Background
During the second half of the 20th Century medical diagnosis was progressively simplified by identification of a reduced set of symptoms and signs for every disease which was consequently incorporated to operational diagnostic systems and clinical guidelines. These systems increasingly relied on laboratory testing, biomarkers, imaging techniques and support decision systems. However, this approach is also related to extreme specialisation and uncontrolled commoditisation of the health care field, resulting in neglect of patients' personal needs and concerns, and weakening of the doctor–patient relationship (Heath, Reference Heath2005). Person-centred medicine proposes the whole person and his/her context as the centre and goal of clinical care and public health (Salloum & Mezzich, Reference Salloum and Mezzich2011) taking into account the patients' values and health experiences, as well as to their resilience, environmental and personal resources, quality of life, and other aspects of positive health (Mezzich et al. Reference Mezzich, Salloum, Cloninger, Salvador-Carulla, Kirmayer, Banzato, Wallcraft and Botbol2010a).
In a landmark report, the Institute of Medicine concluded that the U.S. health system was seriously flawed and requires a new framework with a new set of aims and rules, a key principle being person-centredness (Institute of Medicine, 2001). Along the same lines, the U.S. Presidential Commission on Mental Health (2003) found the national mental health care system is in a state of disarray and proposed a thorough transformation of the system to be driven by the patient and the community. The World Health Organization European Office (2005) proposed an Action Plan to reorganise mental health care around the needs of patients and carers. A similar approach has been adopted in the UK (Department of Health, 2009).
A short history of person-centred medicine
The personalised approach is a distinctive pattern of many ancient medical systems, for example Chinese and Ayurvedic, where practitioners follow the bodily state and the experience of the patient from visit to visit and adjust treatment accordingly (Kirmayer, Reference Kirmayer2004). Ancient Greek philosophers and physicians also advocated for a holistic approach and such encompassing Eastern and Western views are consistent with the World Health Organization's broad definition of health as a complete state of physical, emotional and social well-being, and not merely the absence of disease (Mezzich et al. Reference Mezzich, Salloum, Cloninger, Salvador-Carulla, Kirmayer, Banzato, Wallcraft and Botbol2010a).
The development of the person-centred approach is closely linked to a restricted number of medical disciplines, as family medicine, psychiatry, paediatrics, geriatrics and general internal medicine. Paul Tournier, a Swiss general practitioner, made a seminal contribution to the renaissance of person-centred medicine in the 1940s (Pfeifer, Reference Pfeifer2010). A patient-centred ‘medical home’ model, which aims to provide comprehensive primary care and facilitate partnerships between individual patients and their physicians and, when appropriate, the patient's family, was developed in 1967 by the American Academy of Paediatrics and endorsed later by the American Academy of Family Physicians and a growing number of national health professional associations (Rosenthal, Reference Rosenthal2008). Family physicians have adopted a holistic and contextualised patient-centred approach (McWhinney, Reference McWhinney1989). The American physician Eric Cassell highlighted the importance of suffering as an experience of the whole person, and introduced the concept of personhood in general medicine (Cassell, Reference Cassell1982; Cassell, Reference Cassell2010).
Mental health has also played a decisive role in shaping the person-centred model. In the 1940s Carl R. Rogers in the U.S. argued for a Client-Centered Therapy and for the value of open communication and empowering individuals to achieve their full potential (Rogers, Reference Rogers1951, Reference Rogers1961). The beginnings of the World Psychiatric Association (WPA) in 1950 already revealed interest on the concept of the person as central to the field (Garrabe, Reference Garrabe2008). W.A. Anthony incorporated the concept of personhood and recovery to the psycho-social rehabilitation field (Anthony, Reference Anthony1993, Reference Anthony2004). This approach goes beyond the focus on symptom management and functional improvement to promote wellness and quality of life, in a process that involves shared decision-making, and where the needs of the patients always come first.
The Finnish psychiatrists Y.O. Alanen developed the Need-adaptive Assessment and Treatment approach, which encourages attention to the meaning of patients' experiences and to the nature of their needs (Alanen, Reference Alanen1997). The interest on person-centredness has kept pace with a renaissance of philosophical analysis in psychiatry aimed at addressing the complexity of illness experience and engaging the patient as a person. Values-based practice (Fulford et al. Reference Fulford, Dickenson and Murray2002) and the multilevel explanatory schemas (Schaffner, Reference Schaffner, Salloum and Mezzich2009) are key contributions to this movement.
