Power to the Patient

Against a backdrop of splintered political parties, polarizations within nations, civil unrest, and distrust of established government (such as the growing anti-Washington, D.C. sentiment) comes the not-so-surprising finding that health care authorities and practitioners (with perhaps the exception of insurers) are turning over more and more powers to the individual patient.

This seems to be the natural consequence of the trend, starting from which what was once considered to be peer-reviewed and published evidence that had the power of Gospel to go through its first greening with the 1997 declaration by Sackett:

"Good doctors use both individual clinical expertise (italics mine) and the best available external evidence, and neither alone is enough (emphasis added). Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient."¹

And then the second shoe dropped. By this, I mean the values and expectation of the patient joined the scientific literature and the clinician's judgment in constituting what now became the triad of evidence-based medicine.

This construct was anointed with what could be considered to be its official blessing by Sackett in 2000, who then described EBM as "the integration of best research evidence with clinical experience and patient values."² O'Connor drove the point home a year later by pointing out that "with patients considered the best judge of values, clinical decisions were being recognized as necessarily shared between the patient and the clinician."³

A second line of attack on past principles of patient care seemed to occur in the early 2000s when the term based in EBM was judged to be just a wee bit too hidebound, if not dictatorial, in telling physicians what and what not to do. Instead, the kinder and gentler term informed came into play so as to allow ample breathing space for patient and clinician alike.⁴

Clinical Practice Guidelines: Impact of Patient Preference

From the point of view of the chiropractor, the emerging power of the patient couldn't have been more obvious than what emerged as an updated Delphi panel's production of clinical practice guidelines in 2015.⁵ Here, one finds such clues of the growing importance of the patient as the following:

• Depending upon the individual patient, the clinician may, in certain instances, bypass passive treatments in the initial course of treatment for low back disorders.
• Accommodations are made for the use of ultrasonography or electrical stimulation as part of a multimodal approach, based on clinician judgment and patient preferences – despite the scarcity of definitive published evidence (italics mine). The same is true for lumbar supports in both acute and chronic cases.
• Emphasis is made upon the fact that the patient and clinician must work as a proactive team, outlining the patient's responsibilities. In so doing, active (i.e., exercise) intervention needs to be increasingly integrated in order to increase function and return to the patient's regular activities.
• Patients who are interested in wellness care should be given those options as well. This has much to do with realistically defining what maximal medical improvement is attained and whether maintenance care would be indicated to reduce the likelihood of recurrent episodes of back pain.
• Patient input concerning treatment expectations or support from close relatives or friends affect whether a transition from acute to chronic takes place, and how quickly.
• Prognostic factors based upon the patient's history, age, psychosocial factors, and occupation status are becoming more influential determinants of the course of treatment.
• In describing the outlines of patient power, the authors actually "come out" by plainly declaring that their guidelines are the first to be specific for this purpose, broadly endorsing this concept.

Where Do We Go From Here?

So there you have it – game, set, and match. More and more, it is becoming clear that a patient override feature, at least in chiropractic management of low back pain, is coming into prominence. Thus, it is no surprise that such patient-centered outcome measures as the Health Related Quality of Life Index or even the real-life concerns of cost-effectiveness are becoming more widespread.

Actually, Meridel Gatterman was one of the first to expound upon the significance and value of input from the individual patient when she outlined the principles of a patient-centered paradigm, incorporating such expansive principles as vitalism, holism, humanism, conservatism, naturalism, and rationalism – all identified by a consensus panel with recognition of respect for the patient's values and beliefs.

As long ago as 1995, Gatterman pointed out that patient-centered research needed to reach beyond the randomized, controlled trial into real-world assessments, including both qualitative and quantitative studies.⁶ As in so many instances, this is a vivid demonstration as to why chiropractors must have a seat at the table in determining the course of health care delivery – and by that, I mean the actual table, not the children's table.

I can't help but think that much of this evolution traces back to the dilemma so eloquently presented by Niels Nilsson at the Foundation for Chiropractic Education and Research's International Conference for Spinal Manipulation in 2000,⁷ pointing out that so many of the striking responses of patients to treatment in the doctor's office are severely attenuated when it comes to trying to capture these in conventional outcome measures in randomized clinical trials – and that more patient-responsive instruments are needed.

Now, 16 years later, even randomized, controlled trials and systematic reviews appear to be paying more attention to patient subsets to allow for this variability from individual to individual. I might even go so far as to suggest that, in addition to between-group statistical analyses in evaluating the outcomes of randomized, controlled trials as an earmark of scientific rigor, departures from the respective baselines from each of the experimental groups of participants being compared should be given more serious attention (assuming the baselines themselves are matched).

Finally, the rising tide of individualism in health care treatment may ultimately be part of the overhaul of the traditional pyramid of rigor in the medical sciences, in which case and even cohort studies were once looked down upon in favor of grouping individuals in the more widely accepted randomized, controlled trials. Now, there appears to be more a leveling of the playing field as the entire concept of EBM is reassessed, as I have described at greater length recently.⁸

Indeed, the past two decades could be viewed upon as ones experiencing the emergence of the patient as an active member in health care delivery.

References

1. Sackett DL. Evidence-based medicine. Semin Parinatol, 1997;21:3-5.
2. Sackett DL, et al. Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill-Livingstone, 2000.
3. O'Connor A. Using patient decision aids to promote evidence based decision making. EBM Notebook, 2001;6:100-102.
4. Glasziou P. Evidence based medicine: does it make a difference? Make it evidence informed practice with a little wisdom. BMJ, 2005;330(7482):92; discussion 94.
5. Globe GA, et al. Clinical practice guidelines: chiropractic care for low back pain. JMPT, 2016 Jan;39(1):1-22.
6. Gatterman MI. A patient-centered paradigm: a model for chiropractic education and research. J Altern Complement Med, 1995;1(4):371-86.
7. Nilsson, N. Keynote address, International Conference on Spinal Manipulation. Bloomington, Minn., Sept. 21, 2000.
8. Rosner A. Evidence-based medicine: revisiting the pyramid of priorities. J Bodywork Movement Ther, 2012;16(1):42-49.