The clinical case has been central to the practice of medicine since its inception, but the perceived value of the case, both a source of knowledge and as the basis for clinical decision making, has declined in the era of evidence-based medicine. Thinking in cases, however, is necessary for the practice of person-centered healthcare, ensuring that the individuality of the case-at-hand is recognized and incorporated into diagnostic and therapeutic decisions. The case-at-hand will be compared to other cases, derived from clinical research, pathophysiologic understanding, and clinical experience, as these kinds of cases serve as the repository of medical knowledge. Utilizing analogy and argument, clinicians derive and negotiate warrants relevant to particular patients, in order to make diagnoses, recommendations, and decisions. Case-based reasoning provides a rigorous and explicit framework for delivering person-centered care to individuals seeking healing.
Health and disease are largely seen as structural phenomena - visible changes in tissues and organs, rather than the result of complex adaptive physiological dynamics within the person, constrained by his internal structures and external environments. Health and disease are ecological phenomena; internal structures and external environments provide the landscapes in which the functions - physiological network interactions at the micro and behavioural interactions at the macro level - occur. These interactions are the functional responses in the quest for health and life.Embracing the person as a whole, that is, being person-centered, is thus an expression of a paradigm shift, a shift from the reductionist focus on disease to the complex-adaptive understandings of the person experiencing health, illness and disease.
Drawing on an authentic sickness history the present paper provides arguments for epistemological and ontological shifts in current clinical practice. The kind of sickness accounted for, impairing the health of a person to the extent of full incapacitation, is medically unexplained. Likewise, its pathogenic sources are unidentified, which results in a lack of options for treatment or even amelioration. Given the considerable healthcare investment in this particular “case”, the insufficiency of both diagnostic and therapeutic approaches calls for a different conceptual framework. When applying a socially and phenomenologically informed frame of reference, the lived experience of violation emerges as a salient background for understanding how disrespect and powerlessness have been inscribed with lifelong impact and how they became reactivated by biographic particularities reminiscent of previous objectification. A biomedically unexplained incapacitation is rendered logical when read with a view recognizing the social and corporeal aspects of human experience.
The ideas and terminology of person-centred care have been part of health discourse for a very long time. Arguments that in healthcare one treats the whole person, not her/his component parts, date back at least to antiquity and the need to treat the patient as a person is articulated persuasively by clinical authors in the early twentieth century. Yet it is only in recent years that we have seen a growing consensus in health policy and practice literature that PCC, and associated ideas including patient expertise, co-production and shared decision-making, are not simply “fine ideals” or “ethical add-ons” to sound scientific clinical practice, but rather they represent indispensable components of any genuinely integrated, realistic and conceptually sound account of healthcare practice. The underlying conviction of this volume - one belief that, despite their differences, unites all of its contributors - is that PCC should not become the latest “revolutionary” concept to be “operationalised” before being “conceptualised”. It is imperative that we develop an open and inclusive dialogue about what we do and do not mean by “person-centred” to inform our attempts to implement PCC.
Objective: To develop and validate a patient-centered visualization approach to support decision-making by patients who are choosing between two hypothetic therapeutic options. Methods: Infographics that contrast two hypothetical drugs, Drug A (low benefit/low risk) and Drug B (high benefit/high risk), were developed based on the input of the clinicians and patients. We adopted a crowdsourcing approach to test the association of a stakeholder-informed infographic, versus text-based educational information, with audience understanding of the risks and benefits of therapeutic options and with decision-making concerning a particular therapeutic option. Results: The low benefit/low risk drug was consistently preferred over high benefit/high risk. The importance that people placed on potential benefits was consistently associated with medication choice. Perceived importance of medication harms was associated with medication choice only among low-risk patients. Information display (textual versus infographic) and user literacy were not associated with medication choice. Conclusion: This study demonstrated that patient-centered infographics can be developed using participatory design to support patient decision-making process. The potential benefits of a drug was the most consistent predictor of medication choice in the study. Practice Implications: Participatory design and crowdsourcing demonstrates promise to facilitate the participatory design of educational materials necessary for shared-decision making.
Phronesis has been a popular concept among those attempting to categorize and understand the kind of reasoning that doctor’s employ in the clinic. However, this paper argues that it is not the best possible concept for understanding the kind of reasoning necessary for person-centred care. First, it attends to what is lacking in that concept, and then it proposes an alternative (the concept of effectual reasoning) to demonstrate the potential for a better understanding of clinical reasoning as both open-ended and strategic. That approach is better than phronesis because it allows us to address both relational aspects of autonomy, and the need to center all persons, as such, including healthcare practitioners as well as patients, in healthcare.
It is puzzling to observe that at a time when medicine has allegedly made huge progress in combating disease and increasing human wellbeing a counter-movement has arisen: “Complementary and Alternative Medicine (CAM)”. Sometimes also called “Integrative Medicine” it is quite popular not only in pockets of Society, but across a large part of populations in Western countries. Media campaigns have been started to curb its success. CAM has to be seen against the mainstream background in medicine which has adopted the machine-paradigm proposed by Descartes. While this has been successful within acute medicine, it is less successful in dealing with chronic, functional or lifestyle diseases. By default, the machine paradigm ignores individuality, agency, the psyche, and has placed a taboo on spirituality. This happens, because the mainstream model of modern medicine buys into the materialism that is inherent in the machine paradigm and currently prevalent naturalism. In this sense, CAM can be seen as a counter-movement, mainly driven by public demand, but also by some renegade scientists. It offers the chance to articulate alternative views of the human organism, of human suffering and disease. It allows the discussion of spirituality and other topics that are shunned by mainstream medicine. Complexity science might be a bridge, which has started to understand that that human organism is vastly more complex than the simplistic machine model would have it. We will likely need a new paradigm that can integrate all those elements neglected in the current mainstream model, most notable spirituality and the notion of agency and freedom.