Psychiatry has also played major role in developing a common framework by encouraging networking and bridging in this area. During the past decade the Section on Classification, Diagnostic Assessment and Nomenclature of the WPA promoted and extended the person-centred approach to diagnosis and intervention based on the person-centred model (Mezzich & Ustun, Reference Mezzich and Ustun2002; Banzato et al. Reference Banzato, Mezzich and Berganza2005; Salloum & Mezzich, Reference Salloum and Mezzich2009). This group developed the International Guidelines for Diagnostic Assessment (IGDA), a comprehensive diagnostic schema that integrates a standardised multiaxial formulation, employing scales and official typologies yielding information comparable across the world on illnesses, disabilities, contextual factors and quality of life, and an idiographic, personalised statement allowing clinicians, patients and families to indicate what is unique and most meaningful in the contextualised clinical situation, including positive factors, as well as joint plans for restoration and promotion of health.
Members of the Classification Section and several other WPA scientific sections actively cooperated in the organisation of the Geneva conferences on person-centred medicine (Mezzich, Reference Mezzich, Snaedal, Van Weel and Heath2011b), from which aroused the International Network for Person-centred Medicine (INPCM) (Mezzich, Reference Mezzich2011a), now the International College of Person-centred Medicine (ICPCM) and the International Journal of Person-Centred Medicine (Miles & Mezzich, Reference Miles and Mezzich2011). These initiatives have been landmarks in a process of building a movement of medicine for the person through the collaboration of major global medical and health organizations and a growing group of committed individuals.
The institutions formally involved in the Geneva Conferences have included the World Medical Association (WMA), the World Organization of Family Doctors (Wonca), the International Network for Person-centred Medicine, and other organisations such as the Council for International Organizations of Medical Sciences (CIOMS), the World Federation for Mental Health (WFMH), the World Federation of Neurology (WFN), the World Association for Sexual Health (WAS), the International Association of Medical Colleges (IAOMC), the World Federation for Medical Education (WFME), the International Federation of Social Workers (IFSW), the International Council of Nurses (ICN), the European Federation of Associations of Families of People with Mental Illness (EUFAMI), the International Alliance of Patients' Organizations (IAPO), the University of Geneva School of Medicine and the Paul Tournier Association. Since 2010, the Geneva conferences have been organised together with WHO (Health Systems and other Departments).
The Person-centred Integrative Diagnosis (PID)
The PID is a person-centred approach to diagnosis that continues and expands the previous work made at IGDA. Psychiatric diagnosis is here regarded as an assessment process not only for nosological or differential diagnosis but also for the understanding of the person experience and its contextual instances. The development of PID included three focus or discussion groups with psychiatrists, health professionals and other health stakeholders (patients, families and advocates), and a survey of a global network of national classification and diagnosis groups. The main findings from these consultations include the perception that planning of treatment and care (rather than illness identification or inter-clinician communication) is the main purpose of diagnosis; the desirability of simplifying standard psychopathological classifications through clusters and prototypes; and that diagnosis should cover not only disorders but also disabilities, positive aspects of health, risk and protective factors, and the patient's values and experience on illness and health. These consultations also supported the use of dimensions and narratives in addition to categories as descriptive tools; and the importance of basing the diagnostic process on an active partnership among clinicians, patients and families. These consistently expressed perspectives seem to strongly support a person-centred diagnostic approach in contrast to the conventional disease-centred diagnosis (Mezzich et al. Reference Mezzich, Salloum, Cloninger, Salvador-Carulla, Kirmayer, Banzato, Wallcraft and Botbol2010a).
The PID conceptual framework covers domains of both ill health and positive health along three complementary levels: Health Status, Experience of Health and Contributors to Health (Fig. 1) (Mezzich et al. Reference Mezzich, Salloum, Cloninger, Salvador-Carulla, Kirmayer, Banzato, Wallcraft and Botbol2010a).
Fig. 1. PID domains.
The domain level on Health Status, includes first illnesses or disorders of both mental and physical forms which should be assessed according to the international standards (mainly WHO's International Classification of Diseases and related diagnostic tools). Disabilities would be assessed through procedures such as those based on the International Classification of Functioning and Health (ICF) (WHO, 2001). The assessment of the well-being aspect of Health Status should be developed through scales appraising quality of life and related constructs (Cloninger & Cloninger, Reference Cloninger and Cloninger2011). The domain level on Experience of Health appraises the patient's illness- and health-related values and cultural experiences, which should take into account guided narrative procedure built on world-wide experience with the Cultural Formulation (Mezzich et al. Reference Mezzich, Caracci, Fabrega and Kirmayer2009). The third domain level on Contributors to Health covers the intrinsic and extrinsic biological, psychological and social factors of both risk and protective types. Their assessment should involve a combination of procedures aimed at assessing healthy and unhealthy life-style factors and related health contributors (Alonso et al. Reference Alonso, Walsh and Salvador-Carulla2010; Cloninger & Cloninger, Reference Cloninger and Cloninger2011).
