Failure of the Problem-Oriented Medical Paradigm and a Person-Centered Alternative

Dear James,

great article on a person-centered and goal-oriented medicine.

To promote the integration of these aims within the daily medical decision-processes is also one of my basic interests.

Unfortunately, the needed medical attitude and communication skills to include the patient in a solution- and goal-oriented person-centered medicine are not or only insufficiently taught at most medical schools.

From many years of cooperation with experienced doctors, we have learned that there is a real need for repeated reflection on one's own medical practice and professional attitude, as well as for training the necessary communication skills. Preferably in supervised peer group meetings.

All our experience we have summarized in the book "Mastering the Medical Consultation - A Systemic, Solution-Oriented Process", Bruno Kissling, Peter Ryser, Free Association Books, London, 2021. (The German Original being awarded with the Book Prize of the European Society for Person-Centered Healthcare ESPCH)

The book goes through the consultation, step by step. It contains a pracitcal tool with samples of questions which involve the patient actively within the whole analyzing, "assessing" and therapeutic process. We show ways, how to build a sustainable relation between doctor and patient (the foundation of any collaboration); how to meet the patient on an equal footing - like two experts: the patient being the expert of their unique disease / illness, their psycho-socio-economical context, goals, values, beliefs, experiences and resources. The doctor as an expert of medical knowledge, their professional experiences and, not to forget, whomis always aware of the influence of their personal convictions. We show, how both, doctor and patient can reate a common reality, cope with uncertainty and ambivalence and go through a shared decision making process...

In the book we reflect also the reasons, why the proposed open-ended ways function.

To read a book is a good first step to wake the interest for the item, but we are convinced, that the communication skills have to be trained like all other medical skills, preferably in supervised groups.

We see the book as a contribution to the discourse about the urgently needed re-integration of the medico-technical advances and the patient as a person with their very personal values and goals. We stand for a medicine with the patient in the center of the interest. - A prerequisite for a medicine of high quality and satisfaction for both, the patient and his family, and not less for the doctor...

Let us go ahead.

Best wishes

Bruno

That medicine is complex [1] has already been known to Hippocrates in ancient times, and William Osler [2] and Ian McWhinney [3, 4] in the 20th century. Their calls for a new paradigm, one based on the ‘person’s needs at the centre of the system’, have long been ignored, though over the past 25 years many colleagues have called for it with Barbara Starfield [5, 6] and Andrew Miles leading the effort [7, 8].
The fundamental problem with all our health systems is their focus on disease. Our medical curricula all center around learning about diseases and their management in the abstract, and we rarely [9-11] if ever expose our medical students to patients’ experiences of what it means to live with their diseases. Consequently, we also never really assess their capabilities to acting as physicians who are able to apply their instrumental skills empathically in the context of a patient’s context and health goals [12, 13]. By the end of their course students have little if any appreciation that their patients’ mostly ‘good health’ experiences despite their ailments – their well-being emerges from adaptation with the frame of health being a balance between the physical, emotional, social and sense-making domains (the somato-psycho-socio-semiotic (SPSS) model of health) [14, 15].
The lack of professional as well as public discourse about the nature of health and health care entrenches and perpetrates the prevailing – more accurately called – disease management system. As we know from systems sciences the stability of a system depends on maintain its focus – as long as the focus is maintained even major system perturbations and crises will maintain its current structures and dynamic relationships [16-19].
In short systems changed equals change in FOCUS. Only a change in focus – from disease management to meeting the person’s needs in their entire context [20] – will allow the emergence of new health system structures and dynamics. This shift will result in the best possible application of our biomedical and biotechnical advances to the constantly changing needs of our patients in their personal health journey till the day of ‘going to the other world’. The redesign of a person-centered health systems is achievable [21], we know how to do it, and it is the ethical prerogative of health professionals (and in particular for us as general practitioners/family physicians [22, 23]) to lead the change effort. Jim Mold’s paper should act as the final catalyst to finally get us going [24].

