Integrating patient empowerment as an essential characteristic of the discipline of general practice/family medicine

Abstract

Background: Efforts to improve the quality of healthcare for patients with chronic conditions have resulted in growing evidence supporting the inclusion of patient empowerment as a key ingredient of care. In 2002, WONCA Europe issued the European Definition of General Practice/Family Medicine, which is currently considered the point of reference for European health institutions and general medical practice. Patient empowerment does not appear among the 11 characteristics of the discipline. Objectives: The aim of this study is to show that many characteristics of general practice are already oriented towards patient empowerment. Therefore, promoting patient empowerment and self-management should be included as a characteristic of the discipline. Methods: The following investigation was conducted: analysing the concept and approach to empowerment as applied to healthcare in the literature; examining whether aspects of empowerment are already part of general medical practice; and identifying reasons why the European definition of general practice/family medicine should contain empowerment as a characteristic of the discipline. Results: General practice/family medicine is the most suitable setting for promoting patient empowerment, because many of its characteristics are already oriented towards encouraging it and because its widespread presence can ensure the generalization of empowerment promotion and self-management education to the totality of patients and communities.

Conclusion: “Promoting patient empowerment and self-management” should be considered one of the essential characteristics of general practice/family medicine and should be included in its definition.

• Empowerment
• self-management
• general practice
• chronic diseases

Introduction

One of the most important challenges for national health systems in the 21st century is addressing the increased incidence of chronic disease and the associated burden of human and economic costs. Efforts to improve the quality of healthcare for patients with chronic conditions must consider the “growing evidence from around the world suggesting that patients with chronic conditions do better when they receive effective treatment within an integrated system of care which includes self-management support and regular follow up” [1]. The Chronic Care Model (CCM), developed by Wagner et al. [2], and the Innovative Care for Chronic Conditions (ICCC), edited by the World Health Organization (WHO) [3], propose that an essential ingredient of effective treatment is the partnership between the patient and health professionals, because it offers the opportunity to empower patients to become active in managing their health. When patients are more informed, involved, and empowered, they interact more effectively with healthcare providers and strive to take actions that will promote healthier outcomes [4].

While doctors in general practice and family medicine settings are in a key position to establish a partnership with patients, the definition of general practice and family medicine does not currently include “patient empowerment” as a characteristic of the discipline. The purpose of this paper is to show that patient empowerment should be considered as one of the essential characteristics of general practice/family medicine. In building support for this inclusion, the paper will offer a definition of empowerment, show the relationship of empowerment to patient self-management, and analyze the definition of general practice stated by WONCA Europe, matching its 11 characteristics with the necessary conditions for patient empowerment and self-management education.

Definition of empowerment

The educationalist Paulo Freire first defined the concept of empowerment in the 1960s as “education for liberation”. Freire distinguished between two basic approaches to education—the banking approach and the problem-posing approach. In the banking approach, teachers pour a body of information into “ignorant” learners. In the problem-posing approach, learners are respected as equals, and educators work with them to help them evaluate their personal situation and experiences in order to support the creation of their own plans of action [5], [6].

Freire's theory also identifies different levels of consciousness. For each type of consciousness—natural, magical, and critical—Freire shows the relationship between a person's understanding or awareness and his or her ability to take action [7].

Table I summarizes Freire's proposed relationship between what is understood and the way that actions are chosen and taken. Once a problem is identified and understood, the individual will more likely accept the challenge of formulating a hypothesis about the possible causes, consider various solutions to the problem, and finally make a decision about how to act. The actions chosen will usually correspond to the level of consciousness and type of comprehension. Freire's theory shows that, if an individual's awareness and comprehension of facts is “critical”, then his or her action will also be critical.

Table I.  Freire's types of consciousness.

Types of consciousness	Natural consciousness	Magical consciousness	Critical consciousness
Awareness	Understands facts and their obvious cause at “face value”	Accepts facts as presented, and without question	Understands that clarity about facts requires a logical process
Response to facts	Free to interpret facts as he or she thinks or believes is best	Assumes that facts are derived from a superior, pre-eminent power	Motivated to take action to manage facts or problems
Impact on action	Judges oneself to be “above the facts” and impermeable to challenges situated outside particular basic needs	Lacks personal power to effect change—more likely to develop a fatalistic view	Open to ongoing testing in order to verify, revise, or reconstruct facts

Further, Freire emphasizes that education aiming to enhance critical consciousness requires active listening, open dialogue, and nurturing, since the educational goal is not simply to provide information, but to empower individuals to define problems, find solutions for themselves, and effectively cope with the emotional impact of adjustment and change. Freire's strong assertion that “there isn't dialogue without humility” [5] reinforces the fact that a partnership requires both educators and learners to interact as equals. The content of education based on true dialogue is not intended to convey information or impose ideas but to provide an organized structure so that individuals are more able to identify their own goals, initiate their own decisions and actions, and experience their own power.

