The patient-physician interaction as a meeting of experts: one solution to the problem of patient non-adherence

Practitioners' positive attitudes promote shared decision-making in mental health care

RATIONALE AND AIMS

There is a growing expectation of implementing shared decision making (SDM) in today's health care service, including mental health care. Traditional understanding of SDM may be too narrow to capture the complexity of treatments of mental health problems. Although the patients' contribution to SDM is well described, the contribution from the health care practitioners is less explored. Therefore, our aim was to explore the attitudes of practitioners in mental health care and the associations between practitioners' attitudes and SDM.

METHOD

We performed a cross-sectional study where practitioners reported their sharing and caring attitudes on the Patient-Practitioner Orientation Scale (PPOS) and age, gender, profession, and clinical working site. The patients reported SDM using the CollaboRate tool. We used a mixed effect model linking the data from each practitioner to one or more patients. We presented the findings and used them as background for a more philosophic reflection.

RESULTS

We included 312 practitioners with mean age 46.1 years. Of the practitioners, 60 held a medical doctors degree, 97 were psychologists, and 127 held a college degree in nursing, social science, or pedagogy. Female practitioners reported higher sharing (4.79 vs 4.67 [range 1-6], P = .04) and caring scores (4.77 vs 4.65 [range 1-6], P = .02) than males. The regression model contained 206 practitioners and 772 patients. We found a higher probability for the patient to report high SDM score if the practitioner reported higher sharing scores, and lower probability if the practitioner worked in ambulatory care.

CONCLUSIONS

SDM in mental health care is complex and demands multifaceted preparations from practitioners as well as patients. The practitioners' attitudes are not sufficiently explored using one instrument. The positive association between practitioners' patient-centred attitudes and SDM found in this study implies a relevance of the practitioners' attitudes for accomplishment of SDM processes in mental health care.

From persons to patients and back: How philosophical theory can be applied in the most fundamental area of healthcare practice, the relationship between the provider and the receiver of care

In this paper, I will show how philosophical theory can be applied in the most fundamental area of health care practice, the relationship between the provider and the receiver of care. I will look at the process of becoming a patient and remaining a person. This will begin with a discussion of Heidegger's notion of solicitude alongside the related notions of concern and care, leading to the affirmation of authentic solicitude as the most ontologically appropriate relationship between those who provide and those who receive care. I will then try to understand what happens to us when we become patients and to see what factors make it difficult for us to be persons as well as patients, within the health care environment. This will be followed by a brief discussion of the ancient idea of phronesis (wisdom) in which I will attempt to elucidate, from the side of the health care professional, the way that their relationship with patients can work in a way that recognizes personhood in their patients. I will also consider the dialectical nature of the relationship between patients and doctors (and everyone else who treats us) and try to understand how this points towards the conclusion of a person-centred approach to health care. Following this discussion, I will offer a couple of examples of what person-centred health care might look like in practice, as a means of illustrating, in practical terms, the philosophical approach that I have used.

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There is now broad agreement that ideas like person-centred care, patient expertise and shared decision-making are no longer peripheral to health discourse, fine ideals or merely desirable additions to sound, scientific clinical practice. Rather, their incorporation into our thinking and planning of health and social care is essential if we are to respond adequately to the problems that confront us: they need to be seen not as "ethical add-ons" but core components of any genuinely integrated, realistic and conceptually sound account of healthcare practice. This, the tenth philosophy thematic edition of the journal, presents papers conducting urgent research into the social context of scientific knowledge and the significance of viewing clinical knowledge not as something that "sits within the minds" of researchers and practitioners, but as a relational concept, the product of social interactions. It includes papers on the nature of reasoning and evidence, the on-going problems of how to 'integrate' different forms of scientific knowledge with broader, humanistic understandings of reasoning and judgement, patient and community perspectives. Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under-developed role of phenomenology in medical epistemology, are followed by a broad range of papers focussing on shared decision-making, analysing its proper meaning, its role in policy, methods for realising it and its limitations in real-world contexts.

Patients and agents - or why we need a different narrative: a philosophical analysis

BACKGROUND

The success of medicine in the treatment of patients brings with it new challenges. More people live on to suffer from functional, chronic or multifactorial diseases, and this has led to calls for more complex analyses of the causal determinants of health and illness.

METHODS

Philosophical analysis of background assumptions of the current paradigmatic model.

RESULTS

While these factors do not require a radical paradigm shift, they do give us cause to develop a new narrative, to add to existing narratives that frame our thinking about medical care. In this paper we argue that the increased focus on lifestyle and shared decision making requires a new narrative of agency, to supplement the narrative of "the patient". This narrative is conceptually linked to the developing philosophy of person-centred care.

CONCLUSIONS

If patients are seen also as "agents" this will result in a substantial shift in practical decisions: The development and adoption of this narrative will help practitioners work with patients to their mutual benefit, harnessing the patients' motivation, shifting the focus from treatment to prevention and preventing unnecessary and harmful treatments that can come out of our preoccupation with the patient narrative. It will also help to shift research efforts, conceptual and empirical, from "treating" and "battling" diseases and their purported "mechanisms" to understanding complex contributing factors and their interplay.

Treating real people: Science and humanity

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, overdiagnosis, co-morbidity, and multi-morbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, and health and social care are being revised and their relationships reconsidered: Boundaries are indeed being redrawn; reasoning is being made "fit for practice." Ideas like "person-centred care" are no longer phrases with potential to be helpful in some yet-to-be-clarified way: Theorists and practitioners are working in collaboration to give them substantive import and application.

The Use of Language in Diabetes Care and Education

Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA), convened to discuss language in diabetes care and education. This document represents the expert opinion of the task force. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words-whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.

The Use of Language in Diabetes Care and Education

Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators and the American Diabetes Association, convened to discuss language in diabetes care and education. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words, whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.

From the EBM pyramid to the Greek temple: a new conceptual approach to Guidelines as implementation tools in mental health

Guideline methods to develop recommendations dedicate most effort around organising discovery and corroboration knowledge following the evidence-based medicine (EBM) framework. Guidelines typically use a single dimension of information, and generally discard contextual evidence and formal expert knowledge and consumer's experiences in the process. In recognition of the limitations of guidelines in complex cases, complex interventions and systems research, there has been significant effort to develop new tools, guides, resources and structures to use alongside EBM methods of guideline development. In addition to these advances, a new framework based on the philosophy of science is required. Guidelines should be defined as implementation decision support tools for improving the decision-making process in real-world practice and not only as a procedure to optimise the knowledge base of scientific discovery and corroboration. A shift from the model of the EBM pyramid of corroboration of evidence to the use of broader multi-domain perspective graphically depicted as 'Greek temple' could be considered. This model takes into account the different stages of scientific knowledge (discovery, corroboration and implementation), the sources of knowledge relevant to guideline development (experimental, observational, contextual, expert-based and experiential); their underlying inference mechanisms (deduction, induction, abduction, means-end inferences) and a more precise definition of evidence and related terms. The applicability of this broader approach is presented for the development of the Canadian Consensus Guidelines for the Primary Care of People with Developmental Disabilities.

Theory, experience and practice

Despite its potential hazards, the activity of questioning theoretical frameworks and proposing solutions is necessary if progress is even to be possible. Intellectual history has by no means ended, so we cannot expect to have all the answers, and from time to time the activity of critical questioning will be frustrating. But intellectual progress requires us to continue the process of asking fundamental questions. The alternative to thinking in this way is indeed unthinkable.