References
1. Sturmberg JP, Martin CM. Complexity and health - yesterday's traditions, tomorrow's future. J Eval Clin Pract. 2009;15(3):543-8. https://dx.doi.org/10.1111/j.1365-2753.2009.01163.x
2. Osler W. The Old Humanities and the New Science. 1919: http://www.medicalarchives.jhmi.edu/osler/oldhum.htm.
3. McWhinney IR. 'An Acquaintance with Particulars ...'. Fam Med. 1989;21(4):296-8.
4. McWhinney IR. The Naturalist Tradition in General Practice. J Fam Pract. 1977;5(3):375-8.
5. Starfield B. Politics, primary healthcare and health: was Virchow right? J Epidemiol Community Health. 2011;65(8):653-5. https://dx.doi.org/10.1136/jech.2009.102780
6. Starfield B, Shi L, Grover A, Macinko J. The Effects Of Specialist Supply On Populations’ Health: Assessing The Evidence. Health Affairs - Web Exclusive. 2005(W5):97-105.
7. Miles A, Mezzich JE. 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. 2011;1(2):207-22.
8. Miles A, Mezzich JE. Person-centered Medicine: advancing methods, promoting implementation. International Journal of Person Centered Medicine. 2011;1(3):423-8.
9. Sturmberg JP, Reid S, Khadra MH. A Longitudinal, Patient-Centred, Integrated Curriculum: Facilitating Community-Based Education in a Rural Clinical School. Educ Health (Abingdon). 2002;15(3):294-304. https://dx.doi.org/https://dx.doi.org/10.1080/1357628021000012787
10. Sturmberg JP, Reid AL, Thacker JL, Chamberlain C. A community based, patient-centred, longitudinal medical curriculum. Rural and Remote Health (online) [Internet]. 2003 02-Apr-2022; 3(3):[ 210 p.]. Available from: http://rrh.deakin.edu.au/articles/subviewnew.asp?ArticleID=210
11. Kaufman A, Mennin S, Waterman R, Duban S, Hansbarger C, Silverblatt H, et al. The New Mexico Experiment: Educational Innovation and Institutional Change. Acad Med. 1989;64(6):285-94.
12. Sturmberg JP, Farmer EA. Educating capable doctors - A portfolio approach. Linking learning and assessment. Med Teach. 2008;31(3):e85-9. https://dx.doi.org/https://dx.doi.org/10.1080/01421590802512912
13. Sturmberg JP, Hinchy J. Borderline competence - from a complexity perspective: conceptualization and implementation for certifying examinations. J Eval Clin Pract. 2010;16(4):867-72.
14. Sturmberg JP. The personal nature of health. J Eval Clin Pract. 2009;15(4):766-9. https://dx.doi.org/10.1111/j.1365-2753.2009.01225.x
15. Sturmberg JP. Health: A Personal Complex-Adaptive State. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. p. 231-42.
16. Dolan SL, García S, Diegoli S, Auerbach A. Organisational values as "attractors of chaos": An emerging cultural change to manage organisational complexity. Department of Economics and Business, Universitat Pompeu Fabra; 2000. http://EconPapers.repec.org/RePEc:upf:upfgen:485
17. Sturmberg JP, Martin CM, Moes M. Health at the Centre of Health Systems Reform - How Philosophy Can Inform Policy. Perspect Biol Med. 2010;53(3):341-56. https://dx.doi.org/10.1353/pbm.0.0169
18. Sturmberg JP, O'Halloran DM, Martin CM. Understanding health system reform - a complex adaptive systems perspective. J Eval Clin Pract. 2012;18(1):202-8. https://dx.doi.org/10.1111/j.1365-2753.2011.01792.x
19. Rouse WB. Health Care as a Complex Adaptive System: Implications for Design and Management. The Bridge 2008;38(1):17-25.
20. Sturmberg JP, Picard M, Aron DC, Bennett JM, Bircher J, deHaven MJ, et al. Health and Disease—Emergent States Resulting from Adaptive Social and Biological Network Interactions. Frontiers in Medicine. 2019;6:59. https://dx.doi.org/10.3389/fmed.2019.00059
21. Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.
22. McWhinney IR. The Importance of being Different. William Pickles Lecture 1996. Br J Gen Pract. 1996;46(7):433-6.
23. Rose J, Riolo R, Hovmand P, Cherng S, Ferrer R, Katerndahl DA, et al. Modeling the Paradox of Primary Care. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer 2013. p. 815-25.
24. Mold JW. Failure of the Problem-Oriented Medical Paradigm and a Person-Centered Alternative. The Annals of Family Medicine. 2022;20(2):145-8. https://dx.doi.org/10.1370/afm.2782
For those in the quest, as much as it reinforces the core aim of the International Society for Systems and Complexity Sciences FOR Health (https://www.isscsh.org/).