Patient-oriented research (POR), according to Holmes and colleagues,1 has recently emerged as the method for acquiring the best evidence to deliver quality healthcare. It is a privileged approach, they argue, which marginalises other participatory research approaches; and it is tethered to another privileged approach—evidence-based practice (EBP). In this commentary, after narrating the history of POR and EBP and discussing criticism leveled against them, I contest their dependence primarily on reductionistic quantitative evidence and contend their inclusion of wholistic qualitative evidence, to remedy western medicine's shiny object syndrome (SOS). In 1911, Rufus Cole, recently appointed as director of the newly built Rockefeller Institute Hospital, wrote to Simon Flexner, director of the Rockefeller Institute for Medical Research, articulating his expectations regarding internal medicine's transformation into a clinical research discipline to complement basic scientific research disciplines. As Cole penned in his letter, he aspired to expedite the collaboration between the Institute's research disciplines and its hospital to incite ‘the academic revolution, or evolution, of internal medicine that is bound to come’.2 Over the succeeding decades, the (r)evolution yielded the ‘golden years’ (between the 1940s and 1960s) of clinical research or POR.3 And academically associated hospitals became a place not just for treating patients and for teaching medical students but also for conducting clinical and translational research, as well as basic laboratory research. At the time of Cole's letter, however, dissenting voices, especially among traditional clinicians, expressed concern over the goals of hospitals, particularly those associated with universities, in terms of treating patients, teaching medical students, and conducting clinical research. One such voice was William Osler. In the same year that Cole wrote Flexner, Osler wrote a letter to President Ira Remsen of The Johns Hopkins University about clinical or patient research at university hospitals.4 His fear was that such hospitals would become dominated by clinical professors whose chief task was neither treating patients nor teaching medical students but rather conducting clinical research. In his letter, Osler targeted a recent report on medical education in North America, which was published in 1910 by Abraham Flexner (Simon Flexner's brother) and funded by the Carnegie Foundation.5 Besides pedagogical changes, the report championed inaugurating full-time clinical research professorships and repurposing hospitals and their laboratories to include clinical and basic research, which Osler strongly opposed. But the Flexner report was not the only report aimed at securing the scientification of medicine in the United States. After World War II, Vannevar Bush, director of the Office of Scientific Research and Development under President Franklin Roosevelt, published in 1945 a report entitled, Science, the Endless Frontier.6 In the report, Bush claimed that just as science and technology were indispensable in winning the war so they must be recruited to win the war against disease. And so, US medicine became a science or as Lewis Thomas, an American physician-scientist, observed ‘the youngest science’.7 Although Thomas acknowledged the similarity between his father's ‘1911 medicine’ and his ‘1933 medicine’ with their focus on diagnosis and prognosis, he also declared that introduction of sulphanialamide drugs begot a revolution in medicine in terms of treating disease. In sum, over the last couple centuries, solidism, which entails a rigorous reduction from tissues to cells to proteins and ultimately to DNA in the biomedical sciences, eclipsed humoralism.8 And this eclipse was responsible for the eclipse of physiology by molecular and cell biology, at the close of the 20th century. Thus, the demise of POR's ‘golden years’—beginning in the 1970s—was the product of the radical reduction of disease, as well as the patient, to molecular mechanisms, which established the contemporary biomedical model of healthcare. And clinician-scientists were lured professionally to the molecular aetiology of disease mechanisms and to biomedical research, and away from POR because of the difficulties and challenges associated with it. In the early 1990s, Edward Ahrens from Rockefeller University and one of the chief proponents of clinical research, tackled POR's demise in his book, The Crisis in Clinical Research: Overcoming Institutional Obstacles.9 In the book, Ahrens offered an active agenda, ranging from educational to professional initiatives, to reestablish POR. His book had an impact on the medical profession, especially with the formation in 1998 of the Association for Patient-Oriented Research (APOR). APOR was a professional organisation, of which Ahrens was a founding member, devoted