Person-Centred Health Care : Balancing the Welfare of Clinicians and Patients by Stephen Buetow

Discussions of health care policy and implementation often focus on tripartite factors of access, cost, and quality of care, in many cases with an aim of finding balance among these factors (Thompson, 2013). Not surprisingly, these discussions are often centered on tremendously broad systems-level considerations to the exclusion of more focused topics such as the behavior of health care providers and patients and the interactive aspects of caring processes. These behavioral and relational aspects of health care are crucial, though, and may have a substantive effect on the quality of care provided. Indeed, they constitute the lived experiences of both patients and health care providers and, thus, shape both our understanding of health care and our personal narratives about how well health care is working.

Stephen Buetow's treatment of the interactions between patients and health care providers focuses intently on those micro-level aspects of care with purposeful attention to the consideration of both those receiving care and those providing it.At the center of this discussion is the idea that both patients and caregivers are worthy of consideration as individuals, and that the cognizance of individual values, knowledge, and others will have a substantive effect on improving health care on a broader scale.Buetow divides the book into two sections, with the first outlining the case for a necessary shift in the ways in which we view both health care providers and patients, and the second suggesting fundamental changes to how we think about values in health care and implementing concrete recommendations for "person-centred" care.
In Chapter 1, Buetow provides an introduction to concepts of personhood in health care by describing a case of his own medical care in which he felt that clinicians were treating a condition rather than a whole person.Buetow notes that "[r]eports like mine -of patients feeling dehumanized and a burden -are ubiquitous in health care" (p. 1).The standardization of health care process and reduction of the caring process to a routinized activity are at odds with the fundamental nature of health care as focused on individuals.Despite persistent calls for patient-centered care, Buetow notes that the process "… reflects a pervasive cultural malaise: the 'depersonalization' of patients and clinicians, in its de-humanizing and de-individuating senses" (p.3).
Chapter 2 discusses health care processes from the perspectives of clinicians.This includes what has become our standard perspective of viewing patient care activities in health care -one in which the clinician's care for the patient and the perspectives of the caregiver are brought to the fore -but also the difficulties of the standardization and commodification of health care.Buetow provides a substantive overview of the historical and educational roots of the perspectives of health care professionals as they engage in caring processes, and highlights the concept of the patient-centered perspective as "… an ideal that expects modern clinicians to focus attention on, and care for, patients rather than themselves" (p.19).This chapter also outlines both a principle-based view of clinicians, emphasizing patient welfare, patient autonomy, and social justice (p.22), while also presenting a number of challenges facing this patient-centered view of the clinician-patient experience.
Chapters 3 and 4 both emphasize the need for "self-care" on the part of both clinicians and patients.Chapter 3 discusses the emergence of patient self-care and societal changes in which "patients have increased health consciousness, autonomy, and independence" (p.45).These change emerged both from cultural shifts -increased societal appreciation for health-improving activities -and also from the impact of the health care market and considerations of individual responsibility and cost.This patient self-care, according to Buetow, must acknowledge the interrelationships among individual capabilities and health-related knowledge, patient values, and the potential for dissonance between an individual's self-caring activities and the impact of those activities on their feelings of being healthy.
Chapter 4 extends this discussion of self-care to health care providers, something that is often ignored given that the "… bright light of patient-centred care casts a vast shadow over clinician welfare" (p.61).Buetow highlights the sometimes extreme stressors at work in a health care setting, including increased patient loads and working hours, occupational hazards, patient criticism, and challenges to health care provider authority and expertise produced by increased patient access to health information, all potentially contributing to provider burnout and feelings of dissatisfaction.Health care providers' responses to the challenges vary and include coping methods such as increasing self-identification with the caring process, adopting a relentlessly positive attitude toward their profession, focusing on individual development, and attempting to strike a genuine work-life balance.Other coping mechanisms are less positive such as attempting to maximize profit through extended working hours or avoiding pressures or conflict.Important here is this continued theme of the importance of recognizing the personhood of clinicians, their understanding of the work context and their roles and the ways in which their values and knowledge shape that understanding.
Chapter 5 continues this theme, introducing a rather unique perspective of the caring process, focusing on the patient's care of the clinician.Beutow posits that all individuals need care, including those who are enacting a role of the professional caregiver in a work setting.Clinicians, "[t]hrough self-abnegation, … forego the kindness that, as human beings and vulnerable clinicians, they need" (p.81).These health care providers shun feelings of individual need while engaged in the health care process both given the professional emphasis on this as a value and to create detachment from patients.Changing this, as Buetow notes, requires a shift in the roles of both patient and clinicians and in the feelings and values related to each; patients must be open to considering how they can engage in caring and health care providers must be open to patient expressions of care and gratitude.For clinicians, this may be the most professionally and culturally challenging aspect of this book.
Chapters 6 and 7 provide additional depth for Buetow's central argument that a shift from "patient-centred" to "person-centred" health care is important, and that individuals involved in caring processes must embrace necessary changes in values related to this change.Chapter 6 provides Buetow's conceptualization of personhood and relationships that recognize this personhood, as well as personalized medicine and more comprehensive humanistic models of human caring.Perhaps most importantly, Buteow suggests that those involved in health careand those studying these professions -must recognize concepts of personhood and the need for a shift to person-centered care as an explicit part of what they do.Chapter 7 outlines the necessary values and virtues that go along with this shift.Buetow notes that "[k]ey virtues include justice and caring -in order to respect through joyful, reciprocated caring the value of the moral equality of all persons -in good faith and inter dependently" (p.137).This moral equality is enacted through mutual trust and reciprocal caring and attention to individual authenticity in enacting roles.
Finally, Chapter 8 provides a practically focused discussion of how implementing personcentered care would work.Buetow's treatment of the necessary changes to individuals and systems here is comprehensive, and includes individual moral development from childhood, changes to medical education, improved understanding of character, and an improved understanding of how new technologies have an impact on these in a health care setting.Implementing person-centered care, then, "… requires producing social conditions conductive to clinicians and patients developing and exercising virtues and good character" (p.161).
Buetow's treatment of the concept of person-centered care is conceptually well developed, engaging, and highlights a necessarily personalized view of health care.Losing sight of the people-centered nature of these services does a disservice to both patients and clinicians.The individual, relational, and cultural changes necessary to support this shift are, however, truly impressive and are likely to be overshadowed by broader systems-level discussions that are more concrete and less ethereal.These difficulties, though, should not dissuade patients or clinicians from engaging in activities that might support an enhanced view of personhood in health care.The impacts of these efforts are likely to be felt and appreciated.

Disclosure Statement
The author declares there are no conflicts of interest that relate to the research, authorship, or publication of this article.