Person-Centered Medicine: An Existential Outline beyond the Biopsychosocial Model
Keywords:Person-centered medicine, patient-centered medicine, biopsychosocial model, existential dimension, vital dimension, experiential dimension, subjectivity, hermeneutics, beliefs, thoughts, values, aims, preferences
AbstractStarting from the idea that “medical problems” are always “problems of living” that reflect the existence of a “vital dimension” that is different from the biological, psychological and sociocultural dimensions, this article describes central features of this dimension. From this viewpoint, its inescapable importance in the clinical act is highlighted, an importance that shapes the tasks that are inherent to it – diagnosis and decision making – but also the very process of the doctor-patient relationship. It is argued that “the subjective truth” implicit in the “vital dimension” (in the “existential self”) can only be approached through reflection and interpretation in the context of a dialogue between the professional and the patient/family with the objective of deciding on the action(s) that can better lead to reaching some concrete wishes or desires (values), that in turn require the participants to take on obligations and responsibilities. This relational perspective defines the “person centered” clinical approach as a practice based on dialogue, importantly involving deliberation and collaboration (“collaborative deliberation”). In this dialogue, the emotions, integral elements of the life dimension of its protagonists, play a decisive role both in attaining clinical effectiveness and in building and maintaining the relational process (encouraging or reducing trust) that is indispensable in a clinical activity that is an eminently moral act. Finally, the main challenges that doctors face when implementing this clinical focus and the educational challenges it entails are outlined.
Ruiz-Moral R. What is Person Centered Medicine?: Conceptual review with focus on George Engel’s perspectives. International Journal of Person Centered Medicine, 2016; 6: 83-90.
Zubiri X. Sobre el hombre [About the Man]. Madrid: Alianza, 1986 [Original Published in Spanish]
Szasz TS. The myth of mental illness. New York, Del Publishing Co, 1961
Frankl VE. la voluntad de sentido [The Will to Meaning]. Barcelona: Herder, 1994 [Original Published in German]
Ortega y Gasset J. Meditaciones del Quijote [Meditations on Quixote]. Madrid: Alianza, 2005 (original publicado 1914). [Original Published in Spanish]
Ortega y Gasset J. El tema de nuestro tiempo [The theme of our time]. Madrid: S.L.U. Espasa Libros, 2003 [Original Published in Spanish]
Gertler B. “Self-Knowledge.” In The Stanford Encyclopedia of Philosophy. Edited by Edward N. Zalta. 2008. http://plato.stanford.edu/entries/self-knowledge/
Hernández Muñoz S. Humorismo y vanguardia. La representación gráfica del humor [Humor and art. The graphical representation of humor]. Doctoral dissertation. Universidad Politécnica de Valencia 2011. Acceso 8 Agosto 2015 El humor y su concepto. Humor, humorismo y comicidad [Original Published in Spanish]: file:///C:/Documents%20and%20Settings/Administrador/Mis%20documentos/Downloads/El-humor-y-su-concepto.pdf
Kierkegaard S. La enfermedad mortal o De la desesperación y el pecado [The Sickness unto Death]. Madrid: Guadarrama, 1969 [Original Published in Danish]
Sartre JP. El existencialismo es un humanismo [Existentialism is an humanism]. Barcelona: Edhasa, 2007 [Original Published in French]
Heidegger M. El ser y el tiempo [Being and Time]. Mexico: Fondo de cultura económica, 1977 [Original Published in German]
Mead N, Bower P. Hann M. The impact of general practitioners’ patient-centredness on patient postconsultation satisfaction and enablement. Soc Sci Med 2002;55:283-9
Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995; 40:903–18.
Stewart M, Brown JB, Donner A, McWhinney IR, Oates J,WestonWW, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49:796–804.
Griffin SJ , Kinmoth AL, Veltman MWM, et al Effect on Health-Related Outcomes of Interventions to Alter the Interaction Between Patients and Practitioners: A Systematic Review of Trials. Ann Fam Med 2004;2:595-608.
Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007; 45:340–9.
Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making. 2015 Jan;35(1):114-31
Street Jr RL. Makoul G , Arora NK , Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Pat Edu Couns 2009;74:295-301
Frankl VE. Psicoterapia y humanismo [Psychotherapy and Humanism]. Madrid: Fondo de cultura económica, 2012. [Original Published in German]
Rogers CR. Client-centered therapy: Its current parctice, implications and theory. New York: London: Constable & Robinson, 2003
Ricoeur P. Freud: una interpretación de la cultura [Freud: An interpretation of the culture]. Madrid: Siglo XXI, 1975 [Original Published in French]
Gunzburg JC. Healing Through Meeting: Martin Buber's Conversational Approach to Psychotherapy. Bristol (Pen): Jessica Kingsley Publisher, 1997
Balint M. The doctor, his patient and the illness. London: Churchill Livingstone, 2000
Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine. Fam Pract. 1986 Mar;3(1):24-30.
Stewart M, Brown JB, Weston W, McWhinney IR, McWilliam C. Patient-centered Medicine: Transforming The Clinical Method: Transforming The Clinical Method. Radcliffe Medical Press 2003
Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001;76(4):390-3.
Silverman J KS, Draper J. Skills for communicating with patients. 2nd ed. Oxford: Oxford Radcliffe; 2005.