to advancing POR.10 In addition, as shown in Figure 1 on annual POR publications in the professional literature, the publication rate began to rise sharply in the late 1990s reaching a peak in 2001, only to decrease several years later as sharply as it had risen. Also shown in Figure 1 is a second rise in the annual POR publication rate beginning around 2014, which has yet to peak. Two questions immediately arise concerning the biphasic shape of the Figure's graph. First, why the decrease in articles associated with the first wave? Second, what is responsible for the second wave? The answers have to do, in part, with a range of factors, especially in terms of implementing and supporting POR both institutionally and nationally. The initial increase in the annual POR publication rate, as depicted in Figure 1, was associated with the activity of organisations and institutions, like the APOR, especially in the United States. Although several academic institutional programmes emerged in the United States, sufficient government support, especially from its National Institutes of Health (NIH), was unavailable for them to engender a unified national initiative. For example, at the turn of the 21st century, Harvard initiated the Patient-Associated Science: Training, Education, Understanding, and Research (PASTEUR) programme to introduce and attract medical students to POR, which was later integrated into the broader programme of the Center for Assessment Technology & Continuous Health (CATCH, https://www.massgeneral.org/medicine/catch/about/). But because little support was available from government agencies like the NIH, CATCH and other related US POR programmes were not the dominant driver of US medicine and hence the rapid drop in the annual rate of POR publications after its initial rise. Towards the end of the first decade of the 21st century, however, a renewed effort was made to rejuvenate POR in several countries to improve the quality of healthcare. For example, the 2010 US Patient Protection and Affordable Care Act included resources to create the Patient-Centered Outcomes Research Institute (https://www.pcori.org/), which is a nonprofit organisation that funds research to incorporate patient input and participation in clinical research.11 In addition, the Act served as the foundation for President Barack Obama's 2015 Precision Medicine initiative, which included funding for POR.12, 13 Another example is the United Kingdom's initiative, INVOLVE, sponsored by its National Institute of Health Research, which actively sponsors and funds POR in terms of patient and public involvement in clinical research (https://www.invo.org.uk/). Canada, however, represents probably the best example of a country that is aggressively implementing POR into its national healthcare system. Indeed, Alain Beaudet claimed that Canada can execute POR even more effectively than the United States since ‘We have a universal health care system. That gives us access to fabulous data banks. It opens the possibility of doing things on a large scale that can't be done in the United States’.14 To that end, the Canadian Institutes of Health Research (CIHR) published a report in 2011 on an initiative to implement POR nationally, which was later framed as the ‘Strategy for Patient-Oriented Research (SPOR) Putting Patients First’ (https://cihr-irsc.gc.ca/e/documents/spor_framework-en.pdf). The CIHR report envisions POR as ‘a continuum of research, from the initial studies in humans to comparative effectiveness and outcomes research, and the integration of this research into the health care system and clinical practice’.15 To ensure the strategy's success, SPOR was yoked to EBP—a Canadian invention of the early 1990s.16 EBP relies on hierarchical prioritising of evidence with meta-analyses of evidence obtained from randomised clinical trials. These meta-analyses serve as the principal standard for justifying epistemically sound clinical decision-making. Critics of POR, particularly Canada's SPOR, have raised a number of issues with respect to its implementation into clinical practice.17 A primary issue for critics, especially in terms of POR's dependence on EBP, is evidence. The issue of evidence is multifaceted. First, critics charge that little evidence has been reported to support the claim that POR does improve the quality of healthcare,18 just as critics similarly charged EBP.19 Next, critics claim the evidence reported in the biomedical and clinical literature is of questionable quality and reliability. For example, John Ioannidis20 found that an alarming number of journal articles reported evidence that is simply false. Moreover, if such evidence is false then meta-analyses based on such evidence, the pinnacle of the EBP evidence pyramid, are also false and provide a poor foundation for guiding sound clinical decision-making.21 The response