How to effectively implement evidence-based practice remains a vexed question among many manual therapy and bodywork professionals. This is partly due to the variability in the actual evidence base for some modalities, for reasons ranging from problematic research design to lack of funding or institutional support. Even so, calls to “follow the science” are stronger than ever, with professional discussion groups and communities by and large prioritizing close adherence to evidence-based medicine (EBM), also known as evidence-based practice (EBP) or evidence-based health-care (EBHC) guidelines. Intensive attempts are being made in the manual therapy (MT) professions to promote the “medical” application of their approaches and chosen modalities (sometimes to the detriment of the simple maintenance of well-being). In that context, EBM is of heightened importance.
As I outlined in a previous article (“Science, Pseudoscience, and the Communication Battle,” Massage & Bodywork, July/August 2020, page 42), self-regulation and distancing from pseudoscientific claims, fads, and practices have never been more important to the future of these professions. Care, restraint, and nuance, however, should be part of deciding how the scientific basis, or lack thereof, should be determined, and a binary either-or approach based on randomized controlled trials (RCTs) alone is both uncalled for and inaccurate, as I have also explored elsewhere (“A Cautionary Tale,” Massage & Bodywork, March/April 2020, page 46). In parallel, the biopsychosocial (BPS) model of health care is rapidly being embraced by many health-care workers across disciplines and professions, while the field of pain science is informing MT work in particular. This trio of influences has led to what some are calling an “identity crisis” in MT professions, which may face an uncertain future1 in which some institutions are debating whether to even teach hands-on skills,2 and broad discussions are taking place regarding whether these techniques should be used at all.
Meanwhile, a quiet revolution is taking place in the biomedical disciplines at the very highest levels. The questions of how to implement the BPS approach, how much to “educate” the patient, and how to develop treatment plans have been flipped on their head by allowing patients to guide the process—with clinicians in the role of facilitators rather than all-knowing saviors.
Particularly in the context of primary care (but also at secondary and tertiary levels), an understanding of the limitations of rigid evidence-based medicine (EBM) policies has set in, as well as of certain misinterpretations, misapplications, and shortcomings of the BPS model. This biomedical discipline revolution hinges on the medical humanities—an interdisciplinary field looking to embed humanities-based knowledge and skills within medical practice with the aim of better serving patients—by once again treating them as “whole humans,” rather than simply ailing bodies.
Buzzwords such as person-centered, empathy, mindfulness, and emotional intelligence have been crowding the airwaves for years, with the ultimate goal of acting as a counterweight to the often cold, impersonal, and reductionist biomedical approach. In terms of application and outcomes, though, there has been little to actually show for “the revolution” beyond theoretical self-improvement and a checkbox approach that may pay lip service to BPS principles but does not necessarily have the desired impact on the patient.
Plug the word biopsychosocial into a research database and dozens of articles appear. The majority of these articles concern physician perception of the efficacy of the approach and qualitative outcome measures. A significant number also query its applicability in the context of patient quotas and limited resources. Few, however, deal with the patient’s side of the story.
The keyword here is humanity. The BPS model, as I explore in the next article in this series, has gone a long way toward shifting attitudes regarding the therapeutic relationship, but not far enough. The ultimate aim is still to “reeducate” the patient from a position of authority by imposing one’s opinion on the patient (regardless of whether they are ready to hear it) through a subject-object dynamic in which the patient remains largely a subject, and not an equal partner in the clinical encounter. The true revolution in the rapidly growing subdiscipline of narrative-based medicine (NBM), however, is to reeducate physicians to see their patients not in terms of their pathology, bad habits, lay or “pop” understandings of disease, or assumed ignorance. Instead, they are perceived as whole individuals whose lived experience and whose own narratives of illness will point the way to both assessment and treatment.
Beyond the potential benefit to individual practice, in view of the current restrictions due to the COVID-19 pandemic, this information may provide a valuable path of exploration and training for MTs who are looking for ways to pivot professionally. The information may also be a valuable way to bridge EBM practice with current developments.
