Patient Centric Orthopaedics, Patient Oriented Research and Concept of Clinicothesis

Abstract

Few months back, I wrote an editorial on ‘Patient is the centre of all Medical Research’ [1], and I believe this editorial is a follow up to the same. Many colleagues who read the earlier editorial contacted the editorial office and presented contrasting and conflicting opinions on the editorial. Most in principles agreed that the outcome of research should be beneficial to the patient, but had difficulty in accepting that research design should consider this as the major outcome measure rather than objective clinical outcome measures. The difficult was not is accepting that the final suit will be worn by the patient, but that the concept should be ingrained in the fabric of research itself. Currently a lot of academic research is designed based on, finding the gap in literature or finding topics where the literature is sparse and trying to conduct a study to either establish or reinforce a particular hypothesis. Many a times the basis of original hypothesis is not really tested. For example few days back, I was attending a research meeting of physiotherapy masters students and one student wanted to do a study on ‘Effect of therapy protocol ‘A’ on balance and proprioception in chronic stroke patient’. The further inquiry lead to fact that this protocol is simply a modification of an established protocol. When asked if there is any significant modification done, the answer were some additional exercises, however there was no rational behind adding those exercises, does this new protocol target something that was deficient in the established regimen or the modification was done simply to find a topic for thesis? Again a final query, whether the results of this research would impact the clinical practice or patient outcome, was not answered to satisfaction. While writing research protocols, researchers do a good review and base their study hypothesis on the arguments from literature review. The hypothesis tries to establish scientific relation between variables and is in form of a question similar to what was posed in the above example. The aim of answering the hypothesis is to provide a scientific explanation of the topic that is studied. I believe in addition to hypothesis, every clinical project should also have the question that states ‘how would result of this study affect clinical practice and patient care’. This ‘Clinicothesis’ [an intellectual proposition of Clinical value] is completely focuses on clinical and practical application of the results. From literature review we may conclude that a particular scientific hypothesis needs to be tested and will answer a scientific query. However if from literature review and also personal experiences the researcher come to a conclusion that doing this study would not impact patient care in any meaningful way (Clinicothesis), then it would be waste of resources to conduct the study. Thus at times these would be conflicting scientific and clinical propositions and in clinical studies it is wise to conduct studies where the clinical application has a solid base. Probably this is what can be done to establish a patient centric medicine. The word ‘Patient Centric Medicine’ (PCM) was introduced by British psychoanalyst Balint E in 1969 [2], however I believe the context was quite different. The original concept was introduced against the illness based medicine that was prevalent in those days. The original movement was supported by many and a renewed focus on patient, the social context of his lives and also the system of society that help the patient were proposed to be taken into account while taking clinical decisions about patient [3]. Although the original use was in different context of clinical practice yet it emphasised the importance of shifting the focus from the illness to the patient as a whole. I have used the word in contract to Evidence based Medicine to shift the focus from evidence back to patient again. This has been quite evident in small private case discussion forums where clinicians come together to discussion some complex cases. There are few who would simply quote papers and evidence to make a point, completely ignoring the patient factors and the operative surgeon’s opinions. This doesn’t mean EBM is not trying to be patient centric, just that we are trying to remind ourselves and the research community at large that Clinical paradigm and being patient centric is as important as choosing the correct evidence based research methodology. In that sense at times even biased studies would be more clinically relevant while some strictly unbiased studies might have no clinical relevance at all [4]. The main difference between EBM and PCM, is that EBM Tries to create the hierarchy of valid studies based on reduced bias, while PCM will try to create the hierarchy based on clinical relevance of the study. EBM is an excellent concept to design and execute studies and if it is combined with Clinicothesis and interpreted using PCM concept, the final outcome of studies will create real impact in real world of patient care and not simply exist in pages of journals. We will continue to expand this concept in future editorial too, but to conclude patient oriented research based on valid Clinicothesis and interpretation of studies based on their PCM are important concepts to integrate to current academic research practices. Please write to us at [e-mail] for your comments and suggestions about the concept. Please send your views by email to us at [e-mail] Regards Editor – JOCR