3A.02 70's-80's

In the 1970s and 1980s, the patient-physician relationship changed dramatically due to several developments. First, in the late sixties and early seventies many protest movements and emancipatory organizations struggled for equality on various terrains. Patients' rights advocates and organizations were established including patient self-help groups and self-care movements. Patients claimed their place as active participants in the consultation, and fought for self-determination and legal rights. These social changes eventually resulted in legislation concerning the provision of information, informed consent, privacy protection, and the right to complain about the care received. Furthermore, in the late seventies and early eighties socially active general practitioners founded healthcare centers and addressed not only psychosocial issues but also health-determining societal conditions and inequalities. They regarded patient education as an important means of engaging their patients in illness prevention, improvement of living conditions, and communitybased healthcare. One of the Dutch left-wing political parties stems from such a politically-engaged healthcare center. Second, medico-technical developments complicated treatment decisions. Diagnostic and treatment options expanded rapidly. For several diseases, equivalent treatments became available, and other diseases that were untreatable before or lethal in the short term became chronic conditions, and patients' life spans could be prolonged 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 1974 Lalonde rapport acknowledged for the first time that not only biomedical aspects are important in defining health, but that also citizens in general and patients in particular could improve their health through behavioral factors related to their lifestyle [18]. At first, health-promotion activities mainly used knowledge transfer as the influencing technique, but gradually other behavior modification techniques, originating in 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 healthcare costs increased substantially in the eighties, and the economic climate led to the call for reductions in governmental costs. All these developments forced physicians to pay more attention to patient-centered communication and patient education in their consultations. The concept of patient-centered communication originated from the power-shift model in which the patient-centered exchange of information opposes the doctor-centered exchange of information, especially in the diagnostic phase of a consultation [19]. Gradually, the concept of patient-centeredness 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 [20-22]. Thus, patient education became an inseparable part of patient-centeredness and physicians were supposed to promote patient participation and shared decision-making [23]. However, only general practitioners embraced these ideas and the research on patient-physician communication that blossomed in the early nineties mainly involved primary-care consultations. In primary care, which by definition is 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 [24-26].