Relationship between empowerment and patient self-management in healthcare settings

Julien Rappaport, a community psychologist, defines empowerment as “a process by which people gain mastery over their lives” [8]. More specifically, Feste & Anderson describe both empowerment and self-management within the context of health problems as “an educational process designed to help patients develop the knowledge, skills, attitudes, and degree of self-awareness necessary to effectively assume responsibility for their health-related decisions” [9]. These definitions offer a philosophical and theoretical foundation for an approach to empowerment that can be applied to the management of chronic disease and self-management education. In contrast to compliance-oriented health education designed to reduce patient autonomy and constrain freedom of choice, a patient-empowerment approach designed to support the promotion of self-management requires that patients’ perspectives on their condition, their goals, expectations, and needs are the focus of the treatment goals and management activities. Therefore, if health systems want to encourage patients to assume an active self-management role, it will be necessary to adopt new models of care that focus less on patient compliance and more on empowerment [10].

An empowerment model requires that patients be viewed as experts on their own lives who are responsible for their own health. Only the patient can know the impact that illness has on his or her life. Even if “healthcare professionals have the privilege of being invited into their patients’ lives in which both patient and professional can experience humanity” [9], the doctor cannot always know the details of patients’ lives—what is important to them, what motivates them, or what they hope for in their lives.

When patients are considered the most “knowledgeable” about their life situation, the traditional approach to patient education—giving information to patients about their health—may only partially address the needs of each patient. In contrast, the goals of self-management education—to assist patients in gaining both the skills and confidence needed to manage their health—can be tailored to address individual patient concerns at all phases of primary, secondary, and tertiary prevention.

A self-management model for patient education has three distinctive features: 1) dealing with both the physiological and emotional consequences of disease/illness; 2) addressing the patient's ability and confidence to take an active role in problem solving and decision making, rather than depending only on prescriptions and adherence; and 3) placing patients and health professionals in partnership relationships that continue over the course of the illness and are based on trust and ongoing dialogue [11].

Kate Lorig [12] suggests that self-management education should address the medical, behavioural, and emotional aspects of living with a chronic condition. Since chronic diseases change over time, Lorig believes that only a patient who lives every day with his or her illness can determine its effects and its treatments. By observing the course of the disease and reporting accurately to their healthcare providers, patients offer information that is essential to good management of their condition.

Whereas traditional education offers information and technical skills, self-management education teaches problem-solving skills in a person-centred approach [13]. For self-management education to be effective, patient care must be coordinated between members of the healthcare team, and the patient must be an active member of the team, taking responsibility for daily self-management [14].

Bodenheimer et al. [13] maintain that self-management education should be incorporated into primary-care practice, where both collaborative care and self-management education can be combined to strengthen aspects of the patient–physician partnership. Collaborative care promotes proactive teamwork between patient and doctor, aiming to develop individual action plans. Each action plan must be tailored to the individual, taking into consideration culture, age, health status, and personal preferences [15]. Both research and practice of empowerment would benefit from a narrative approach that links process to practice and attends to the voices of the patients [16].

The challenge of helping patients develop individualized plans is assigned to the entire healthcare team, with the patient being the most important member—the one who will carry out the necessary actions [17].

Current research addressing the impact of patient empowerment and self-management education is being conducted for different chronic diseases: diabetes, asthma, heart failure, arthritis, depression, HIV/AIDS, etc. To date, there is general evidence suggesting that self-management improves clinical outcomes and patient satisfaction, and that it has a positive impact on overall healthcare costs [13], [18]. Further longitudinal studies are needed in this area to determine how long favourable outcomes and reduced costs are sustained after a self-management intervention has taken place. Ongoing support appears essential, particularly for patients to maintain long-term behavioural changes and to face the new challenges that may occur over the course of a chronic condition.