The clinical case has been central to the practice of medicine since its inception, but the perceived value of the case, both a source of knowledge and as the basis for clinical decision making, has declined in the era of evidence-based medicine. Thinking in cases, however, is necessary for the practice of person-centered healthcare, ensuring that the individuality of the case-at-hand is recognized and incorporated into diagnostic and therapeutic decisions. The case-at-hand will be compared to other cases, derived from clinical research, pathophysiologic understanding, and clinical experience, as these kinds of cases serve as the repository of medical knowledge. Utilizing analogy and argument, clinicians derive and negotiate warrants relevant to particular patients, in order to make diagnoses, recommendations, and decisions. Case-based reasoning provides a rigorous and explicit framework for delivering person-centered care to individuals seeking healing.
Background: Specialist community perinatal mental health (PMH) teams offer specialist psychiatric and psychological assessments and care for women with complex or severe mental health problems during the perinatal period. This paper reports on the findings from an evaluation of a Specialist PMH service. Methods: The evaluation used a longitudinal mixed-methods design with repeated measures. Quantitative data collection was facilitated through Patient reported outcome measures (PROMs) on admission and discharge from 40 women who attended for specialist PMH treatment. Qualitative data was collected through focus group discussions with practitioners providing the service. Within-group t-tests were used to test for significant differences in mental health and wellbeing (α = 0.05) between time points. Thematic analysis was undertaken on qualitative data. Results: Patients showed statistically significant improvements, with large effect sizes, in mean scores across all outcome measures from the first to the last appointment. Key themes in terms of enabling effective service delivery were identified as consistency in service priorities during times of change, team working, breaking down barriers, and seeing what the service can achieve. Inadequate funding, recruitment and training issues, and having to find new ways of working were perceived as challenges to effective service delivery. Conclusions: The findings illustrate that women can now access appropriate, high quality specialist PMH care and are provided with a service that clearly focuses upon recovery. From the perspectives of practitioners within the specialist PMH team, effectiveness was contingent on strong leadership and consistency, alongside team working and collaboration
In this issue of the Journal, we begin the serialisation of a seminal new text which has significantly advanced current understandings of the conceptual basis of person-centered care (PCC) [1]. The volume, edited by Michael Loughlin and Andrew Miles, brings together 42 distinguished scholars, writing over the course of 28 chapters, divided into 6 definitive sections, spanning some 420 pages of text. Each of the chapters has distinct merit and, when studied collectively, the scale of their contribution to current thinking in the field becomes quickly apparent. The volume is scheduled for production towards the end of the current year and will be published by Aesculapius Medical Press (AMP), the publishing Imprint of the European Society for Person Centered Healthcare (ESPCH). A detailed overview of the volume has been provided by Loughlin, the lead co-editor of the book [2]. Loughlin’s paper [2] is a model of clarity, providing admirable insight into the content of the individual chapters, placing each of them within the context of the ongoing debate. As Loughlin [2] rightly notes, “the ideas and terminology of person-centred care ... have been part of health discourse for a very long time ... (and) ... arguments that in healthcare one treats the whole person, not her/his component parts, date back at least to antiquity” (italicisation mine). He emphasises that “... it is only in recent years that we have seen a growing consensus in health policy and practice literature that PCC, and associated ideas including patient expertise, co-production and shared decision-making, are not simply fine ideals or ethical add-ons to sound scientific clinical practice, but rather they represent indispensable components of any genuinely integrated, realistic and conceptually sound account of healthcare practice” (italicisations mine). These observations, indeed truisms, explain the rationale which underpinned the creation of the European Society for Person Centered Healthcare, and which continue to direct its mission.
Both the Evidence Based Medicine (EBM) and Person Centered Healthcare (PCH) movements recognize that decisions on how to manage the care of individual patients in the clinical encounter require more than simple application of those therapies shown effective in a clinical trial. GRADE, a popular framework for developing clinical recommendations, identifies patient “values and preferences” as an important consideration in clinical decision making and a component in determining a clinical recommendation and its strength. However, how patient “values and preferences” are conceptualized in GRADE are problematic if one believes the individual patient’s care should be aligned with her values and preferences. GRADE focuses on “typical” patient “values and preferences” in the process of determining the recommendation. There is no guarantee that the values and preferences of the typical patient will represent that of the individual patient in the clinical encounter. Furthermore, the strength of the recommendation (“strong” vs . “weak”) appears to impact how much patient engagement is warranted (under GRADE), which affects the extent to which information on the “values and preferences” of the individual patient will be sought out or revealed in the clinical encounter. The issues raised in this paper stem from a lack of an underlying theory and empirical support to explain why certain elements have been included in the framework, and others not. A failure to clearly define, operationalize, and measure a patient’s “values and preferences” may limit the value of GRADE derived recommendations and subsequent clinical practice guidelines in managing the care of individual patients consistent with PCH.