What is Narrative-Based Medicine?
Narrative-based medicine (NBM) emerged to counter the problem that “scientifically competent medicine alone cannot help a patient grapple with the loss of health or find meaning in suffering.”3 In the NBM framework, disease, dysfunction, and pain are to be seen first and foremost as a narrative inextricable from the person’s life, rather than as a list of codes, difficult names, protocols to be followed, or corrections to be shared. This is the true definition of person-centered care. By no means does this mean that therapists and physicians will not use their expertise or take the necessary steps in the face of red flags, and it is unlikely that NBM can be extensively applied in the context of the emergency room.
Nevertheless, in all other health-care contexts, NBM is a game changer in terms of the renewed dynamic between clinician and patient. As noted by Trisha Greenhalgh, GP, DPhil (an international authority on applying and implementing evidence-based medicine), on the value of narrative medicine as early as 1999, NBM “may provide a way of mediating between the very different worlds of patients and health professionals. Whether . . . performed well or badly, [it] is likely to have as much influence on the outcome of the illness from the patient’s point of view as the more scientific and technical aspects of diagnosis or treatment.”4 From this perspective, NBM is critical to truly ethical practice.
With mediation as its goal, NBM has been quietly gaining ground since the turn of this century. Founded by internal medicine specialist Rita Charon, MD, PhD, at Columbia University and taken up by biomedical specialists worldwide, more and more medical curricula are beginning to incorporate training in NBM’s methods and applications, with nascent international centers also emerging. The goal is to refocus the way medicine is being practiced through the development of an applicable holistic diagnostic framework that is based on patient narratives of their condition, with particular attention paid to the body-mind connection. Clearly this is examined in parallel with any required biomedical assessments, but rather than “telling,” “educating,” or “directing” the patient, it is the patient and their articulated needs that guide the process.
Is NBM Revolutionizing Mediation?
Practitioners of integrative health will be quick to observe that they have been using this holistic approach for well over a century—indeed, there are many commonalities with the principles of osteopathy in particular.5 So, where is the revolution? It lies in the fact that all of this is happening at the heart of biomedical science, yet the news does not seem to have reached the manual therapy professions quite as broadly. Some osteopathic schools are catching up, but not as rapidly as one might have expected.6 There are readers who will be quick to cite the biopsychosocial approach—this is not a reinvention of that particular wheel.
Rather than seeing the patient as someone to be educated and corrected, thus imposing on them a receptive role that is on unequal footing with the practitioner, NBM reverses this relationship and puts the person-centered focus into tangible practice using hands-on, practical methods. This relationship change does require the development of certain skills, but no more than is usually needed for satisfying continuing education requirements.
Importantly, NBM does not challenge biomedicine or EBM (it does itself rest on substantive evidence).7 On the contrary, it seeks to instill holistic and humanistic assessment and treatment at the heart of primary health care.
In such a climate of change, there is tremendous potential for building proper bridges with integrative and allied health professions with far more solid foundations than in the past. Such developments may also make it possible to solve the impasse that some MTs find themselves dealing with in relation to “hands-on” or “hands-off” in their efforts to adhere to EBM guidelines, because in some cases, it will come down to what is appropriate, not just based on the literature but based on the patient.
History of the Medical Revolution
In order to understand the revolution that is taking place in the biomedical disciplines, let’s back up a little and take a look at where this all started.
