conditions, is often transferred to other health care providers such as specialised nurses, nurse practitioners, dietarians, physiotherapists and psychologists, discharging medical specialists from their patient education duties. Thus, medical specialists are neither encouraged nor compelled to demonstrate excellent patient education.

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