The role of holistic, patient-centred research

I was struck by the article by Dr Crossley and its consideration of the tensions between being ‘person centred yet scientific’.¹ We strive to provide patient-centred care within the framework of evidence-based medicine, although we try to ascertain that evidence base using structured, standardised processes.

Other thinking behind the patient-centred approach has been developed by Fulford, expanding arguments surrounding the concept of disease.² In his model of the ‘balanced or fullfield model of health care’ he examines the balance between the objective concept of disease and the subjective concept of illness. In these, he states, there is a tension between the views of the patient (who is subjectively experiencing the feelings and complaints of being ill) and the doctor (who takes the role of the expert in the area of disease, an objective, scientific concept).

If we want to emphasise the subjective experience of patients in our work, then I would like to suggest we increase our exposure to the subjective experience in research. Categorising original research articles over two decades from the three highest-profile general psychiatric journals, rated by both journal impact factor and the proportion of psychiatrists reading them³ (the British Journal of Psychiatry, the American Journal of Psychiatry and Archives of General Psychiatry) showed that their focus is on objective research, with biological or epidemiological domains accounting for 70% of the articles published (n = 5710). When articles were rated using a narrow operational definition of whether their main aim was to study the subjective experience of the patient,⁴ only 2% (156 articles) met the criteria. Variables associated with subjective experience research (perhaps unsurprisingly) included psychosocial research topics (odds ratio (OR) = 10.2; 95% CI 7.4-14.2), and qualitative (OR = 34.6; 95% CI 5.74-208.7) and cross-sectional (OR = 4.2; 95% CI 3.1-5.9) research methodologies. It is likely that journals from other disciplines (such as the social sciences and psychology) would have more articles pertaining to the subjective experience of patients, as would psychiatric journals with explicit aims to publish articles relating to ethics and patient-centred care; however, British psychiatrists are less exposed to these than to the journals investigated.³

There is no reason why a subjective, values-based approach cannot sit alongside the objective, factual approach, and conflicts between values-based practice and evidence-based medicine are unnecessary. To be person-centred we must have a strong understanding of the factual evidence for our interventions, but also understand the patient's unique set of values and experiences. Evidence-based medicine promotes the integration of three key elements: best research evidence, clinical expertise and patient values.⁵ To do this effectively, patient-centred ethos should be applied when taking into account the illness experience, the person and the context in which the illness presents, to find common ground between both the physician's and the patient's perspective.