Cartesian Dualism
The roots of modern science stem from a philosophical position known as Cartesian Dualism. In the early 1600s, French philosopher René Descartes aimed to establish a way of discovering absolute truth and “a single, unified science”8 based on the belief that there exists such a thing as universal reason. He argued that the evidence of the emotions, the senses, and of mathematics—anything leaving space for doubt—should be rejected.9
Descartes’s noble—if impossible—aim was to create a foundation for scientific humanity in which the essence of being human could be utterly divorced from the uncertainties of nature, making humanity “the masters and possessors of nature . . . to enjoy trouble-free the fruits of the earth and all the goods found there.” Of these, the greatest of all possible goods was health, and he thought he could contribute to providing this to humanity through the development of this foundation (although we now know that this idea of removing uncertainty—although well-meaning—is only possible in the world of philosophy), thus he established a basis for medical science in which thought, emotion, and what some call the soul were to be forever considered as entirely separated from nature.10
Modern Medicine and the Scientific Method
The division of medical science gave us modern medicine and the scientific method, based on an overall mechanistic view of the body.11 The practice of dissection added to this, which was an inspiration to Descartes and those who built on his perspectives, whereby physical points of commonality discovered by anatomists offered the desired scientific objectivity and added to the depersonification of the body in the process.12 This is the basis for the same “allopathic” approach that holistic practitioners have decried for many decades, claiming it is quite impossible to divorce mind from body, and earning themselves decades of challenges in the process—though that is a separate discussion. This mechanistic perspective became the bedrock of biomedical epistemology (the study, understanding, and basis of knowledge).
From a Cartesian epistemological standpoint, all that is worth knowing about the body in order to understand and heal it rests on mechanistic, physicochemical principles. In terms of knowledge creation, organization, and application, this standpoint created an insurmountable division between body and mind, since this dualistic separation became the basis for the foundation of biomedical research and practice.13
Ethics in Medicine
With the mind conveniently severed from the body, physicians in Western societies enjoyed a superior authority conferred in part by years of learning, but largely from the dynamic of the doctor-patient relationship. Social class, education, and wealth are swept away in the face of illness, and doctors (past and present) have often enjoyed a significantly privileged status, whether ministering to kings or to paupers. As explained by Charon, founder of Narrative Medicine: “The patient’s lived experience of having the disease does not automatically count for much in health-care’s proceedings. The power is all on one side. When disagreements between them arise, the power asymmetry privileges the stance of the professional. If [. . .] a patient refuses medical treatment, the patient is charged with incompetence.”14
Despite the foundation of bioethics in the mid-20th century in response to a growing number of scandalous events that began a reexamination of medical practice overall, it often did not go far enough, and the ethical frameworks developed in the late 1970s and early 1980s still left too much room for confusion. Initially, four key principles were established as the central moral elements of bioethics: respect for patient autonomy; nonmaleficence (do no deliberate harm); beneficence (have the patient’s best interests in mind); and justice.15 Since then, other ethical frameworks have emerged in an attempt to improve, ring-fence, or develop the guidelines to correct the detached and impersonal nature of earlier frameworks.
In the context of physical therapy specifically, it is worth reviewing the work of Carol Davis, DPT, who has offered important clarifications on how ethics (distinct from morality) should be taught and practiced.16 Still more recently, social justice perspectives and a closer focus on personal morality have challenged and reshaped definitions of what is ethical within medical practice.
Narrative ethics appeared on the scene in the 1980s, promising real change. Instead of bringing the breadth of medical knowledge to bear on a set of walking symptoms, they attempted a form of “ground-up” ethics that started with the individual patient and adapted how the medical knowledge base could be appropriately applied to their particular situation. Through a series of interdisciplinary exchanges, “narrative ethics merged the perspectives of humanities scholars with the viewpoints of clinicians facing ethical situations in patient care.”17
Utilizing techniques from the social sciences and literary disciplines to help reconcile difficult or contradictory information, a narrative physician (or a narrative ethicist in role of mediator) listens “closely to stories told by patients and their families, searching for the necessary voices that might have been silenced . . . so that their stories, too, through representation, can become visible and can aid in envisioning the way forward. By reading these accounts together, patients, ethicists, and clinicians can together discover central but sometimes hidden elements in the situation they face.”18 It is claimed that such narrative practices are not simply a means to an end, but are “the therapy itself.”19
In facilitating the decision-making process for the patient, by returning their own agency to them, the subject-object disparity is neutralized. If we look back at the key principles of bioethics leading back to Hippocrates, we might note that this is the true definition of applying justice and doing no harm. First and foremost, we must dispense with the quest for certainty, and examine our own assumptions, prejudices, and biases. This is the first step toward self-awareness, critical thinking, and compassionate, ethical practice.