The PID conceptual model is also linked to a novel evaluation system and new cooperation needs. The Pluralistic Descriptive Procedures system (Mezzich et al. Reference Mezzich, Salloum, Cloninger, Salvador-Carulla, Kirmayer, Banzato, Wallcraft and Botbol2010a) follows an open building-blocks approach to generate an evaluation system usable within the PID framework. For example, the diagnostic evaluation process should be broadened to incorporate probabilistic and prototypical categories (Westen, Reference Westen2012), clinimetrics (Feinstein, Reference Feinstein1987) and categorical–dimensional hybrid models (Muthén, Reference Muthén2006). It should also incorporate narratives as a critical component of the evaluation process, given its importance of understanding patients' illness experience in the context of their life stories and current illness narratives. The person's illness narrative and account of health and resilience offer the clinician a clear picture of issues and priorities that can organise and guide clinical intervention (Kirmayer, Reference Kirmayer, Mattingly and Garro2000).
Psychiatric research has already incorporated many of the components of PID in transcultural studies (Mezzich et al. Reference Mezzich, Caracci, Fabrega and Kirmayer2009), managerial epidemiology (Krumholz et al. Reference Krumholz, Currie, Riegel, Phillips, Peterson, Smith, Yancy and Faxon2006) and translational research (Wang et al. Reference Wang, Heinssen, Oliveri, Wagner and Goodman2009; Ruggeri, Reference Ruggeri2011). However, the practical implementation of Pluralistic Descriptive Procedures implies a full change of mental health evaluation, particularly as regards to the incorporation of narratives, personal experiences and positive health components such as resilience or flourishing. Narratives have been used extensively in qualitative research and are a valuable source of information (Charon, Reference Charon2006), but the development of a set of metaphors for quantitative analysis, and its use in routine practice or to generate evidence-informed care poses many challenges to psychiatric evaluation. The use of Semantic Web Knowledge techniques (Tao et al. Reference Tao, Wei, Solbrig, Savova and Chute2010) in the analysis of narratives may allow for extensive review of the personal experiences of patients with severe mental disorders including positive accounts of recovery (Roberts, Reference Roberts2000). The development of narrative banks of health experiences may contribute to a better understanding of positive and negative aspects of ill health and may also contribute to improve diagnosis and treatment planning based on personal preferences and experiences. This approach has been suggested to improve knowledge on medication intake, attitudes and adherence in mental disorders (Tibaldi et al. Reference Tibaldi, Salvador-Carulla and García-Gutierrez2011). PID has been adopted by the Revision of the Latin American Guide for Psychiatric Diagnosis (GLADP) produced by the Latin American Psychiatric Association (Saavedra et al. Reference Saavedra, Otero, Salloum and Mezzich2011a). It is important to note that the scientific application of the PID principles should not be limited to high income countries, as they are particularly important in low- and middle-income countries.
The World Health Organisation has recently produced Community-Based Rehabilitation (CBR) guidelines (WHO, 2010a) within its CBR programmes currently applied in over 90 countries. In order to provide a common framework for the CBR programmes a CBR matrix was developed in 2004 which consists of five key components: health (including promotion and prevention), education, livelihood, social and empowerment. The later includes advocacy and communication, community mobilisation, political participation, self-help groups and disabled peoples organisations. Recent psychiatric epidemiological studies in Peru covered ill- and positive-health, and employed narratives in addition to categories and dimensions (Instituto Nacional de Salud Mental, 2002; Saavedra et al. Reference Saavedra, Cruz and Mezzich2011b).
In order to put the PID model into practice the development of cooperation is essential. Therefore, Partnership for Evaluation is a fundamental element of person-centred care, and involves the pursuit of engagement, empathy and empowerment as well as respect for the autonomy and dignity of the consulting person. In fact, it is crucial for achieving shared understanding for diagnosis and shared decision making for treatment planning with the patient and his/her family (Mezzich et al. Reference Mezzich, Salloum, Cloninger, Salvador-Carulla, Kirmayer, Banzato, Wallcraft and Botbol2010a).
Bridging and knowledge transfer in person-centred medicine
Being a multidisciplinary and relational field (Mezzich, Reference Mezzich2011a), person-centred medicine is closely linked to the new science of bridging, knowledge management and knowledge transfer.
