The Nexus Between Patient-Centered Care and Complementary Medicine: Allies in the Era of Chronic Disease?

Evidence-Based Medicine and PCC

Within the field of conventional medicine and, to a lesser extent, that of CM, contemporary philosophical discussion has delved into the paradigm of evidence-based medicine (EBM) and its application as evidence-based practice (EBP). ^8,9 These, over the past two decades, have anchored clinical health care in an increasingly scientific, empirical, and, some may argue, reductive grounding. ¹⁰ Some assert, however, that in its application in practice, EBP has failed to align with the practicalities of clinical care by neglecting to acknowledge the role of patients' individual circumstances and of the patient–practitioner relationship as part of the evidence base. ^10,11 To be truly evidence based and inclusive of the third pillar of EBM (“patient characteristics, culture, and preferences”), ¹² EBP must be applied in a less reductive way and instead be viewed in conjunction with a patient-centered approach. ¹³

Recent discussions regarding optimal clinical health care provision have often focused on the paradigm of person-centered care or PCC. ^{14 –16} This is an approach influenced by Carl Rogers' person-centered therapy in the 1940s and developed through the Picker Institute and Harvard School of Medicine. ¹⁷ Clinical health care provision is significantly shaped by the consultation process and the patient–practitioner relationship, the nature of which can impact on clinical and psychosocial health outcomes. ^18,19 PCC has subsequently grown with the emergence of a greater medical focus on the subjective experience of patients. ²⁰ PCC is now considered of paramount importance in the landscape of health care delivery. ^6,7,17,21,22 As already noted, appropriately applied, PCC may also be viewed as intrinsic to EBP.

The Relationship Between PCC and Holism

PCC has also emerged in a context of greater interest in holistic and whole systems approaches. PCC has been described as holistic due to its “whole-person” focus. ²³ There are indeed many similarities between the paradigms of PCC and that of holism (for an overview of these similarities, see Table 1). PCC is an individualized paradigm of clinical care, commonly defined by the following core elements: education and shared knowledge; collaboration; respect for patients' needs, values, and preferences; sensitivity to both medical and nonmedical aspects of care; involvement of family and social networks; and accessibility of information and care. ²⁴ To facilitate the core elements already listed, PCC demonstrates a patient–practitioner relationship characterized by communication, collaboration, ²⁵ practitioner empathy, and patient empowerment. ²⁰ In addition, it may be more time intensive than usual care.

Holism began not as a system of clinical care but as a philosophy describing what its author identified as an “inherent character of the universe,” fundamental to nature. ²⁶ Holistic philosophy seeks to understand intersecting relationships between systems (such as body and mind, individual, and environment) and illuminate the concept of synergy: the whole is greater than the sum of its parts. ²⁷ When applied as a paradigm of clinical care, holism is analogous with PCC in that it accounts for all aspects of the individual patient (body, mind, and soul/psyche); for the environmental and social factors affecting the individual's health; and for sustainable health promotion that empowers the patient. ^23,27,28 Holism has been framed as dichotomous to conventional, reductionist approaches to health and medicine, which treat the disease or symptoms from a positivist perspective rather than pragmatically considering the whole person. ²⁹

Although holistic approaches have been embraced to some extent in conventional health care settings, such as nursing, ³⁰ or through implementation of biopsychosocial models, ³¹ holistic philosophy applied as a paradigm of clinical care is most consistently aligned with the principles of professions commonly defined as CM and IHM. ^28,32,33 Espousal of holism across the variety of these professions is so consistent that holism is perceived by both its practitioners and users as a delineating theme separating CM from conventional health care. ^34,35 As may be expected in the practice of a paradigm grounded in philosophy, understandings of holism present fluidly in the perspectives of CM practitioners. ³⁶ Western herbal medicine (WHM) practitioners have described their practice of holism through lenses of biological homeostasis, biopsychosocial perspectives, and spiritual perspectives. ³⁶ Naturopathy holds holism as one of its six core principles, outlined under the directive to “treat the whole person,” ³⁷ and holism is considered integral by practitioners and professional organizations of other CM professions and systems, such as acupuncture, homeopathy, ³⁸ and Ayurvedic medicine. ³⁹

