Through a Glass, Darkly:  The Challenge of Integration of the Science and the Art of Medicine.

Peter Wyer; Suzana Alves Silva

doi:10.5750/ejpch.v2i1.697

Through a Glass, Darkly: The Challenge of Integration of the Science and the Art of Medicine.

Peter Wyer, Suzana Alves Silva

Abstract

We have entered a new phase in the dialogue between proponents of evidence-based medicine and humanistic medicine. Over 30 years of parallel development of patient-centered and evidence-based care make possible concrete approaches to the integration of the fruits of these developments. Such integration is of increasing importance to the viability of today’s highly structured and regulated healthcare environment. Attempts at integrated model building on the part of proponents of both EBM and humanistic care have suffered from common deficiencies. These include the failure to distinguish between decision-making and practice models, failure to illuminate processes traversing categories of knowledge and information, failure to embrace the principles of relationship-centered care and failure adequately to address the epistemological issues inherent to the integration of the experiential and scientific domains of clinical practice. A published model-building attempt is used to illustrate what a correction of such limitations might look like. Efforts to develop person-centered care as an integrated and patient-centered vision of healthcare are encouraged.

Keywords

Art of medicine, clinical decision-making, doctor-patient relationship, epistemology, evidence-based medicine, modern clinical practice, narrative, paradigm, paternalism, person-centered medicine, personhood, preferences, science of medicine, values

Full Text:

PDF

References

Guyatt, G.H. (1991). Evidence-Based Medicine (editorial) American College of Physicians Journal Club. Annals of Internal Medicine 114 (Supplement 2) A1-16.

Evidence-Based Medicine Working Group. (1992). Evidence-based medicine: A new approach to teaching the practice of medicine. Journal of the American Medical Association 268, 2420-2425.

Tanenbaum, S.J. (1993). What Physicians Know. New England Journal of Medicine 329, 1268-1271.

Miles, A. & Mezzich, J.E. (2011). The care of the patient and the soul of the clinic: person-centered medicine as an emergent model of modern clinical practice. International Journal of Person Centered Medicine. 1 (2) 207-222.

Harzband, P. & Groopman, J. (2009). Keeping the Patient in the Equation: Humanism and Health Care Reform. New England Journal of Medicine 361, 554-555.

Charles, C., Gafni, A. & Freeman, E. (2010). The evidence-based medicine model of clinical practice: scientific teaching or belief-based preaching? Journal of Evaluation in Clinical Practice 17, 597-605.

Tonelli, M.R. (2006). Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 12 (3) 248-256.

Balint, E. (1969). The possibilities of patient-centered medicine. Journal of the Royal College of General Practice 17, 269-276.

Berwick, D.M. (2009). What "Patient-Centered" should mean: confessions of an extremist. Health Affairs 28, w555-w565.

Frank, A.W. (2002). At the will of the body: Reflections on illness. New York: Houghton Mifflin.

Epstein, R.M. & Street, R.L. (2011). The Values and Value of Patient-Centered Care (Editorial). Annals of Family Medicine 9, 100-103.

Pew-Fetzer Task Force. (1994). Health professions education and relationship-centered care: Pew Health Professions Commission at . Accessed 4 April, 2012.

Engel, G.L. (1977). The Need for a New Medical Model: A Challenge for Biomedicine. Science 196, 129-136.

Maturana, H.R. & Varela, F.J. (1998). The Tree of Knowledge: The Biological Roots of Human Understanding. Boston: Shambhala.

Varela, F.J., Thompson, E. & Rosch, E. (1991). The Embodied Mind. Cambridge, MA: MIT.

Malterud, K. (1995). The legitimacy of clinical knowledge: Towards a medical epistemology embracing the art of medicine. Theoretical Medicine and Bioethics 16 (2) 183-198.

Beach, M.C. & Inui, T. (2006). Relationship-centered Care: A Constructive Reframing. Journal of General Internal Medicine 21, S3-S8.

Frankel, R.M., Eddins-Folensbee, F. & Inui, T.S. (2011). Crossing the Patient-Centered Divide: Transforming Health Care Quality Through Enhanced Faculty Development. Academic Medicine 86, 445-452.

Sehon, S.R. & Stanley, D.E. (2003). A philosophical analysis of the evidence-based medicine debate. BMC Health Services Research 3, 14.

Wyer, P.C. & Silva, S.A. (2009). Where Is The Wisdom: I. A Conceptual History of Evidence Based Medicine Journal of Evaluation in Clinical Practice 15, 891-898.

Eddy, D.M. (2005). Evidence-based medicine: A unified approach. Health Affairs 24, 9-17.

Charon, R. (1986). To render the lives of patients. Literature in Medicine 5, 58-74.

Hunter, K.M., Charon, R. & Coulehan, J.L. (1995). The study of literature in medical education. Academic Medicine 70, 787-794.

Haynes, R.B., Devereaux, P.J & Guyatt, G.H. (2002). Clinical expertise in the era of evidence-based medicine and patient choice. American College of Physicians Journal Club 136, A11-A14.

