“Best available research” refers to the body of scientific evidence underpinning various pathology prevention interventions. “Clinical expertise” is the competency of the Health Guardian responsible for carrying out the interventions. “Patient characteristics, culture, and preferences” refer to the most relevant aspects distinguishing individual patients.
In EBP, these three parts are supposed to be integrated to create a best holistic pathology prevention practice. The two parts, [clinical expertise] and [patient characteristics, culture, and preferences], are legitimated and shaped by the part [best available research]. Consequently, important extra-scientific data from these two parts, [clinical expertise] and [patient characteristics, culture, and preferences], contain essential information for a holistic treatment of pathology prevention.
In the policy-statement, the two parts called [clinical expertise] and [patient characteristics, culture, and preferences] are legitimated and defined through empirical studies of [best available research], indicating that these non-scientific data are significant factors in effective and efficient pathology prevention.
As expected, the definition of [patient characteristics, culture, and preferences] data is comprehensive and includes elements such as religious views, personality traits, and personal preferences. Nonetheless, patient preferences are a legitimate part because an understanding of ‘what works for whom’ provides an essential guide to an effective holistic pathology prevention practice.
Some of the differences between medical evidence and holistic pathology prevention evidence can explain the conceptual confusion in EBP. If they were applied to medical practice, the three parts in EBP would be more readily discernible. Many medical cures are effective regardless of the involvement of a clinical expert such as a Health Guardian without emphasizing patient characteristics, culture, or preferences in the treatment process. In pathology prevention, however, some of the major factors empirically associated with good pathology prevention are tied to clinical expertise and patient culture and characteristics. It has been shown that factors such as goal consensus/collaboration, empathy, the alliance, positive regard/affirmation, therapist effects, and congruence/genuineness outweigh the importance of differences in specific treatment practices of pathology prevention models.
However, research also indicates that expertise is only associated with better outcome under specific circumstances. There is similar research evidence supporting the importance of patient culture and characteristics. We argue that it is the patient who is most likely to determine successful outcome. We claim that patient variables found to have a relationship with outcome are severity of disturbance, motivation and expectancy, capacity to relate, degree of integration, coherence, perfectionism, and ability to recognize and verbalize focalized problems.
In addition, cultural adaptation is associated with improved outcomes. It explains more of the variation in outcome than choice of treatment practice or method.
In the policy statement for EBP, scientific findings define clinical expertise and the ideal clinical expert emulate a scientist. The ideal EBP practitioner tests hypotheses and interventions in practice as a local clinical scientist. In the policy statement, it is recognized that clinical experts process information differently from the Health Guardian and that clinical practice corroborates existing expertise. Nonetheless, it emphasizes how experts seek and use scientific knowledge in a manner emulating scientific practice.
In contrast, some of the most influential holistic models of pathology prevention accentuates that one of its hallmarks is that it transcends propositional or scientific knowledge. When necessary, the practical experience of the Health Guardian provides a greater ability to improvise and synthesize information in novel situations. The point is not that the understanding and actions of the Health Guardian need to be at odds with scientific results, but that the understanding and actions of the Health Guardian are not perpetually controlled by scientific or propositional knowledge. Whereas the clinical expert is fragmentally rule-bound, the Health Guardian acts more intuitively. Furthermore, the Health Guardian has a deep and often at least partly tacit knowledge including a rich situational and contextual awareness. This results in a capability to handle the many arising challenges and impediments with the fluency generally demanded in settings of a holistic pathology prevention practice.
Patient Characteristics, Culture, and Preferences
In the policy statement, it is argued that there is a “growing empirical literature related to human diversity” which makes “an understanding of patient characteristics” like “values, religious beliefs, worldviews, goals, and preferences […] essential to the EBP. However, a critical extra-scientific argument for including the part “patient characteristics, culture, and preferences” is that the patient should have the right to influence choices involving the patient’s own life. This is highlighted by the term “preferences” in the policy statement, notwithstanding, of course, that preferences are entangled with characteristics and culture.
This also entails that patient preferences ought to play a significant role in clinical practice even when the patient prefers something that diverges from what science indicates would be, or even de facto is, effective and efficient. The individual patient’s preferences are not determined by scientific findings.