Pinto Responds

Valuing and using patient input in diagnosis and treatment are principles that guide the ethics of medicine, social work, and public health without always being realized in practice.^1–3 These principles are crystallized in social work’s person-in-environment concept, which asks practitioners to conduct thorough assessments of patients’ health, psychosocial and environmental issues to ensure linkages from assessment to intervention.⁴ This resembles the transdisciplinary approach in Brazil’s Sistema Único de Saúde (SUS; Unified Health Care System) and differs from the philosophy of evidence-based practice (EBP), which encourages practitioners to base clinical decisions on a hierarchy of rigorous evidence. EBP privileges results from randomized controlled trails and quasi-experimental designs,⁵ tends to ignore patient input, and so may miss contextual issues that might inform proposed interventions.⁶

Our model, focused on Brazil’s SUS, suggests a correlation between the practitioners’ use of patient input in treatment planning and service integration. We collected data from 32 physicians (12% of the sample) from 30 clinics in two municipalities, and from community health workers and nurses. Each clinic employed at most two physicians. There is no simple explanation for large differences in EBP engagement across professions. But understanding the interaction of small effects, as our study shows, will help us expand the concept of rigorous evidence to include patient input to help patients address their multiple health, psychosocial, and environmental problems.

Another, previously unseen association in our model was a significant effect of EBP on practitioners’ familiarity with the community they served. Brazil’s SUS means to provide free primary care to all citizens, and it employs nearly 300 000 community health workers (CHWs) as liaisons between physicians and nurses and community members.^7,8 Our qualitative data showed that CHWs were using empathic communication and perseverance to engage patients in positive health behaviors. These strategies reflect the value CHWs place on patients’ experiential knowledge and input to guide their practice.⁹ We encourage researchers and practitioners to expand our adaptable model to include other practitioner-level and patient-level factors that may have an effect on EBP.¹⁰ By becoming more familiar with the culture and day-to-day of patient struggles, as CHWs are, physicians and nurses may become better able to understand their patients as fully integrated in the environment and more often use their input in practice. Expanding studies of such practice is the only way to determine with rigorous evidence the added value of such knowledge and input.