New definition of general practice/family medicine

In 2002, WONCA Europe issued the European Definition of General Practice/Family Medicine, describing its essential role within health systems. The definition was the result of an in-depth debate that involved the WONCA European Council, general practice academies, and experts. This definition is now the point of reference for European health institutions [19] as well as general practices, delineating “the essential elements of the academic discipline and providing an authoritative view on what family doctors in Europe should be providing in the way of services to patients, in order that patient care is of the highest quality and also cost effective” [20].

The definition is described in a handbook, which includes the following information: Introduction (chapter 1); European definitions 2002 (chapter 2, I–II), defining both the discipline of general practice/family medicine and professional tasks, and describing the core competencies required of general practitioners (III); explanatory notes (chapters 3 and 4); academic review and analysis (chapters 5 and 6); and appendices.

While the current 2002 definition of general practice/family medicine does not make specific reference to promoting patient empowerment or self-management education, a review of the characteristics of practice shows that they directly or indirectly relate to these concepts. For example, the definition supports a patient-centred, longitudinal approach, including self-management education and collaborative care, all consistent with patient empowerment.

In negotiating management plans with their patients they [general practitioners] integrate physical, psychological, social, cultural, and existential factors, utilising the knowledge and trust engendered by repeated contacts. (ref. 19, chapter 2, part II)

It is as important to understand how the patient copes with and views their illness as dealing with the disease process itself. (ref. 19, chapter 3)

A more explicit reference in chapter 5 calls for family doctors to assist patients in the self-management of their medical conditions:

An area of increasing importance over recent years has been the concept of patient autonomy and with it the role of the family doctor in developing the expertise of patients in managing their own illness, and contributing to this management by changing behaviour. This is likely to become increasingly important as patients become better informed due to the wide variety of information systems now becoming available to them, for example the internet.

Further evidence supporting the inclusion of empowerment and self-management in the definition can be found in documents or reference papers written to describe or implement the WONCA practice definition. The Royal College of General Practitioners suggests that it is a requirement of general practice that doctors be skilled in assessment and problem solving, and that it is the doctor's responsibility to collaborate with the patient in order to develop a care plan, and to prepare the patient to respond to risks [21]. “To selectively gather and interpret information from history-taking, physical examination, and investigations and apply it to an appropriate management plan in collaboration with the patient” requires among others a “[…] willingness to involve the patient in the management plan”. Providing a comprehensive approach with “adequate handling of risk factors by promoting self-care and empowering patients is an important task of the general practitioner”.

Discussion concerning self-management of chronic conditions

The patient is, in fact, the true manager of his or her wellbeing. With certain exceptions, in which the patient is completely dependent upon others, it is the patient who makes decisions about lifestyle, taking medicine, and physical activity, blending information from outside sources with personal culture, expectations, wishes, and attitude. While the range of decisions to be made by patients with acute illness is limited (following doctor's instructions, taking medication, etc.) and occurs for a limited time, decisions for patients with chronic disease affect their whole existence and last a lifetime. Ultimately, the question is not whether patients will manage their diseases, but how they will manage. Doctors in family medicine are in a strategic position to help patients increase their power and confidence in managing their chronic condition.

As Freire points out: “when a patient understands his illness, he acts in accordance with what he understood. The kind of actions the patient takes will correspond to the level of his comprehension. If his comprehension is critical or predominantly critical then his actions will also be critical, aware.”

The health and wellbeing of a patient depend on the patient's ability to take action. Advice from others, prescriptions, and medical consultations are only an influence, albeit an important one, on the patient's behaviour. Patient empowerment and self-management are effective methodologies for coping with chronic diseases and allowing patients to assume a critical conscientiousness about their health problems.

While the current WONCA definition does not include empowerment as a fundamental characteristic of general practice and family medicine, the current 11 characteristics are consistent with the goals of an empowerment approach. Analysis of family medicine and the basic conditions for developing patient empowerment and self-management clearly shows that promoting empowerment and self-management should be incorporated into the general practice setting.

Table II illustrates how each of the 11 characteristics of general practice/family medicine in the European definition includes aspects of patient empowerment and self-management. In the left column, the characteristics are listed and described. In the right column, the benefits of empowerment and self-management are listed to correspond to the current WONCA definition.

Table II.  Incorporating empowerment into the definition of general practice/family medicine.