Bridging encompasses a broad range of concepts, tasks, technologies and practices aimed at improving knowledge sharing and cooperation in care and support for persons with health problems. Bridging concepts should be based in health ontology and develop a common terminology knowledge base (Salvador-Carulla, Reference Salvador-Carulla2009). Once a PID model has been agreed, it may be helpful to agree to the development of a conceptual map of related concepts, as well as a link with the ontology health databases such as SNOMED-CT (Rosenbloom et al. Reference Rosenbloom, Brown, Froehling, Bauer, Wahner-Roedler, Gregg and Elkin2009). For example, it is necessary to clarify the existing difference between the concepts of well-being, quality of life, health experiences and values and contributors to health. The ontology and the semantic interoperability of the information systems developed in areas related to person-centred care has to be established. Bridging tasks may include all activities of dissemination, coordination, assessment, empowerment, delivery, management, financing and policy within the field of person-centred medicine. Bridging technologies include mainly information technologies, and the evaluation system that may eventually provide a usable battery of assessment instruments, analysis techniques and evaluation guidelines. Bridging practices in the field of person-centred medicine should also be registered and incorporated to practice banks.
Knowledge transfer is not a linear one-time event; it requires ongoing active dialogue and exchanges between researchers, policy makers, practitioners and client groups, in order to develop and to implement a holistic integrative care and support; or to effectively exchange the procedures and experiences in translational research, transdisciplinarity, and in the development of multidisciplinary groups in research, education, provision, management and policy (McDaid et al. Reference McDaid, Cieza and Gomez2009). The role of networks, knowledge brokering and partnerships deserve special attention. The coordination and partnership may include all stakeholders from health researchers to policy decision makers and society. In 2009, the Barcelona declaration on bridging and knowledge transfer opened the road for a formal development of this field (Salvador-Carulla et al. Reference Salvador-Carulla, Balot, Weber, Zelderloo, Parent, McDaid, Solans, Knapp, Mestheneos and Wolfmayr2009). Several members of the International Network of Person-Centred Medicine participated in the related international conference and contributed to define this new field of expertise.
Setting links with people-centred care and personalised medicine
Health-related person-centredness and PID encompasses all health sciences and person-centred medicine should be defined within the broader context of person-centred care. However, the relationship, boundaries and hierarchy of person-centred medicine should be established with the areas of people-centred care and personalised medicine to enable a more effective model of integrated care.
According to WHO, people-centred care covers person-centred care as it is an umbrella term that better encapsulates the foremost consideration of the patient across all levels of health systems (WHO, 2010a). The WHO vision for people-centred health care ‘is one in which individuals, families and communities are served by and are able to participate in trusted health systems that respond to their needs in humane and holistic ways. The health system is designed around stakeholder needs and enables individuals, families and communities to collaborate with health practitioners and health care organizations in the public, private and not-for-profit health and related sectors in driving improvements in the quality and responsiveness of health care’ (WHO, 2007). Providing equitable access to people-centred care has been described as one of the key components of an effective health system by WHO (WHO, 2010b).
However, differences exist between the individual care approach and the population policy approach that go beyond this perspective. The WHO proposal of a hierarchical relationship of these terms into one parent category (people-centred care) and a child category (person-centred care) should be revised. Recent developments in people-centred care and person-centred care are closely coordinated particularly through the partnership developed at the Geneva conference series since 2010 (Mezzich, Reference Mezzich2011b).
The advances in new diagnostic and treatment technologies have coalesced in the model of personalised medicine (Abrahams et al. Reference Abrahams, Ginsburg and Silver2005) aimed at tailoring diagnosis and treatment to every individual's genomic profile and biomedical characteristics. As person-centred medicine has produced an integrative model of diagnosis, a similar process has occurred in the field of individualised medicine. ‘Theranostics’ (a term formed by the combination of ‘Therapeutics’ and ‘Diagnostics’) describes the process of diagnostic therapy for individual patients using biomarkers to test possible reaction to taking a new medication and to predict the most suitable drug for a patient along with assessing the efficacy of the drug and other care interventions (e.g. changes in health-related habits) based on the test results. Theranostics is broadly used in functional imaging and nanomedicine. Both personalised medicine and theranostics are highly commoditised and have raised an increasing interest by health companies and governments in contrast with the limited commercial support provided to implement person-centred medicine into actual practice. A ‘Genomics and PersonalizedMedicine Act’ was introduced to the US Congress in 2006, 2007 and 2010 to address scientific barriers, adverse market pressures and regulatory obstacles even though the reliability, the health economic aspects and usability of personalised medicine is still in its infancy (Ng et al. Reference Ng, Murray, Levy and Venter2009).
In spite of their evident complementarities, personalised medicine and person-centred medicine are currently at odds. These two approaches will certainly have a major impact in mental health care, training and policy. It may be path-opening that high-tech personalised medicine and person-centred medicine that articulates science and humanism build bridges to develop an integrative medical practice that finally encompasses high technology with high human contact. Current models of integrative care do provide a framework for supporting this common perspective on behavioural sciences and mental health (Singer & Ryff, Reference Singer and Ryff2001).
Declaration of interest
None.
