3A.04 21th Century
In the first decade of this century, electronic information supply by the internet became commonplace, and patients with internet access now collect health information away from the traditional patient-physician encounter [31-33]. Furthermore, health and health-related subjects are nowadays a dominant topic in the societal discourse, with ample attention paid to subjects related to healthy lifestyles, such as healthy food, losing weight, and physical exercise. These societal developments revived the ideas from the 1980s about patient participation and self-management. However, patients are now better-informed healthcare consumers, which places greater demands on accessibility, service, and outcomes [34]. Just as in the eighties, idealistic motives as well as politico-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 afore mentioned memorandum of the Dutch National Board of Public Health, in which patient participation is strongly advocated, the training in patient education of healthcare professionals and especially of physicians, is emphasized, and professional organizations are obliged to include patient education competencies in their registration prerequisites [3]. From the 1990s up until the present, the concept of patient-centeredness has dominated the research of physicians' patient-education behavior and outcomes. However, patient-centeredness has turned out to be a complex and elusive concept, which does not come with a sound theoretical framework from which the patient-education objectives of a consultation and the matching communication tasks of the physician can be derived [14,35-38]. The evidence about the effects of patient-centered communication on patient outcomes has also remained limited [14,21,39,40]. As a consequence, functional models of patient education have emerged, which clarify the relationships between physicians' patient education goals and communicative behaviors, on the one hand, and patients' responses and outcomes, on the other [40-43]. Some models elucidate the prerequisites and processes that determine the outcomes of patient-education activities [40,44,45]. Patient-education elements, such as fostering the relationship, listening to patients' wishes and concerns, proper explaining, and involving the patient in treatment decisions, have had unmistakably positive effects on patient satisfaction, comprehension, recall, and adherence [4,6,16,46-51]. However, the effects of enhancing patient participation and shared-decision making in medical consultations on intermediate outcomes, such as adherence to regimes and self-management, and on health outcomes are less convincing [52,53]. On the other hand, more advanced patient-education methods, which directly aim to improve health decisions and health behavior, such as facilitating regime adherence, risk communication, usage of decision aids, and motivational interviewing have been quite successful [54-59]. Despite the call for more attention to patient education in clinical practice and in medical-specialist training, patient education is still undervalued in medical-specialist consultations [10,60]. This lack of interest may be attributable 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 healthcare providers, such as specialized nurses, nurse practitioners, dietitians, physiotherapists, and psychologists, discharging medical specialists from their patient-education duties. Thus, medical specialists are neither encouraged nor compelled to demonstrate excellent patient education.