Frank JR. The CanMEDS 2005 physician competency framework: better standards, better physicians, better care. Otawa: Royal College of Physicians and Surgeons of Canada; 2005.
von Fragstein M, Silverman J, Cushing A, Quilligan S, Salisbury H, Wiskin C. UK consensus statement on the content of communication curricula in undergraduate medical education. Med Educ. 2008;42(11):1100-7.
Kiessling C, Dieterich A, Fabry G, Holzer H, Langewitz W, Muhlinghaus I, et al. Communication and social competencies in medical education in German-speaking countries: the Basel consensus statement. Results of a Delphi survey. Patient Educ Couns. 2010;81(2):259-66.
Henry SG, Holmboe ES, Frankel RM. Evidence-based competencies for improving communication skills in graduate medical education: a review with suggestions for implementation. Med Teach. 2013;35(5):395-403.
Bachmann C, Abramovitch H, Barbu CG, Cavaco AM, Elorza RD, Haak R, et al. A European consensus on learning objectives for a core communication curriculum in health care professions. Patient Educ Couns. 2013;93(1):18-26.
Garcia de Leonardo C, Ruiz-Moral R, Caballero F, Cavaco AM, Moore P, Dupuy LP, et al. A Latin American, Portuguese and Spanish consensus on a Core Communication Curriculum for undergraduate medical education. BMC Medical Education 2016;16:99
Miller WR, Rollnick S. Motivational interview. Helping people change . London: The Guilford Press, 2013
Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ. 2010;341:c5146.
Gallop R, Lancee WJ, Garfinkel PE. The empathic process and its mediators. A heuristic model. J Nerv Ment Dis. 1990;178:649–54
Riess H. Empathy in Medicine—A Neurobiological Perspective. JAMA. 2010;304:1604-1605
Rudebeck CE. Imagination and the empathy in the consultation. Br J Gen Pract 2002;52:450-3
Marvel MK. Involvement with the psychosocial concerns of patients: observation of practicing family physicians on a university faculty. Arch Fam Med.1993;2:629-633.
Byrne PS, Long BE. Doctors Talking to Patients. London, England: Her Majesty's Stationery Office; 1976
Suchman, A.L. Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. J Am Med Assoc.1997; 277: 678–682
Lang F; Michael R. Floyd MR, Beine KL. Clues to Patients’ Explanations and Concerns About Their Illnesses A Call for Active Listening. Arch Fam Med. 2000;9:222-227
Levinson, W., Gorawara-Bhat, R., and Lamb, J. A study of patient clues and physician responses in primary care and surgical settings. J Am Med Assoc. 2000; 284: 1021–102
Benbassat J; Baumal R. What Is Empathy, and How Can It Be Promoted during Clinical Clerkships? Academic Medicine 2004;79:832-839
Thompson BM, Teal CR, Scott SM, Manning SN, Greenfield E, Shada R, Haidet P. Following the clues: Teaching medical students to explore patients’ contexts. Pat Edu Couns 2010;80:345-50
Bonvicini KA, Perlin MJ, Bylund CL, Carroll G, Rouse RA, Goldstein MG. Impact of communication training on physician expression of empathy in patients encounters. Pat Edu Couns 2009;75:3-10
Ruiz Moral R ; Caballero F; Garcia de Leonardo C; Monge D; Perula L. Teaching Medical Students to Express Empathy by Exploring Patient Emotions and Experiences. 14th International Conference on Communication in Healthcare ICCH. September 7– 10 September, 2016; University of Heidelberg, Germany
Elwyn G, Lloyd A, van der Weijden T, Stiggelbout A, Edwards A, Frosch Dl, et al. Collaborative deliberation: a model for patient care. Pat Edu Couns 2014;97:158-64
Damasio A. Descartes’ Error: Emotion, reason and the human brain. New York: Penguin Books, 2005
Epstein RM. Mindful practice JAMA 1999;282:833-839
Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. JAMA 1997;278:502-9
Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Families, Systems, & Health, Vol 21(1), 2003, 11-17
Sargeant J, Eva KW, Armson H, Chesluk B, Dornan T, Holmboe E, et al. Features of assessment learners use to make informed self-assessments of clinical performance. Med Educ 2011;45:636-47
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287:226-35
Eva KW, Regehr G. Exploring the divergence between self-assessment and self-monitoring. Adv Health Sci Edu 2011;16:311-29
Lain Entralgo P. Doctor and Patient. New York: McGraw Hill Book Company, 1969
Gracia D, Pose C. Introducción a la bioética: origen, fundamentación y método. Informe [Introduction to Bioethics: origin, rationale and method. Report], Facultad de Medicina, Universidad Complutense, Madrid, 2010. [Original Published in Spanish]
Gracia D. Como arqueros al blanco. Estudios de bioética [As archers to target. Studies bioethics] Madrid: Triacastela, 2004 [Original Published in Spanish]
Ruiz-Moral R. The role of physician-patient communication in promoting patient-participatory decision making. Health Expectations 2010;13:33-44
Epstein RM, Street RL. Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness. Ann Fam Med. 2011; 9:454–461
Zatlev J, Racine T, Sinha C, Itkonen E. Shared mind: perspectives on intersubjectivity. Philadelphia, PA: John Benjamins; 2008.
Pellegrino E, Thomasma D. The virtues in medical practice. Oxford (UK): Oxford University Press, 1993
Street RL, Haidet P. How well do doctors know their patients? Factors affecting physician understanding of patients' health beliefs. J Gen Intern Med. 2011; 26(1):21-7.