Until the late 1950s, the medico-centric perspective dominated the patient-physician relationship. The physician had authority and was solely responsible for decisions about diagnosis and treatment. Especially in medical-specialist consultations, patient education only consisted of disease-related information, often in incomprehensible medical language and treatment-related instructions. Patients were not expected to participate actively in diagnosis and treatment decisions, and their ideas, beliefs, and values were not taken very seriously.

In his book The Doctor, His Patient and the Illness, Michael Balint was one of the first to stress the importance of good patient-physician communication [3]. He stated that the physician himself was the most used medicine in general practice, and that despite our lack of knowledge about the effects of reassurance and advising, both are probably the most frequently used types of medical treatment. He asked for recognition of the emotional as well as the physical aspects of a patient’s complaint and was probably the first to advocate the skills of attentive listening to patients. Balint’s ideas inspired many general practitioners, especially in their approach to patients with medically unexplained complaints. However, these ideas mainly focused on the diagnosis of physical complaints, and patient education was still not really part of the picture. Although the study of patient adherence dates back to the 1940s, and the terms “compliance” and “adherence” were first used in 1966 [4], in specialist-medicine consultations less than 5 % of consultation time was used for patient education [5].

In the 1970s and 1980s, the patient-physician relationship changed dramatically due to several developments. First, in the late 1960s and early 1970s, 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 1970s and early 1980s, 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 community-based healthcare.

Second, medico-technical developments complicated treatment decisions. Diagnostic and treatment options expanded rapidly. For several diseases, equivalent treatments became available, 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 1970s due to the rise of behavioral and lifestyle-related diseases. The 1974 Lalonde report 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 [6]. 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 1980s, 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 [7]. 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 [8–10]. Thus, patient education became an inseparable part of patient-centeredness, and physicians were supposed to promote patient participation and shared decision-making [11]. However, only general practitioners embraced these ideas, and the research on patient-physician communication that blossomed in the early 1990s mainly involved primary-care consultations. In primary care, which is by definition 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 [12–14].

In the 1990s, patient education became more and more a natural part of primary-care consultations. This development was supported by legislation, on the one hand, and media attention, on the other. In most Western countries, patients’ rights were firmly anchored in health laws [15], and the media paid ample attention to health and the healthcare system. Numerous programs were broadcasted about health problems and the healthcare system, varying from educational programs about coping with illness, medical procedures, and the work of physicians to entertainment programs about patients’ experiences and physicians’ misconduct. Thus, the general public became more aware of their rights and became more critical about the care they received, which forced physicians to be more transparent about their work and achievements. Medical specialists, especially in oncology, also became more aware of the importance of patient education for secondary prevention and improvement in quality of life [16]. Medico-technical innovations played a role too. Patients were confronted with more complex and specialized procedures, patients faced more healthcare choices that were consequential, and patients with chronic conditions had to adhere to complex drug and lifestyle recommendations in order to achieve prolonged quality of life. Furthermore, patient-education research became a grown-up discipline with national and international research platforms, journals, and congresses [17].

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 [18–20]. 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 place greater demands on accessibility, service, and outcomes [21]. Just as in the 1980s, 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. For instance, the Dutch National Board of Public Health published a memorandum in which patient participation was strongly advocated, the training in patient education of healthcare professionals and especially of physicians was emphasized, and professional organizations were obliged to include patient-education competences in their registration prerequisites [22].

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 [8, 23–27]. The evidence about the effects of patient-centered communication on patient outcomes has also remained limited [9, 27–29]. 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 [29–32]. Some models elucidate the prerequisites and processes that determine the outcomes of patient-education activities [29, 33, 34]. 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 [35–41]. 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 [42, 43]. 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 [44–49].

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 [50, 51]. This lack of interest may be attributable to several factors. First, patient education in medical specialist consultations is not rewarded financially or otherwise. The financial reimbursement of medical practice is usually based on the performance of diagnostic procedures and medical treatments and not on the time invested in individual patients. Time constraints and the medical problem-solving culture even discourage patient-education efforts. Especially for healthcare workers who adhere to the BPS model, this financial and cultural system works out badly since they often use time-consuming patient-education methods such as counseling and refrain from medical procedures that are more harmful than beneficial for the patient at hand. 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.

Until the early 1970s, the Flexner Report was what shaped undergraduate medical education [52]. Basic and clinical sciences were separated. Basic sciences, such as anatomy, physiology, histology, and biochemistry, were dealt with in the initial years, while clinical sciences, such as pathology, pharmacology, and surgery, were covered in later years. The distinctive medical specialties and their related knowledge and skills, such as history-taking and physical examinations, were addressed just before students began their internships. Lectures were the dominant teaching method, and examinations focused on knowledge reproduction. Sometimes the curriculum contained lectures about psychology with patient-physician communication as one of the topics. However, the teaching of communication skills was not embedded in the curricula [53], and most medical students graduated without ever interviewing a patient under direct supervision [53].

In the 1970s, some medical schools such as the McMaster University in Hamilton, Canada, and the Maastricht University in the Netherlands, developed a problem-based curriculum with small-group tutoring and skills training. Communication skills training (CST), including small-group sessions with videoed demonstrations, role-play exercises, feedback, and reflection, acquired a fixed place in these curricula [54, 55]. However, CST programs have traditionally concentrated on the first, diagnostic half of the consultation. Patient-education issues were less often addressed [56–61].