Evidence-Based Medicine
Around the same time that bioethicists were reexamining the social and moral dynamics of health care, the question of scientific method also came under close scrutiny. Calls to standardize research methods and to practice within a clear evidence-based framework took center stage, championed in the 1970s by epidemiologist David Sackett. Aiming to counter broad variability in the quality of health care, as well as traditional deference to medical authority, he argued that a more critical and scientific approach was needed, defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” A more recent definition clarifies that “evidence-based medicine is the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation, or management of individual patients.”20
The ensuing revolution made EBM the standard model of teaching, researching, and practicing medicine, nursing, and the biomedical sciences on both sides of the Atlantic—providing a blueprint for the regulation, implementation, and management of health care and its economic and legal offshoots.21 Scientific research was revolutionized, with the modern research hierarchy (randomized controlled trials, systematic reviews, and meta-analyses) emerging as a result. Though largely based on pharmacological research, this fresh focus on evidence-based practice extended across biomedical and allied health practice. The scientific publishing model—now critical to any scientific career—is largely based on quantitative EBM, with the structure of scientific publishing shaped to build evidence, although how much of this ever trickles down to practitioners is another question altogether that I have addressed elsewhere.22
Statistics on the uptake of EBM in general practice are both revealing and shocking. In the 1970s, between 10–20 percent of all health interventions in use in the US were evidence-based, rising to 21 percent in 1990. A more recent British Medical Journal survey showed that in primary health care about “18 percent of decisions were based on ‘patient-oriented high-quality evidence.’ ”23 The reasons can be summed up as a combination of resistance to change, practical considerations (such as a lack of time), an overreliance on anecdotes and personal clinical experience, and a lack of research literacy.
With this situation in biomedical primary care, we might expect things to be even more complex among the MT professions, where the evidence base still lags behind actual practice. This has troubled manual therapists—as well as those in other allied health fields—often leading to intense debates, with some expressing frustration that EBM should trump experience, while tradition and others insist that it must be implemented to the highest possible degree.
These debates are not unique to the MT world, and the frustrations of how to apply EBM in real time are an ongoing source of debate in the biomedical professions as well. Greenhalgh24 is practically a household name among British primary-care clinicians. Her book How to Read a Paper: The Basics of Evidence-Based Medicine and Healthcare, now in its sixth edition, is required reading among medical students and clinicians alike. It is possibly the clearest introduction to the topic any busy clinician could ask for.
Writing in 2019, Greenhalgh notes that evidence-based health care has “outlived its honeymoon period” and provides a well-argued explanation of criticisms against EBM—both when practiced badly and when practiced well—with salient recent examples. In the second case, she notes that an almost unachievable formalization and standardization of clinical practice harms the outcome and “de-skills the practitioner,” while overreliance (or over-regulation) based on this formalization can lead to “yesterday’s best evidence” dragging down “today’s guidelines and clinical pathways.” Greenhalgh’s final point is the most relevant here: “Perhaps the most powerful criticism of EBHC [evidence-based health care] is that if misapplied, it dismisses the patient’s own perspective on the illness in favor of an average effect on a population sample or a column of quality-adjusted life-years . . . calculated by a medical statistician.”25
Misapplication can be equally seen in blind adherence to protocol, ignoring patient concerns, but also in relying either on poor evidence or evidence that does not apply to the case in question. It is not enough, in short, to simply “follow the science,” nor to overly rely on elements such as a large sample size or higher level of research in a checkbox-style approach. A systematic review or meta-analysis is only as good as the studies it investigates, for example. One must also consider whether the “evidence” applies to the individual case, which may not fall within the narrow parameters of a given RCT.
Greenhalgh is in no way an EBM skeptic, and strongly states as much. However, she is able to clarify both the benefits and the valid criticisms of EBM while proposing applicable remedies, noting elsewhere that its failings do “not mean that evidence-based medicine is broken; it simply lacks the needed maturity.”26 It might be worth considering this same phrase for approaches and modalities across the allied health fields.
