Evidence should inform more than prescribing decisions

Short abstract

Linked Article: Hewitt et al. Br J Dermatol 2022; 187:82–88.

For many years researchers have investigated optimal approaches to delivering patient‐centred care. Patient‐centred medicine was a term first used by Michael Balint in the late 1960s; it challenged the orthodox illness‐oriented model of care and proposed seeing each patient as a unique human being. ¹ The notion of patient‐centred care has evolved; recent reviews suggest nine core themes: (i) empathy, (ii) respect, (iii) engagement, (iv) relationship, (v) communication, (vi) shared decision making, (vii) holistic focus, (viii) individualized focus and (ix) coordinated care. ² In more recent years the focus has shifted to person‐centred care, the key difference being the aim of the former is a functional life, while the latter strives to enable a meaningful life. ² Both concepts have a clear place in dermatology care where people are living with conditions such as psoriasis which impact on wellbeing and quality of life. Shared decision making is a key component of person‐centred care. ³ It is essential in dermatology practice, ⁴ , ⁵ as it provides a foundation to enable the significant and sustained self‐management that must be integrated into the person’s everyday life.

The ‘personal models of illness’ theory emerged in the 1990s and defines ‘personal models’ as an amalgamation of individual beliefs, emotions, knowledge, attitudes and experiences that influence behavioural responses to illness. ⁶ Existing research mainly focuses on patients, but one study of clinician personal models in psoriasis concludes that although most participants recognized psoriasis as a complex condition they continued to treat it as a skin condition alone. ⁷

In this issue of the BJD, Hewitt et al. ⁸ report on a qualitative study designed to deepen understanding about how dermatologist’s personal models inform a patient‐centred approach to psoriasis management with a focus on prescribing a new treatment. In this rigorous research a patient‐centred approach to clinician’s care decision was not universal. One clinician offered the powerful quote: ‘Well, my patients, they actually do what I tell them to do (laughs) […] In this regard, I am conservative (laughs) and if you don’t like that, you should find someone else.’

In dermatology, as with all healthcare, we espouse the principles of evidence‐based practice. In prescribing Apremilast clinicians will be adhering to evidence‐based guidance. This article points to the need to give more thought to other types of equally important evidence. We know that person‐centred care can improve patient satisfaction, knowledge and quality of life in other long‐term conditions, for example prevention and treatment of chronic wounds. ⁹ Extensive literature suggests shared decision making is a key component of person‐centred care in dermatology. ⁵ Now is the time to influence the personal models of those clinicians who have yet to integrate this important evidence that will improve patient experience and outcomes.