Bridging the gap.: The separate worlds of evidence-based medicine and patient-centered medicine
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)
- et al.
Personal significance: the third dimension
Lancet
(1998) Evidence-based medicine: an incomplete method for informing treatment choices
Lancet
(1997)Death of the personal doctor
Lancet
(1996)Exploring information-exchange in consultations: patients’ view of performance and outcomes
Patient Educ Couns
(1995)- et al.
Information and decision-making preferences of hospitalized adult cancer patients
Soc Sci Med
(1988) - et al.
Improving patient and provider communication: a synthesis and review of communication interventions
Patient Educ Couns
(1991) - et al.
Evidence-based medicine: what it is, and what it isn’t
Br Med J
(1996) - et al.
Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease
Br Med J
(1997) - et al.
An evidence based approach to individualising treatment
Br Med J
(1995) Why we need observational studies to evaluate the effectiveness of health care
Br Med J
(1996)