Characteristics of general practice/family medicine (WONCA 2002)	Evidence/benefits of patient empowerment and self-management education
a. Is normally the point of first contact within the healthcare system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex, or any other characteristic of the person concerned	- Patients have a point of reference for health problems, a “medical home”-Patients are more comfortable and proactive about contacting their doctor [11]
b. Makes efficient use of healthcare resources through coordinating care, working with other professionals in the primary care setting, and by managing the interface with other specialities taking an advocacy role for the patient when needed	- Patients are actively involved in coordinated care, taking part as team members regarding their own care [10], [14]-Patient/provider partnership allows for better assessment, more appropriate referrals
c. Develops a person-centred approach, orientated to the individual, his or her family, and their community	- Patients are viewed as experts on the impact of their illness has on their life, their family, and their situation [12]-Patient-centred education addresses individual needs [13]
d. Has a unique consultation process, which establishes a relationship over time, through effective communication between doctor and patient	- Enhanced communication through consistent, ongoing care relationship [9]-Partnership offers the opportunity for patients to become active in managing their health [17]
e. Is responsible for the provision of longitudinal continuity of care as determined by needs of the patient	- Provision of care is based on the specific needs of the patients [16]-Care is ongoing, individualized, and responsive to specific needs over the entire course of the illness
f. Has a specific decision-making process determined by the prevalence and incidence of illness in the community	- Patients are more aware of opportunities to participate in decision making with their doctors [12]
g. Manages simultaneously both acute and chronic health problems of individual patients	- Comprehensive approach and good management of chronic conditions requires attention to any acute healthcare problem [17]
h. Manages illness which presents in an undifferentiated way at an early stage in its development, which may require urgent intervention	- As a philosophy of care, empowerment offers patients support for coping with all aspects of their health-Empowerment can be applied at the earliest stage of a disease and be incorporated into primary, secondary, and tertiary prevention practices [12]
i. Promotes health and wellbeing both by appropriate and effective intervention	-Patients are able to participate in care planning because they have awareness of the disease and treatment options (effectiveness and appropriateness)-Patients are aware of the rationale, timing and expected results of treatment choices based on evidence-based guidelines [2]
j. Has a specific responsibility for health of the community	- Applicable to individuals, groups, and communities [8]
k. Deals with health problems in their physical, psychological, social, cultural, and existential dimensions	- A holistic approach empowering patients to recognize three key components involved in living with a chronic condition—medical, behavioural, and emotional management [12]

Furthermore, family medicine, because of its widespread presence, can ensure the generalization of empowerment promotion and self-management education to the totality of patients and communities, according to the principle of equity of the European national health systems.

Conclusion

If we consider the empowerment and self-management education of patients as essential for managing disease—particularly chronic diseases—it will be necessary for general practice and family medicine to include these as basic characteristics of the discipline. Only when included will the discipline be able to ensure that the vision of empowerment is supported and applied with educational content, research, evidence-based and clinical activity, and a clinical speciality orientated to primary care. As the concept of empowerment is applied, patient education efforts will expand to include the goal of patient self-management, requiring that patients play a more active role in collaboration with their doctors.

A recent UK Department of Health publication, a White Paper addressing community services, highlights the need for “a strong emphasis on patient education and empowerment, so that people are fully informed about their condition and are better able to manage it”, and calls for professional education to support patient empowerment and self-care: “We will take action at each stage of the professional education and regulatory process to change the underlying culture profoundly and encourage support for individuals’ empowerment and self-care” [22].

We think that these suggestions are well grounded not only for the UK National Health Service but also for all European health systems, and we therefore recommend that the following changes be proposed as additions to the current WONCA Europe Definition of General Practice/Family Medicine:

1. Include as 12th characteristic of the discipline in chapter 2, paragraph I, after point e): “e bis) promotes patient empowerment and self-management”; or add to the conclusion of definition I, after characteristic k), the following statement: “The general practice and family medicine setting is the most suitable setting for promoting the goals of patient empowerment and self-management.”

2. Regarding the specialty of general practice/family medicine (II), the statement should be changed to read: “In negotiating management plans with their patients, they integrate physical, psychological, social, cultural, and existential factors, utilising the knowledge and trust engendered by repeated contacts”, adding at the end “[…] in order to promote patient empowerment and self-management”.

3. Regarding the core competencies outlined for the general practitioner/family doctor (III), point 2 could also refer to the characteristic e bis).

Applying Freire's theory, replacing the “banking approach” with the “problem-posing” approach towards patient education could be the core of a dynamic relationship between GP and patient, shifting the goal from compliance to patient empowerment.

Acknowledgements

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.