Bridging the gap.: The separate worlds of evidence-based medicine and patient-centered medicine

https://doi.org/10.1016/S0738-3991(99)00087-7Get rights and content

Abstract

Modern medical care is influenced by two paradigms: ‘evidence-based medicine’ and ‘patient-centered medicine’. In the last decade, both paradigms rapidly gained in popularity and are now both supposed to affect the process of clinical decision making during the daily practice of physicians. However, careful analysis shows that they focus on different aspects of medical care and have, in fact, little in common. Evidence-based medicine is a rather young concept that entered the scientific literature in the early 1990s. It has basically a positivistic, biomedical perspective. Its focus is on offering clinicians the best available evidence about the most adequate treatment for their patients, considering medicine merely as a cognitive-rational enterprise. In this approach the uniqueness of patients, their individual needs and preferences, and their emotional status are easily neglected as relevant factors in decision-making. Patient-centered medicine, although not a new phenomenon, has recently attracted renewed attention. It has basically a humanistic, biopsychosocial perspective, combining ethical values on ‘the ideal physician’, with psychotherapeutic theories on facilitating patients’ disclosure of real worries, and negotiation theories on decision making. It puts a strong focus on patient participation in clinical decision making by taking into account the patients’ perspective, and tuning medical care to the patients’ needs and preferences. However, in this approach the ideological base is better developed than its evidence base. In modern medicine both paradigms are highly relevant, but yet seem to belong to different worlds. The challenge for the near future is to bring these separate worlds together. The aim of this paper is to give an impulse to this integration. Developments within both paradigms can benefit from interchanging ideas and principles from which eventually medical care will benefit. In this process a key role is foreseen for communication and communication research.

Introduction

Modern medicine is dominated by two general beliefs or paradigms: one is called ‘evidence-based medicine’; the other is called ‘patient-centered medicine’. Both concepts are generally accepted as ‘good’, ‘valuable’, and something to strive for. Few people will deny the relevance of either of them. But two serious questions can be raised. How patient-centered is evidence-based medicine? And, how evidence-based is patient-centered medicine? Close inspection of the literature reveals that evidence-based medicine and patient-centered medicine seem to belong to separate worlds. Bridging the gap is a major challenge for all who want to protect the humane face of medicine in the next millennium. In this article, it will be argued that doctor–patient communication plays a key-role in bridging the gap between evidence-based medicine and patient-centered medicine.

Section snippets

The separate worlds of evidence-based medicine and patient-centered medicine

The terms ‘evidence-based medicine’ and ‘patient-centered medicine’ are seldom used by the same authors. A recent search in Medline on ‘evidence-based medicine’ showed 1023 hits, all from the last 5 years; the first emerging in 1992, with a sharp increase to nearly 600 in 1997. A similar search on ‘patient-centered medicine’ got 317 hits; showing a steady but modest stream from 1970 onwards with an increase since 1993, which parallels but does not equal the rise of evidence-based medicine in

How patient-centered is evidence-based medicine?

Evidence-based medicine owes its rapidly growing popularity to its image of providing the ideal integration of individual clinical expertise and external scientific evidence, offering clinicians the best available evidence about the most adequate treatment for their patients [1]. At first glance, that sounds rather patient-centered, and yet it is not. There are two reasons for it.

The first reason is that evidence-based medicine is disease-oriented, and not patient-oriented [2]. Evidence-based

Strengthening the patient-centeredness of evidence-based medicine

Evidence-based medicine is not a byword for patient-centered medicine. Physicians know that. Glass wrote in a recent editorial in the Journal of the American Medical Association that physicians should use the best sources science has to offer to their patients, but never in a way that neglects important psychosocial issues or the uniqueness of each patient as a person [10]. Kassirer wrote in the New England Journal of Medicine: ‘as our medical decisions become more and more codified, we should

How evidence-based is patient-centered medicine?

Now we have seen that the world of evidence-based medicine does not correspond with the principles of patient-centered medicine, the question arises how both worlds do compare when faced from the opposite direction. That is where the second critical question enters the picture, which is the mirror of the previous question: ‘How evidence-based is patient-centered medicine?’.

The very first thing that comes into mind when reflecting about the concept of patient-centered medicine is that it is at

Grounding the concept of patient-centeredness

Preparing patient-centeredness for empirical research means that the concept has to be clarified. An illuminating way of doing this is by contrasting the concept with its opposite. With patient-centered medicine this can be done in at least two ways.

The first is to place ‘patient-centered’ opposite to ‘disease-centered’, as for instance Moira Stewart has done in her groundbreaking work [14]. By making this contrast, it is emphasized that the patient is more than his or her disease, and as

Strengthening the evidence-base of patient-centered medicine

Now that we have made clear that patients are different in what they want to discuss in the consultation, and also in the part they want to take in decision making, it is also evident that the best way to know the patients’ agenda is still, and will perhaps always be, listening to the patients’ story and seeking the right balance in the decision making process. At this moment we do not have the knowledge, or the evidence or even a comprehensive theoretical framework to know beforehand and in

Conclusion

Evidence-based medicine and patient-centered medicine are two prevailing paradigms that both deserve our full attention. It has been shown that both worlds have little in common whereas the challenge for the near future is for integration of these paradigms. In our view, this means, that:

  • (a) evidence-based medicine should become more patient-centered, for instance by incorporating patient preferences in RCT designs [44], and

  • (b) patient-centered medicine should become more evidence-based by more

References (45)

  • P.A. James et al.

    Patient-centered clinical decisions and their impact on physician adherence to clinical guidelines

    J Fam Pract

    (1998)
  • R.S. Hayward et al.

    Users’ guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid? The Evidence-Based Medicine Working Group

    J Am Med Assoc

    (1995)
  • M.C. Wilson et al.

    Users’ guides to the medical literature. VIII. How to use clinical practice guidelines. B. What are the recommendations and will they help you in caring for your patients? The Evidence-Based Medicine Working Group

    J Am Med Assoc

    (1995)
  • R.M. Glas

    The patient–physician relationship. JAMA focuses on the center of medicine

    J Am Med Assoc

    (1996)
  • J.P. Kassirer

    Incorporating patients’ preferences in medical decisions

    N Engl J Med

    (1994)
  • K. Taylor et al.

    Physicians’ reasons for not entering eligible patients in a randomized clinical trial of adjuvant surgery for breast cancer

    N Engl J Med

    (1984)
  • E. Cassell

    The nature of suffering and the goals of medicine

    (1991)
  • M. Stewart et al.

    Patient-centred medicine: transforming the clinical method

    (1995)
  • R.C. Smith et al.

    The patient’s story: integrating the patient- and physician-centered approaches to interviewing

    Ann Intern Med

    (1991)
  • P.S. Byrne et al.

    Doctors talking to patients. A study of the verbal behavior of general practitioners consulting in their surgeries

    (1976)
  • C. Laine et al.

    Patient-centered medicine. A professional evolution

    J Am Med Assoc

    (1996)
  • D.J. Hyman et al.

    Cholesterol treatment practices of primary health care physicians

    Public Health Rep

    (1992)
  • Cited by (0)

    View full text