to this crisis in evidence has occasioned a clarion call for paradigm change in what constitutes quality evidence22 and in how such evidence is obtained and then used in the clinical encounter.23 Another issue is the type of clinical evidence needed for the delivery of best quality healthcare. One of the major criticisms of EBP is that it often fails to include patients' beliefs, values, and preferences as evidence in clinical trials, guidelines, and practices.24 Moreover, critics of EBP have argued that such failure often reflects the exclusion of the human or personal dimension in clinical practice, especially the personhood not only of patients but also of clinicians.25 And this exclusion of the personal is also evident from the various descriptions of POR within the literature in which clinical evidence pertains chiefly to the biological or material. For example, the NIH describes POR as ‘research conducted with human subjects (or on material of human origin, such as tissues, specimens, and cognitive phenomena) that requires direct interactions with human subjects’26 [emphasis added]. But the interactions are generally in terms of patients as research subjects and not as peers or partners. In other words, patients are material resources of fluids, cells, and/or tissues for research projects and not agents in devising or conducting such projects. Thus, POR is primarily concerned with reductionistic quantitative evidence, such as laboratory data on patient material, and not with wholistic qualitative evidence, such as illness narratives. Part of the reason is that qualitative evidence is often viewed as subjective in comparison to objective quantitative evidence and that collecting and analyzing qualitative evidence can at best be challenging if not seemingly unfeasible.27, 28 EBP has also been criticised from a postmodern perspective, which has spawned a lively debate over the nature of western healthcare.29, 30 Dave Holmes and colleagues have contributed to this debate, arguing that EBP is akin to fascism in the sense that it is autocratic in its approach to healthcare vis-à-vis other approaches.31 They rely on several postmodernists for their critique of EBP, especially Michel Foucault and his notion of the ‘regime of truth’ as institutionalised truth. For example, in their criticism of the Cochrane Collaboration, they claim that EBP qua regime of truth excludes evidence from other approaches because it ‘currently enjoys a privileged status’ and they conclude that ‘there exists a scientific and ethical obligation to deconstruct such regime’. Their solution to this totalitarian regime is a pluralistic stance in which other forms of evidence based on alternative healthcare approaches are included in the clinical encounter to establish truth. Their criticism gained notoriety with Ben Goldacre's 2006 article, ‘Objectionable “objectives”’,32 in his Guardian series ‘Bad science’ in which Goldacre defends Archie Cochrane and EBP from such fascist criticism (see33 for further discussion). Regardless of the clamour that has arisen over their article, Holmes and colleagues' postmodern critique of EBP as a privileged approach to the clinical encounter that restricts evidence to the quantitative, does unmask how EBP can at times impede the delivery of best quality healthcare. For example, citing Foucault's notion of the ‘clinical gaze,’ they argue that ‘the authority of the clinician must be understood as a discursive power that shapes the realm of the possible and, in doing so, often ignores certain symptoms that would allow a more appropriate diagnosis’.31 The issues associated with EBP's hegemony and its myopic clinical gaze are aptly illustrated by Richard Weinberg's essay, ‘Communion’,34 in which a mid-20-year-old female presents with a chief complaint of gastrointestinal distress but no obvious symptomology to provide an accurate or appropriate diagnosis. During the third clinical encounter, however, Weinberg notices dark rings under her eyes and he enquires about her sleeping. She confesses she suffers from a recurring nightmare and Weinberg asks her to recount it. The nightmare reveals that she was sexually assaulted as a teenager and to exculpate her shame she engaged in bulimic behaviour, resulting in her chief complaint. What is instructive about this clinical case is Weinberg's observation of the dark rings—a symptom that would normally be ignored by a gastroenterologist in diagnosing the patient's chief complaint. However, his observation was the key evidence to the aetiology, diagnosis and treatment of the patient's illness, which supports Holmes and colleagues' postmodern critique of EBP in that pertinent qualitative evidence is often ignored during the clinical encounter because the clinical gaze is primarily directed towards the patient qua quantitative clinical evidence. Now with the publication of this lead