Person-centred care and traditional philosophies in the evolution of osteopathic models and theoretical frameworks: Response to Esteves et al.

Abstract

We congratulate Esteves et al. on their provocative article titled “Models and theoretical frameworks for osteopathic care – a critical view and call for updates and research” [[1]Esteves J.E. Zegarra-Parodi R. van Dun P. Cerritelli F. Vaucher P. Models and theoretical frameworks for osteopathic care - a critical view and call for updates and research.Int J Osteopath Med. 2020; https://doi.org/10.1016/j.ijosm.2020.01.003Abstract Full Text Full Text PDF Scopus (35) Google Scholar]. The points raised by the authors regarding the need for academics to critically engage with the central tenets of osteopathy are irrefutable. Thought leadership in any field requires advancement of scholarship. The current pattern of research activities within osteopathy reflect a more task-oriented viewpoint whereby a substantial proportion of research is focused on clinical or educational activities [[2]Steel A. Blaich R. Sundberg T. Adams J. The role of osteopathy in clinical care: broadening the evidence-base.Int J Osteopath Med. 2017; 24: 32-36Abstract Full Text Full Text PDF Scopus (20) Google Scholar]. This may reflect the self-identity of many osteopathy academics as ‘clinicians who research’ or ‘clinicians who teach’ [[3]Steel A. Hemmings B. Sibbritt D. Adams J. Research challenges for a complementary medicine higher education institution: results from an organisational climate survey.Eur J Integrat Med. 2015; 7: 442-449Abstract Full Text Full Text PDF Scopus (8) Google Scholar]. If this is the case, for osteopathy researchers to undertake the type of research proposed by Esteves et al. they need to shift their identity to being ‘researchers first’. As we reflected on this article, we identified two points for which we wished to contribute to the discussion and encourage the osteopathic research community to thoughtfully consider as the profession evolves: person-centred care and traditional knowledge in contemporary practice. As mentioned by Esteves et al., person-centred care (PCC) is dominant and increasing in interest within the wider discourse of health and medicine, as well as in public health policy [[4]World Health Organisation WHO global strategy on people-centred and integrated health services: interim report. World Health Organisation, Geneva2015Google Scholar], but not necessarily in applied practice [[5]Moore L. Britten N. Lydahl D. Naldemirci Ö. Elam M. Wolf A. Barriers and facilitators to the implementation of person-centred care in different healthcare contexts.Scand J Caring Sci. 2017; 31: 662-673Crossref PubMed Scopus (161) Google Scholar]. While PCC is not unique to osteopathy, conventional medicine is still challenged to implement it; patients are often experiencing the conventional health system as lacking in PCC, resulting in unmet health needs and unsatisfactory experiences of clinical care [[6]Fox S. Chesla C. Living with chronic illness: a phenomenological study of the health effects of the patient–provider relationship.J Am Acad Nurse Pract. 2008; 20: 109-117Crossref PubMed Scopus (29) Google Scholar,[7]Håkanson C. Sahlberg-Blom E. Ternestedt B.-M. Being in the patient position: experiences of health care among people with irritable bowel syndrome.Qual Health Res. 2010; 20: 1116-1127Crossref PubMed Scopus (39) Google Scholar]. While professions such as osteopathy may have values that align with PCC [[8]Foley H. Steel A. The nexus between patient-centered care and complementary medicine: allies in the era of chronic disease?.J Alternative Compl Med. 2017; 23: 158-163Crossref PubMed Scopus (18) Google Scholar], they may not be fully manifesting all aspects of PCC in the application of those values to practice [[9]Foley H. Steel A. Patient perceptions of patient-centred care, empathy and empowerment in complementary medicine clinical practice: a cross-sectional study.Adv Integrat Med. 2017; 4: 22-30Crossref Scopus (23) Google Scholar]. Traditional medicine philosophies such as holism have contributed to shaping the osteopathic approach as it relates to PCC, though while holism and PCC are similar, they are not the same. Additionally, while PCC explicitly aims to centre patients in practice, discussion around the practice of PCC or the alignment of holistic philosophy with PCC takes place with little input or guidance from patients themselves. If clinicians are to claim a PCC paradigm of practice, confirmation of this through research examining patient perspectives is essential and may also provide the evidence required to distinguish the identity of osteopathic practice from person-centred practices in conventional medicine settings. Members of our team are currently undertaking research to address this gap for osteopathy and other professions with traditional values argued to align with PCC and hope that the outcomes of our research will be valuable to this wider conversation among the osteopathic research and professional community. Irrespective of the outcomes of our research, osteopaths may benefit from adopting the PCC model more explicitly in their training. Challenging the curriculum to align with PCC in collaboration with the five models of osteopathic care may assist in reducing the gap in treatment often seen by osteopathic patients who present with conditions that do not marry up to a textbook description of disease or illness. Often in such cases the involvement of other aspects of health outside of the five models can benefit treatment through a sense of a therapeutic relationship and empowerment to govern one's