Open Access Open Access  Restricted Access Subscription or Fee Access

Reflecting on Evidence Based Medicine, Person Centered Medicine and Small Area Variations: how contemporary frameworks for medicine address (or not) the needs of the individual patient

Mathew Mercuri, Amiram Gafni


Over the past few decades the medical literature has given much attention to three movements: Evidence Based Medicine (EBM), Person Centered Medicine (PCM) and Small Area Variations (SAV).  Each claims to provide a framework for improving the care of individual patients. This paper examines why attention to the individual patient is important in the provision and delivery of healthcare and how each of these movements seek to address individual patient needs. We suggest that EBM, PCM and SAV all suffer from a number of issues that render their use as a framework to address individual patient needs inadequate. In the case of EBM, it is a reliance on (at best) population level study (e.g., clinical trials) that do not necessarily translate to individual patients. PCM appears to recognize the information requirements to care for individual patients, but is unclear on how that information can be obtained. Likewise, SAV is limited in that its methods do not discriminate between warranted and unwarranted variation and its reliance on the EBM approach in assessing what is the correct treatment for patients. This paper concludes that EBM, PCM and SAV are not solving the problem of how to provide care for individual patients. While we do not offer a solution here, it is only when we admit we do not have the answers to this problem that we can begin to look for a solution.


Evidence Based Medicine, medical practice, patient context, Person Centered Healthcare, philosophy of medicine, variations

Full Text:



Ben-Zion, U. & Gafni, A. (1983). Evaluation of Public Investment in Health Care: Is the Risk Irrelevant? Journal of Health Economics 2, 161-165.

Sackett, D.L., Rosenberg, W.M.C., Muir Gray, J.A., Haynes, R.B. & Richardson, W.S. (1996). Evidence-based Medicine: What it is and What it Isn’t. British Medical Journal 312 (7023) 71-72.

Charles, C., Gafni, A. & Freeman, E. (2011). The evidence-based medicine model of clinical practice: scientific teaching or belief-based preaching? Journal of Evaluation in Clinical Practice 17, 597-605.

Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group. (2004). Grading quality of evidence and strength of recommendations. British Medical Journal 328, 1490-1494.

Oxford Centre for Evidence-Based Medicine Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. Available at: Accessed on October 19, 2017.

Evidence Based Medicine Working Group. (1992). Evidence-based medicine: a new approach to teaching the practice of medicine. Journal of the American Medical Association 268 (17) 2420-2425.

Sackett, D.L. & Rosenberg, W.M.C. (1995). The need for evidence-based medicine. Journal of the Royal Society of Medicine 88, 620-624.

Borgerson, K. (2009). Valuing Evidence: Bias and the Evidence Hierarchy of Evidence-Based Medicine. Perspectives in Biology and Medicine 52 (2) 218-233.

Mercuri, M., Baigrie, B. & Upshur, R.E.G. (2018). Going from Evidence to Recommendations: Can GRADE get us there? Journal of Evaluation in Clinical Practice doi:10.1111/jep.12857.

Bensing, J. (2000). Bridging the gap. The separate worlds of evidence-based medicine and patient-centred medicine. Patient Education and Counseling 39, 17-25.

Worrall, J. (2002). What Evidence in Evidence-Based Medicine? Philosophy of Science 69 (S3) S316-S330.

Haynes, R.B., Sackett, D.L., Guyatt, G.H. & Tugwell, P. (2006). Clinical Epidemiology: How to Do Clinical Practice Research (3rd edn). New York: Lippincott Williams & Wilkins.

Mercuri, M., Sherbino, J., Sedran, R.J., Frank, J.R., Gafni, A. & Norman, G. (2015). When Guidelines Don’t Guide: The Effect of Patient Context on Management Decisions Based on Clinical Practice Guidelines. Academic Medicine 90, 191-196.

Morgan, S. & Yoder, L.H. (2012). A Concept Analysis of Person-Centered Care. Journal of Holistic Nursing 30 (1) 6-15.

Stewart, M. (2001). Towards a global definition of patient centred care: The patient should be the judge of patient centred care. British Medical Journal 322, 444-445.

Engel, G.L. (1977). The need for a new medical model: a challenge for biomedicine. Science 196 (4286) 129-136.

Rogers, C.R. (1961). On becoming a person. New York, NY: Houghton Mifflin.

Balint, E. (1969). The possibilities of patient-centered medicine. Journal of the Royal College of General Practitioners 17 (82) 269-276.

Greenhalgh, T., Howick, J. & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? British Medical Journal 348, g3725.

World Health Organization. (2007). People-Centred Health Care: A Policy Framework. Manila, Philippines: WHO Press, Western Pacific Region. Available at: Accessed on November 14, 2017.

Epstein, R.M. & Street, Jr., R.L. (2011). The Values and Value of Patient-Centered Care. Annals of Family Medicine 9 (2) 100-103.

Anjum, R.L. (2016). Evidence Based or Person Centered? An Ontological Debate. European Journal for Person Centered Healthcare 4 (2) 421-429.

Miles, A. & Loughlin, M. (2011). Models in the balance: evidence-based medicine versus evidence-informed individualized care. Journal of Evaluation in Clinical Practice 17, 531-536.

Stewart, M., Brown, J.B., Weston, W.W., McWhinney, I.R., McWilliam, C.L. & Freeman, T.R. (1995). Patient-Centred Medicine: Transforming the Clinical Method. Thousand Oaks: Sage Publications.

Mumford, S. & Anjum, R.L. (2011). Getting Causes from Powers. Oxford: Oxford University Press.

Glover J.A. & Wilson J. (1932). The End-Results of the Tonsil and Adenoid Operation in Childhood and Adolescence. British Medical Journal 2 (3740) 506-512.

Glover, J.A. (1938). The Incidence of Tonsillectomy in School children. Proceedings of the Royal Society of Medicine 31, 1219-1236.

Wennberg, J. & Gittelsohn, A. (1973). Small Area Variations in Health Care Delivery: A population-based health information system can guide planning and regulatory decision-making. Science 182, 1102-1108.

Wennberg, J. (2011). Time to tackle unwarranted variations in practice. British Medical Journal 342, 687-690.

Wennberg, J.E. (1993). Future Directions for Small Area Variations. Medical Care 31 (5) YS75-YS80.

Wennberg, J.E. (1984). Dealing with Medical Practice Variations: A Proposal for Action. Health Affairs 4, 6-32.

Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P-A.C. & Rubin, H.R. (1999). Why Don’t Physicians Follow Clinical Practice Guidelines? A Framework for Improvement. Journal of the American Medical Association 282 (15) 1458-1465.

Davis, D.A. & Taylor-Vaisey, A. (1997). Translating guidelines into practice: A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Canadian Medical Association Journal 157, 408-416.

Wennberg, J.E. (2002). Unwarranted variations in healthcare delivery: implications for academic medical centres. British Medical Journal 325, 961-964.

Mercuri, M. & Gafni, A. (2011). Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations. Journal of Evaluation in Clinical Practice 17, 671-677.

Charles, C., Gafni, A., Whelan, T. & O’Brien, M.A. (2005). Treatment decision aids: conceptual issues and future directions. Health Expectations 8, 114-125.



  • There are currently no refbacks.