When I commenced lecturing in Nutrition and Dietetics at Charles Sturt University in 2001, the ‘evidence-based medicine’ (EBM) or more broadly the ‘evidence-based practice’ (EBP) movement was in full swing, having begun in the early 1980s.1 The term was originally coined by Gordon Guyatt in Canada, but it was his mentor, David Sackett, a clinical epidemiologist, who is regarded as the pioneer of EBM.1,2 EBP, which aims to improve the quality of health care, is defined as the ‘conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’.3 EBP requires health professionals to do more than examine the scientific evidence to address a particular clinical question; they must also integrate that evidence with clinical judgement and patient values.4
Incorporating ‘patient values’ into practice indicates that the patient’s perspective is a key component of clinical decision making in EBP. My interpretation of the literature, at least in the early years, is that EBP was focussed less on considering patient values and more on asking the right clinical questions, gathering the best available evidence, and incorporating the health professional’s clinical expertise.2,4-6 Merely incorporating patient values into a patient’s care plan has connotations of patients remaining passive in their care, rather than being active participants.
Nevertheless, Richardson,7 who worked closely with Sackett and his contemporaries, argues that the underlying philosophy of EBP embraces care that is both patient-centred and evidence-based. He contends that shared decision-making between the clinician and patient is equally fundamental to the EBP model, with the clinician and patient having different sources of knowledge that are drawn on at each clinical encounter.
Contemporary health care also demands greater consideration of patient preferences, motivation and personal goals for treatment…
Yet, other researchers claim that EBP fails to take account of the current health care environment that is awash with an aging population, experiencing more complex, chronic conditions and co-morbidities. Focussing on single diseases is no longer adequate. Contemporary health care also demands greater consideration of patient preferences, motivation and personal goals for treatment, which is underpinned by effective therapeutic partnerships between patients and health care professionals.6
So as EBP ebbs in its influence in both policy and practice, ‘patient-centred’ care (PCC) is reaching its zenith. Like EBP, PCC’s purpose is to improve the quality of health care, with additional potential benefits, such as enhanced patient and health professional satisfaction.8 Interestingly, scanning the health and human services literature, there is no commonly accepted definition of PCC. One narrative review of the policy, medical and nursing literature draws out three main themes of PCC:
1) Patient participation and involvement – the patient participates in care as a respected and autonomous individual; patient care is integrated and coordinated; and the physical and emotional needs of patients are met.
2) Genuine relationship between the patient and health professional – allows for open communication regarding knowledge and personal and clinical expertise.
3) Context where care is delivered – considers access to health care, barriers to PCC and the therapeutic environment from a system perspective.9
In the specific context of the substance use disorder treatment, a systematic scoping review generated four core principles of PCC: a holistic focus to care, an individualised focus to care, shared decision-making and an enhanced therapeutic alliance.10
Similar concepts for PCC are found in the human services literature, which encompasses aged care, mental health and disability, but the language substitutes ‘person-centred’ for ‘patient-centred’ care.11 The common themes emerging in this body of literature are: honouring the person, being in relationship, facilitating participation and engagement, social inclusion/citizenship, experiencing compassionate love, being strengths/capacity focussed and organisational characteristics that are grounded in values-based care.
…there also needs to be a greater focus on improving the nation’s health literacy and supporting people to be active participants in their health care…
Despite the commonalities in the health and human services literature in relation to the core elements or themes of PCC, successfully translating them into practice requires establishing a shared understanding of PCC amongst the health care team (including the patient/consumer).9
If PCC is to become genuinely embedded into practice across the entire health care system, there also needs to be a greater focus on improving the nation’s health literacy and supporting people to be active participants in their health care. In 2006, a national survey of Australians’ level of health literacy tested people’s understanding of health promotion, health protection, disease prevention and management, and navigation of the health system.12 The survey found that only 41% of Australians aged between 15 and 74 years were assessed as having adequate or more than adequate health literacy skills. Drilling further into the demographics, the proportion of Australians in the oldest age category of 60-74 with adequate or better health literacy skills was a low 22%.12 What does that result mean for the people over 74 years, who are amongst the most likely group to be accessing health care? It is incumbent on all health care providers to help people navigate the health system, provide sufficient information to allow them to manage their own health and make sure that information is easy to find and understandable.
A useful 10 or 13 item tool, Patient-Activated Measure (PAM),TM measures a person’s knowledge, skills and confidence in being able to manage his or her own health care.14 The tool, categorises a person’s activation into four levels, from disengaged at level 1 to maintaining a healthy lifestyle at level 4. The PAMTM tool has been validated for use in many different countries and cultures and is being used extensively in USA, UK and more recently in Australia. It is worth considering using it in population health and in individual case management, but it can also be used for organisations to track improved patient activation. Its main value is in accurately assessing patient activation, but then in supporting them to improve their activation, if necessary.
It is my hope that PCC does not become another fad, in the way that EBP has lost favour. It is up to health care professionals and the organisations in which they work, to make sure that it remains central to high quality health care.
- Thoma A & Eaves FF. A brief history of evidence-based medicine (EBM) and the contributions of Dr David Sackett. Aesthet Surg J. 2015;35(8):NP261-NP263.
- Zimerman AL. Evidence-Based Medicine: A short history of a modern medical movement. AMA J Ethics. 2013;15(1):71-76.
- Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71.
- Masic I, Miokovic M, Muhamedagic B. Evidence Based Medicine – new approaches and challenges. Acta Inform Med. 2008;16(4):219-225.
- Akobeng AK. Principles of evidence based medicine. Arch Dis Child. 2005;90:837-840.
- Fava GA. Evidence-based medicine was bound to fail: a report to Alvan Feinstein. J Clin Epidemiol 2017;84:3-7.
- Richardson WS. The practice of evidence-based medicine involves the care of whole persons. J Clin Epidemiol. 2017;84:18-21.
- Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10(1):38–43.
- Kitson A, Marshall A, Bassett K & Zeitz K. What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. J Adv Nursing. 2012; 69((1):4-15.
- Marchand K et al. Conceptualizing patient-centred care for substance use disorder treatment: findings from a systematic scoping review. Subst Abuse Treat, Prev and Policy. 2019;14:37.
- Waters RA, Buchanan A. An exploration of person-centred concepts in human services: A thematic analysis of the literature. Health Policy. 2017;121:1031-1039.
- AIHW. Australia’s health 2018. Health Literacy. Canberra: AIHW. https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/indicators-of-australias-health/health-literacy Accessed 18 October 2019.
- Australian Bureau of Statistics. National Health Survey: Health Literacy, 2018. ABS cat. no. 4364.0.55.014. Canberra: ABS. https://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4364.0.55.014Main+Features12018?OpenDocument Accessed 20 October 2019.
- Insignia Health. Patient-activated measure: Increasing activation starts with measurement. 2018. Portland, Oregon: Insignia Health. https://s3-us-west-2.amazonaws.com/insignia/PAM-Fact-Sheet-20180212.pdf?mtime=20180308103715