own health. A syncretic collaboration between the principles of PCC and the five models of osteopathic care will also shed light on the unique capacities of osteopathic care to deliver truly person-centred services informed and shaped by the traditional foundations of the profession, preserving the value of osteopathic identity while maintaining relevance to the contemporary health care landscape. We also note that osteopathy, like other professions that may exist outside of a mainstream health system in some countries, must find the balance between defining and retaining their core philosophies and models of care without fixating on them. We propose that, as is seen in some other health professions, osteopathic researchers and clinicians must not fall into the trap of focusing so much on any real or perceived point of difference in health care that they do not learn from others and evolve, or lose sight of what makes a difference to their patients [[10]Steel A. Peng W. Gray A. Adams J. The role and influence of traditional and scientific knowledge in naturopathic education: a qualitative study.J Alternative Compl Med. 2019; 25: 196-201https://doi.org/10.1089/acm.2018.0293Crossref PubMed Scopus (10) Google Scholar]. This approach takes a certain maturity within the profession, particularly one that defines itself by concepts drawn from a traditional body of knowledge [[10]Steel A. Peng W. Gray A. Adams J. The role and influence of traditional and scientific knowledge in naturopathic education: a qualitative study.J Alternative Compl Med. 2019; 25: 196-201https://doi.org/10.1089/acm.2018.0293Crossref PubMed Scopus (10) Google Scholar]. Osteopathy must be a living tradition whereby it evolves and changes as new practices and insights are uncovered and old practices and models are found insufficient as new evidence comes to light. Evolution can also occur through adaption of clinical practice resulting from the process of implementation or de-implementation of traditional treatments. This process has been initiated for naturopathy by members of our team [[11]Reid R. Steel A. Wardle J. Adams J. Naturopathic medicine for the management of endometriosis, dysmenorrhea, and menorrhagia: a content analysis.J Alternative Compl Med. 2019; 25: 202-226https://doi.org/10.1089/acm.2018.0305Crossref PubMed Scopus (7) Google Scholar] and we offer some lessons from our experience for the osteopathic community. In the process of evaluating the core tenets of osteopathy, the profession must be open to, and in fact welcome, criticism. By embracing internal and external criticism, osteopathy as a profession can redefine its clinical boundaries, scope of practice and the underlying foundations of its practice. While sometimes confronting and frequently challenging, by keeping the patient at the centre of the process, the profession can only gain from the outcome. Through allowing traditional practices and philosophies to take centre stage in study design, a stronger understanding, more effective adaption, and overall improvement of osteopathic treatments is possible for the profession and patients alike [[12]Schloss J. McIntyre E. Steel A. Bradley R. Harnett J. Reid R. et al.Lessons from outside and within: exploring advancements in methodology for naturopathic medicine clinical research.J Alternative Compl Med. 2019; 25: 135-140Crossref PubMed Scopus (6) Google Scholar]. It also affords respect to these traditions by treating them as equally worthy as contemporary practices by subjecting them to the same level of critical engagement and scrutiny. While evolving the osteopathic profession through changes to curriculum and clinical practice can span over many years if not decades, adapting models of research to advance this process is a worthy pursuit in the immediate future so any changes are informed by appropriate evidence that respects tradition [[12]Schloss J. McIntyre E. Steel A. Bradley R. Harnett J. Reid R. et al.Lessons from outside and within: exploring advancements in methodology for naturopathic medicine clinical research.J Alternative Compl Med. 2019; 25: 135-140Crossref PubMed Scopus (6) Google Scholar]. Allowing not only clinical practitioners and higher education institutions to have a voice in this process but targeting the end user – the patient - through co-design can have great benefit in identifying gaps in care and designing solutions the meet the needs of all stakeholders [[13]Steel A. Rapport F. Adams J. Towards an implementation science of complementary health care: some initial considerations for guiding safe, effective clinical decision-making.Adv Integrat Med. 2018; 5: 5-8Crossref Scopus (9) Google Scholar]. Research models such as knowledge mobilisation and implementation or de-implementation science, can permit areas of care that may require advancement to come to the fore front [[14]Adams J. Steel A. Reid R. A holistic approach to implementation science (IS): Broadening the IS Gaze to traditional, Complementary and Integrative medicine.Public health and health services research in traditional complementary and integrative health care: International perspectives. World Scientific, London2019: 99-117Crossref Google Scholar]. Through this process, the profession can take ownership for the advancement of their practice by better understanding the philosophies and principles that underpin their traditional practices and in doing so provide a foundation to embrace other models of care that may strengthen the osteopathy as a whole. AS developed the concept for the manuscript. HF, RR and AS all contributed to drafting the manuscript. All authors reviewed and approved the final version.