article,1 Holmes and colleagues have extended their postmodern critique of EBP to POR, which is the focus of the present set of commentaries. Through their critique of POR, they have accurately diagnosed what is ailing not just medicine but also healthcare in general—the SOS. POR is the shiny object that is heralded as the method for acquiring the best evidence to deliver quality healthcare. And their treatment of the syndrome is to deconstruct POR as the colonising royal science of the healthcare system and to reconstruct the system by incorporating indigenous nomadic participatory research programmes into it. Their remedy for POR's syndrome, then, is to include into the healthcare system a diversity of approaches to participatory research that produce not simply reductionistic quantitative evidence but also wholistic qualitative evidence.35 Health is more than simply biology; it also includes mental, behavioural, environmental, political, cultural and even spiritual dimensions. By deconstructing POR to treat healthcare's SOS, they make room for incorporating radical nomadic participatory research programmes, which often include qualitative evidence, thereby providing a greater opportunity for POR to be truly participatory and ultimately therapeutic. The challenge is how to develop such nomadic programmes and to implement them into EBP-bounded POR. One means to that end is to deconstruct the post-positivist view of science, as Holmes and colleagues recommend, which is the epistemic foundation of the biomedical sciences. An example of such deconstruction is Francis Peabody's critique of medicine's scientification, which was prompted in part by the Flexner report. In his 1927 article, ‘The care of the patient’, Peabody36 narrates the clinical case of Mrs. Brown who presents at a Boston hospital with nondescript gastrointestinal distress, much like Weinberg's patient. The attending intern performs the latest laboratory and diagnostic tests on her, which do not yield sufficient quantitative evidence for a diagnosis. The intern informs Mrs. Brown that ‘There really is nothing the matter with you…We have used all the most modern and scientific methods and we find that there is no reason why you should not eat anything you want to’. Peabody goes on to ask whether the diagnosis was too scientific. His answer is no! In fact, he claims it was not scientific enough in the sense that the intern ‘stopped short of even an attempt to determine the real cause’. According to Peabody, identifying the disease's cause depends on a ‘clinical picture’ that is ‘not just a photograph of a man sick in bed’ but rather ‘an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears’. For Peabody, the clinician qua scientist continues to probe and ask questions until the evidence is sufficiently forthcoming to make a diagnosis, as exemplified in the Weinberg clinical case. POR, especially in terms of a royal science that relies heavily on reductionism, is a shiny object that has been distracting the healthcare system for around a century and directing it along a path towards the commercialisation and commodification of healthcare and to the dehumanisation of patients and healthcare professionals alike.37 Sadly, healthcare professionals no longer profess healthcare, rather they are now providers of healthcare goods and services that patients as clients consume.38 And it is big business, and it is broken, especially in the Unied States.39 Modern western medicine with its allopathic approach emphasising reductionistic quantitative evidence is myopically focused on molecular and pathophysiological mechanisms to manage the contemporary explosion in chronic diseases of western civilisation, such as heart diseases, cancers and metabolic diseases like type-2 diabetes, through drugs and devices, to the exclusion of wholistic qualitative evidence. Inclusion of such qualitative evidence, as illustrated in the two clinical cases, would empower POR to determine the causes of these diseases so as to treat or even possibly to prevent them. Holmes and colleagues are correct in asserting that a scientific and an ethical duty exists for deconstructing POR and for reconstructing a robust approach to participatory research from a diversity and an inclusionary stance, based on humanistic values rather than simply on commercial or political values alone. Whether POR is a revolution or whether it is the next stage in healthcare's evolution is an important issue, however, the critical issue is to prevent POR from emerging as a corrupt regime or devolving into a population of maladapted specialties, thereby jeopardising healthcare's prime objective not to harm patients. Holmes and colleagues' postmodern deconstruction of POR to relieve its SOS is a crucial step in avoiding such harm so that if a drop in the second wave of annual POR publication occurs, it is not its last.