Haynes, R.B., Sackett, D.L., Gray, J.R., Cook, D.C. Guyatt, G.H. (1996). Transferring evidence from research into practice: 1. The role of clinical care research evidence in clinical decisions (Editorial). American College of Physicians Journal Club 125, A14-A16.

Silva, S.A. & Wyer, P.C. (2009). Where is the wisdom? II – Evidence-based medicine and the epistemological crisis in clinical medicine. Exposition and commentary on Djulbegovic, B., Guyatt, G. H. & Ashcroft, R. E. (2009) Cancer Control 16, 158–168. Journal of Evaluation in Clinical Practice 15, 899-906.

Polanyi, M. (1967). The Tacit Dimension. New York: Anchor Books.

Tonelli, M.R. (1998). The philosophical limits of evidence-based medicine. Academic Medicine 73, 1234-1240.

Tonelli, M.R. (1999). In Defense of Expert Opinion. Academic Medicine 74, 1187-1192.

Tonelli, M.R. & Callahan, T.C. (2001). Why Alternative Medicine Cannot Be Evidence-based. Academic Medicine 76, 1213-1220.

Malterud, K. (2006). The social construction of clinical knowledge – the context of cultureand discourse. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 12, 248–256. Journal of Evaluation in Clinical Practice 12, 292-295.

Charles, C., Gafni, A. & Whelan, T. (1997). Shared decision-making in the medical encounter: what does it mean? (or, it takes at least two to tango). Social Science and Medicine 44, 681-692.

Gafni, A., Charles, C. & Whelan, T. (1998). The physian-patient encounter: the physician as a perfect agent for the patient versus the informed treatment decision-making model. Social Science and Medicine 47, 347-354.

Joosten, E.A.G., DeFuentes-Merillas, L., de Weert, G.H., Sensky, T., van der Staak, C.P.F. & de Jong, C.A.J. (2008). Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status. Psychotherapy and Psychosomatics 77, 219-226.

Barratt, A. (2008). Evidence Based Medicine and Shared Decision Making: The challenge of getting both evidence and preferences into health care. Patient Education and Counseling 73, 407-412.

Barry, M.J. & Edgman-Levitan, S. (2012). Shared Decision Making: The Pinnacle of Patient-Centered Care. New England Journal of Medicine 366, 780-781.

Goyal, R.K., Charon, R., Lekas, H., Fullilove, M.T., Devlin, M.J., Falzon, L. & Wyer, P.C. (2008). ‘A local habitation and a name’: how narrative evidence-based medicine transforms the translational research paradigm. Journal of Evaluation in Clinical Practice 14, 732-741.

Thaler, R.H. & Sunstein, C.R. (2003). Libertarian Paternalism. American Economic Review 93, 175-179.

Foucault, M. (1973). The Birth of the Clinic: An Archaeology of Medical Perception. New York: Vintage Books.

Rier, D.A. (2000). The missing voice of the critically ill: a medical sociologist's first-person account. Sociology of Health and Illness 22, 68-93.

Silva, S.A., Charon, R. & Wyer, P.C. (2011). The marriage of evidence and narrative: scientific nurturance within clinical practice. Journal of Evaluation in Clinical Practice 17, 585-593.

Charon, R. (2005). Narrative Medicine: Attention, Representation, Affiliation. Narrative 13, 261-269.

Silva, S.A. & Wyer, P.C. (2012). The Roadmap: a blueprint for evidence literacy within a Scientifically Informed Medical Practice and LEarning model. International Journal of Person Centered Medicine. In Press.

Charon, R. (2006). Attention, Representation, Affiliation. In: Narrative Medicine: Honoring the Stories of Illness pp. 131-153. New York: Oxford University Press.

Straus, S., Tetroe, J. & Graham, I.D. (2009). Knowledge Translation in Health Care. Oxford: Wiley-Blackwell.

Freire, P. (1974). Education for Critical Consciousness. New York: Continuum.

Wilson, H.J. (2000). The myth of objectivity: is medicine moving towards a social constructivist medical paradigm? Family Practice 17, 203-209.

Epstein, R.M. & Peters, E. (2009). Beyond Information: Exploring Patient's Preferences. Journal of the American Medical Association 302, 195-197.

Heng, H.H.Q. (2008). The conflict between complex systems and reductionism. Journal of the American Medical Association 300, 1580-1581.

Nonaka, I. & Takeuchi, H. (1995). The Knowledge-Creating Company: How Japanese Companies Create the Dynamics of Innovation. New York: Oxford University Press.

Malterud, K. (2001). The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet 358, 397-400.

Charon, R., Wyer, P., for the NEBM Working Group X. (2008). The art of medicine: Narrative Evidence-Based Medicine. Lancet 371, 296-297.

Levenstein, J.H., McCracken, E.C., McWhinney, I.R. & Stewart, M.A. (1986). The patient-centred clinical method: a. A model for the doctor-patient interaction in family medicine. Family Practice 3, 24-30.

Tonelli, M.R. (2007). Advancing a casuistic model of clinical decision making: a response to commentators. Journal of Evaluation in Clinical Practice 13, 504-507.

DOI: http://dx.doi.org/10.5750/ejpch.v2i1.697

Refbacks

There are currently no refbacks.