Several factors promoted this attention to the diagnostic part. First, the curricula still suffered from the historically developed imbalance, reflected in clinical practice, between the teaching of “diagnosis” and “problem management” [62]. Second, medical education adopted much of the social sciences curricula, which already contained social-skills programs, based on the ideas of Carl Rogers [63] and Allen Ivey [64], with much attention paid to listening skills and, to a lesser extent, to the skills of conversational control. Third, the CST programs prepared students for their main task during their internships, which is questioning patients about their complaints and health status. Interns were not supposed to educate patients. Thus, students were not taught patient-education skills with one curious exception: breaking bad news. Although breaking bad news is regarded as one of the most challenging consultations, many CST programs contained one or two small-group sessions with role-play exercises in breaking bad news, while students still lacked basic patient-education knowledge and skills [61].

The problem-based curricula and CST programs also required new assessment procedures and instruments. In addition to knowledge assessment, skills assessment was needed. The Objective Structured Clinical Examination (OSCE) was developed in order to reliably assess clinical skills in standardized conditions [65]. For the teaching and assessment of communication skills, several guidelines and accompanying assessment instruments were developed [66, 67]. Nearly all guidelines and assessment instruments were based on the concept of patient-centeredness and used checklists or rating scales featuring required communication behaviors, ordered according to the different phases of a consultation. The instruments differed in their empirical validation. However, these instruments lacked a theoretical basis that would have clarified the shifting consultation goals and the physician’s tasks along with matching the communication skills to attain these goals nor did they predict clinical outcomes [27, 31, 68].

Although most instruments contained items concerning patient-education issues, such as explaining and shared decision-making, patient-education skills were hardly assessed in undergraduate OSCEs, since communication skills training and assessment of students focused on history-taking.

In the late 1970s, communication skills training also became part of general-practice vocational training [69–72]. At first, the main educational approach consisted of reflection on real patient encounters. Since the 1990s, in several Western countries, patient-physician communication issues have been addressed in primary care and general-practice vocational training by means of assessment of and feedback on videoed consultations with real patients [69, 71, 73–77]. Also starting in the 1990s, communication workshops and courses were offered to medical specialist residents and consultants especially in the field of oncology. These elective courses mainly concerned exploring patients’ concerns and breaking bad news, using didactics, demonstrations, role-play with feedback, and reflection as teaching methods [78, 79]. Some workshops for consultants even focused on the teaching of communication skills to students and residents [80–82]. Other workshops focused attention on the use of learned skills in clinical practice [83]. However, assessment of communication performance in clinical practice was lacking [84]. In the Netherlands, elective courses and workshops for consultants were offered [85]. Several initiatives used videoed outpatient consultations for assessment and feedback [14, 86]. In some Western countries, elective communication courses were offered in residency training [87, 88], and in the late 1990s, compulsory courses were incorporated in the training of Dutch residents in obstetrics and gynecology and in surgery [89, 90]. These courses addressed challenging patient-education issues such as breaking bad news and dealing with conflict, nonadherence, and complaints. However, the effects of these courses on residents’ communication behavior in clinical practice were not investigated.

Recently, in a Dutch study, a small but significant improvement of the patient-education competency of residents was found due to a workplace-based training program using videoed outpatient consultations for assessment and feedback [91]. In Switzerland, a compulsory psychosomatic training for residents in obstetrics and gynecology consisting of small-group case discussions demonstrated an increase in self-reported psychosomatic competences. However, whether the residents also improved their patient-education skills in clinical practice was not examined [92].

At the turn of the century, medical education, inspired by a renewed emphasis on the essential abilities that physicians need for optimal patient outcomes and on preparing students for clinical practice, switched from problem-based learning to an outcomes-based or competency-based approach. The CanMEDS competency framework, which was developed in the 1990s, is probably the best-known example of this approach [1]. Nowadays, all Dutch medical-specialist curricula are based on this competency framework [93]. The CanMEDS framework comprises numerous competences organized thematically around 7 “meta-competences” or roles that a physician should master. At the heart of the framework lies the physician’s role as a medical expert, complemented by six generic roles such as communicator, collaborator, and manager. As medical experts, physicians integrate all areas of expertise defined by the CanMEDS framework. Thus, expertise that is defined as the superior and stable ability to handle challenging situations [94] is the benchmark for the assessment of physicians’ ability to handle clinical situations. Challenging patient-education issues that are mentioned in the CanMEDS framework are obtaining informed consent; delivering bad news; addressing anger, confusion, and misunderstanding; and dealing with nonadherence.

The introduction of the CanMEDS framework in undergraduate and postgraduate curricula influenced the teaching of communication skills in several ways. First, since the key competences of the communicator role explicitly refer to patient-education competences, the teaching of patient-education skills was gradually implemented in undergraduate curricula [95, 96] and in postgraduate courses [97]. However, during their internships, students still focus their attention on history-taking and time management and are still not supposed to educate their patients [98]. Second, the concept of patient-centeredness was criticized and regarded as being unsuitable as a leading concept for communication programs [27, 30]. Today, a functional approach is advocated, in which the physicians’ communication tasks and matching skills are derived from the goals and desired outcomes of the consultation [29–31, 99]. Third, workplace-based learning came into focus. Workplace-based learning means that students and residents improve their competences by applying their knowledge and practicing their skills in supervised clinical situations followed by constructive feedback and reflection. New assessment methods matching workplace-based learning were also developed, such as the mini-clinical evaluation exercise (mini-CEX), the direct observation of procedural skills (DOPS), and multisource feedback [100, 101]. All the assessments, feedbacks, and reflections that a learner has collected are documented in the learner’s portfolio. As mentioned previously, communication assessment and feedback based on videoed consultations already existed in primary care and general-practice vocational training. In undergraduate education, several initiatives have since been developed using videoed consultations for self-assessment, feedback, and reflection [102]. One program used videoed consultations for communication assessment and feedback in medical specialist training [91].