Two particularly integral aspects of both holism and the PCC paradigm are empathy and empowerment. Practitioner empathy involves both ability and motivation to identify, consider, understand, and reflect patients' emotions, perspectives, and experiences. ⁴⁰ Empathy may be described as the foundation of a patient-centered consultation as it allows for development of rapport in the patient–practitioner relationship that will shape the consultation process. ⁴¹ Patient empowerment refers to patients' ability to take an active role of responsibility in the management of their health and may be expressed as enablement, self-efficacy, transference of power, or control. ⁴² Patient empowerment may be seen as the natural or desired outcome of a holistic or patient-centered approach and may, therefore, rely largely on the translation of philosophical ideals to allow patient empowerment to be embodied in practical, clinical application.

Alignment of Values and Practice in This Era of Chronic Disease

Although holistic values would seem to lend an inherent quality of PCC to CM practice, investigation is recommended to determine whether challenges such as integration and EBP are undermining holism, or holistic philosophy is truly being translated into patient-centered CM practice. ^43,44 Preliminary research has demonstrated the occurrence of a number of elements of PCC in CM. ^{45 –47} However, this research is predominantly qualitative and there is insufficient quantitative data to identify the extent to which PCC is characteristic of CM.

The value of exploring PCC in CM may extend to managing chronic disease, ⁴⁸ which contributes to the burden of disease on a global level. ⁴⁹ PCC is increasingly viewed as an effective strategy in chronic disease management, and a number of national frameworks and guidelines have been developed accordingly in Europe, ⁵⁰ Canada, ⁵¹ and Australia, ⁵² among others. Elements of PCC, such as practitioner empathy ⁵³ and patient empowerment, ⁵⁴ are recognized contributors in driving positive health outcomes among patients with a chronic disease. This current emphasis on PCC for chronic disease management, considered alongside the high rates of CM use among individuals with chronic disease, ^{2 –4} suggests that CM should be explored as a potential existing resource of PCC for this population group. ⁵⁵

Individuals with chronic health conditions who choose to consult with CM practitioners have cited holistic and patient-centered clinical care paradigms as driving factors in this choice. ^{56 –58} Indeed, the nature of clinical care in CM is a frequently cited driver of use among CM patients as a whole. ^45,59 For example, CM practitioners' approach to clinical care is expected by CM patients to provide a whole-person approach, ⁵⁷ opportunity for active patient participation, ⁶⁰ patient–practitioner communication and collaboration, ⁵⁹ and the potential for empowering personal growth. ^61,62

PCC in CM: Is Philosophy Translating into Practice?

A number of influences in the contextual landscape of contemporary health care present challenge to the maintenance of holism in CM and IHM. Attempts to improve clinical care by combining CM with conventional practice in the form of integrative medicine have been argued to result in marginalization, co-option, and reduction of holistic methods in the consultation process. ⁶³ Some have suggested that efforts to legitimize professions such as WHM and naturopathy through greater emphasis on scientific EBP detract from traditional holistic practices and values. ⁶⁴ Similarly, some have argued that CM practitioners seeking to make their services approachable in a mainstream market may feel pressured to compromise on aspects of holism to meet modern consumers' expectations and demands; efforts to appeal to consumers often involve advertising treatment for specific conditions, which may detract from the whole-person approach of holism. ³⁸

Although the relationship between CM, holism, and PCC is often asserted, there is a need to more objectively examine the ways contemporary influences upon CM practice impact the reality of these relationships. If the consistent application of PCC principles in CM and IHM is confirmed, the potential role of these approaches and practitioners within contemporary health care provision may be elucidated as a vested resource of PCC. Such identification may shift the view of policy-makers toward CM by highlighting its relevance to managing the burden of disease, most notably in the field of chronic disease management. If, however, the reality of CM practice is not found to be representative of PCC, the translation of CM philosophies into clinical consultation ought to be examined and addressed to ensure the effectiveness of CM clinical care, its alignment with traditional CM principles, and its relevance to contemporary health care provision. Understanding the role of CM and the scope of CM clinical care as it is currently practiced requires research to objectively measure the presence of PCC in CM and IHM, and particularly in patients with chronic conditions.