Conclusion
In the next article, I summarize the principles of narrative medicine in comparison to EBM and the BPS model, and highlight the issues that emerge. In the meantime, the following resources offer key sources on narrative medicine.
For those looking for a place to start, I cannot recommend highly enough Rita Charon’s videos:
• Rita Charon, MD, PhD. “Honoring the Stories of Illness.” TEDx, Atlanta, GA: November 4, 2011. youtu.be/24kHX2HtU3o.
• Rita Charon, MD, PhD. “A Sense of Story, or Narrative Medicine for the Chaos of Illness.” OHMA Columbia, Columbia University, NY: January 24, 2018. youtu.be/d892f0ynSWc.
• Rita Charon, MD, PhD. “The Power of Narrative Medicine.” CHCMCCSMTV: June 13, 2017. youtu.be/AYUc1uIHO9A.
Also, the University of Delaware Representative Print and Online Resources for Narrative Medicine web page offers research resources (from books to available courses and databases) on humanism as applied to medical practice at sites.udel.edu/jdel/representative-print-and-online-resources-for-narrative-medicine.
Another great resource for those interested in integrating narrative medicine with pain science is the Integrative Pain Science Institute. Start with this podcast with physiotherapist Lissanthea Taylor at integrativepainscienceinstitute.com/latest_podcast/pain-and-the-power-of-stories-how-to-use-narrative-medicine-in-pain-care-with-physiotherapist-lissanthea-taylor.
Notes
1. William H. Kolb et al., “Editorial: The Evolution of Manual Therapy Education: What Are We Waiting For?” Journal of Manual & Manipulative Therapy 28, no. 1 (January 2020): 1–3, https://doi.org/10.1080/10669817.2020.1703315.
2. Cameron W. MacDonald, Peter G. Osmotherly, and Darren A. Rivett, “Editorial: COVID-19 Wash Your Hands but Don’t Erase Them from Our Profession: Considerations on Manual Therapy Past and Present,” Journal of Manual & Manipulative Therapy 28, no. 3 (July 2020): 127–31, https://doi.org/10.1080/10669817.2020.1766845.
3. Rita Charon, “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust,” Journal of the American Medical Association 286, no. 15 (October 2001): 1897–1902, https://doi.org10.1001/jama.286.15.1897.
4. Trisha Greenhalgh and Brian Hurwitz, “Why Study Narrative?” British Medical Journal 318, no. 7175 (January 1999): 48–50, https://doi.org/10.1136/bmj.318.7175.48.
5. Mauro Fornari, Luca Carnevali, and Andrea Sgoifo, “Single Osteopathic Manipulative Therapy Session Dampens Acute Autonomic and Neuroendocrine Responses to Mental Stress in Healthy Male Participants,” Journal of the American Osteopathic Association 117, no. 9 (September 2017): 559–67, https://doi.org/10.7556/jaoa.2017.110; Charles E. Henley et al., “Osteopathic Manipulative Treatment and Its Relationship to Autonomic Nervous System Activity as Demonstrated by Heart Rate Variability: A Repeated Measures Study,” Osteopathic Medicine and Primary Care 2, no. 7 (June 2008): 1–8, https://doi.org/10.1186/1750-4732-2-7; Aaron T. Henderson et al., “Effects of Rib Raising on the Autonomic Nervous System: A Pilot Study Using Noninvasive Biomarkers,” Journal of the American Osteopathic Association 110, no. 6 (June 2010): 324–30.
6. Julet Baltonado and Tyler Cymet, “Can the Humanities Humanize Health Care?” Journal of the American Osteopathic Association 117, no. 4 (April 2017): 273–75, https://doi.org/10.7556/jaoa.2017.046; Patricia Sexton, “Maintaining Balance in Medical School through Medical Humanities Electives,” Missouri Medicine 115, no. 1 (January/February 2018): 35–36; Craig M. Klugman, “Medical Humanities Teaching in North American Allopathic and Osteopathic Medical Schools,” Journal of Medical Humanities 39 (November 2017): 473–81, https://doi.org/10.1007/s10912-017-9491-z; Gary Hoff et al., “A Call to Include Medical Humanities in the Curriculum of Colleges of Osteopathic Medicine and in Applicant Selection,” Journal of the American Osteopathic Association 114, no. 10 (October 2014): 798–804, https://doi.org/10.7556/jaoa.2014.154.
