Health care professionals should listen more to their patients. Symptoms and signs in person centred care. Article and researcher in focus: Sara Wallström

Article: Person-centred care in clinical assessment. Link to the article.

Researcher: Sara Wallström

Appointment: Postdoctoral Researcher (a temporary appointment after the completion of doctoral studies).

Age: 35

Which personal resources do you use in your research? I am very organised, and I have an ability to see both the “big picture” and pay attention to detail. Thus, it is quite easy for me to monitor a project from a holistic perspective, and to see if there is a logical continuity at the same time as I am good at keeping an eye on the details. For instance, I am good at editing and reviewing. However, this is not that advantageous for me as I find it quite boring!

In this article, you are contending that the significance of symptoms in health care has to be emphasised and that there is a need to differentiate between symptoms and signs. Could you tell me more about this? We do indeed. Because of the scientific development, symptoms, i.e. self-reported illness such as pain and anxiety have become secondary. They are considered less credible. Signs, that are measurable by someone externally, for example biochemical markers, elevated blood pressure or ECG changes, are considered more important and more trustworthy. Since we are able to measure more and more, the meaning of the narrative and the person’s own illness experience has become secondary. If measurable signs are found in a person, he/she is considered unwell, but if no such signs are found, there is nothing wrong. However, methods exist for measuring symptoms. A patient may for example self-rate his/her symptoms on a scale from one to ten. The scientific development has been a great thing, but now that we have so much to measure, we have forgotten to listen to the patient.

Sometimes, symptoms and signs are lumped together and called just symptoms. However, our aim is to show that there is a difference between the two and thereby to highlight this situation. There is actually a hierarchy. Signs are considered objective whilst symptoms are subjective and this is something we want to challenge. Measured signs are assessed by someone, and filtered through his/her perceptions, for example abdominal palpation. The same thing goes for thresholds for biochemical markers. Someone has set those thresholds and they are changed every now and then. Even an ECG is the subject of interpretation. What we want to emphasize is that these signs are measurable but not always objective.

The hierarchy between symptoms and signs also has to do with signs traditionally belonging to the field of medicine, i.e. the physician’s domain, whilst symptoms have been part of the nurses’ domain. Nurses are the authors of many scientific studies focusing on symptoms.

So even in person centred care, the patients’ self-reported symptoms are being overlooked? Yes, and that was part of the reason for writing this article. In person-centred care, the narrative is central for planning the care. Also in this context, symptoms have become secondary since we have mostly focused on goals and resources. We must never forget listening to the person with the illness and his/her experience of this.

Further, there is actually a very poor connection between perceived illness and measured signs. A patient may have severe measurable pathological changes but may still not perceive the situation as bothersome or vice versa. Research is clearly showing that self-reported symptoms or self-perceived illness can predict both mortality and re-admission in a credible way. The consequences of the symptoms are therefore measurable.

This article is theoretical, not empirical. What does that mean? It means that it is not based on any collected data; it is rather based on a theoretical framework retrieved from existing literature about signs and symptoms, and how these may be connected. At GPCC, we write few theoretical articles, but they are important for the development of the theoretical framework that person-centred care should be based on when we are conducting empirical studies. An empirical study is for example a randomised controlled study in a clinical setting, where we can test the effects of for instance person-centred care in comparison with “conventional” care.

What are you currently working on? I don’t have a typical Postdoc appointment, which would normally entail working with a defined project, or working abroad. Instead I am involved in several different projects. My tasks are very varied and this is partly because I am still writing empirical articles based on the data from my time as a PhD student. Partly also because I am involved in a couple of randomised studies within GPCC, mainly PROTECT (web-based support for patients with COPD/heart failure in primary care), but also PROMISE (a similar web-based support, but for patients with burnout syndrome).

I also spend a lot of time writing applications to various research funding agencies. This summer I went to Almedalen week*, where I participated in a seminar organised by Novartis. I presented my research and how care should be organised for COPD and heart failure patients. For the past two years, I have also analysed data from the national SOM-surveys**. The results are clearly showing that the Swedish population wants more person-centred care.

* Almedalen week (also known as Politician's Week) is an annual event taking place every summer in and around Almedalen, a park in the city of Visby on the Swedish island Gotland. With speeches, seminars and other political activities, it is considered to be the most important forum in Swedish politics. During the week, representatives from the major political parties in Sweden take turns to make speeches in Almedalen. (Read more about Almedalen week on Wikipedia by clicking here.)

** National SOM-surveys The SOM Institute has conducted surveys to collect research data and presented annual trend analyses on public opinion and media habits in Sweden since 1986. The Institute's analyses are often referred to in the public debate in Sweden and are used to form many important decisions influencing Swedish society. (Read more about the SOM-surveys by clicking here.)