7. See the Gold Foundation databases on humanism in health care at www.gold-foundation.org/resources/#databases.
8. Rita Charon et al., The Principles and Practice of Narrative Medicine (New York: Oxford University Press, 2017).
9. René Descartes, Discourse on Method and Meditations on First Philosophy, 4th ed., trans. Donald A. Cress (Indianapolis: Hackett, 1998), 18–9.
10. Elizabeth Grosz, Volatile Bodies: Toward a Corporeal Feminism (Bloomington: Indiana University Press, 1994), 6.
11. Rita Charon et al., The Principles and Practice of Narrative Medicine, 80–81.
12. Drew Leder, “Tale of Two Bodies: The Cartesian Corpse and the Lived Body,” in The Body in Medical Thought and Practice, ed. Drew Leder (Boston: Kluwer, 1992), 19; Peter Finkelstein, “Studies in the Anatomy Laboratory: A Portrait of Individual and Collective Defense,” in Inside Doctoring: Stages and Outcomes in the Professional Development of Physicians, eds. R. H. Coombs, D. Scott May, and Gary W. Small (New York: Praeger, 1986), 22–42.
13. Elizabeth Grosz, Volatile Bodies: Toward a Corporeal Feminism, 6.
14. Rita Charon et al., The Principles and Practice of Narrative Medicine, 114–15.
15. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York: Oxford, 1979); National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Department of Health, Education, and Welfare, The Belmont Report, No. 78-0012 (Washington DC: US Printing Office, 1978).
16. Carol M. Davis, “Affective Education for the Health Professions: Facilitating Appropriate Behavior,” Physical Therapy 61, no. 11 (November 1981): 1587–93, https://doi.org/10.1093/ptj/61.11.1587.
17. Rita Charon et al., The Principles and Practice of Narrative Medicine, 119.
18. Rita Charon et al., The Principles and Practice of Narrative Medicine, 120–21.
19. Rita Charon et al., The Principles and Practice of Narrative Medicine, 129.
20. Trisha Greenhalgh, How to Read a Paper: The Basics of Evidence-Based Medicine and Healthcare, 6th ed. (Hoboken: Wiley-Blackwell, 2019), 1.
21. Maria Giulia Marini, Narrative Medicine: Bridging the Gap between Evidence-Based Care and Medical Humanities (Switzerland: Springer, 2016), 2.
22. Sasha Chaitow, “Whose Research is it Anyway?” Journal of Bodywork and Movement Therapies 23, no. 3 (July 2019): 435–38, https://doi.org/10.1016/j.jbmt.2019.08.002.
23. Trisha Greenhalgh How to Read a Paper: The Basics of Evidence-Based Medicine and Healthcare, 6th ed., 4.
24. Trisha Greenhalgh, GP, is a professor of Primary Care Health Sciences, Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, UK.
25. Trisha Greenhalgh, How to Read a Paper: The Basics of Evidence-Based Medicine and Healthcare, 6th ed., 235–36.
26. Trisha Greenhalgh, “Is Evidence-Based Medicine Broken?” Project Syndicate, October 8, 2014, accessed January 15, 2021, www.project-syndicate.org/commentary/is-evidence-based-medicine-broken-by-trish-greenhalgh-2014-10.
With 20 years in teaching and over a decade in journalism and academic publishing, Sasha Chaitow, PhD, is series editor for Elsevier’s Leon Chaitow Library of Bodywork and Movement Therapies and former managing editor of the Journal of Bodywork & Movement Therapies. Based between the UK and Greece, she teaches research literacy and science reporting at the University of Patras, Greece. She is also a professional artist, gallerist, and educator who exhibits and teaches internationally.