The second element of evidence based practice is fully respecting and integrating our patients' values and circumstances into our collaborative decision making. We bring our expertise as clinicians (Section I) and our knowledge and appraisal of the available evidence (Section III) to working with our patients to make these clinical decisions. Patients and their families bring their own preferences and choices. These preferences and choices are based on cultural norms, personal attitudes and beliefs, and prior knowledge (patient values); and on their own situations related to the location of care and the resources available and needed to provide care (patient circumstances). This element of evidence based practice is often underrepresented in the literature. We regard it as critically important in making evidence based practice all that it can and should be.
The conceptualization of the three elements of evidence based practice applies to all health professions, but it is perhaps even more meaningful to physical therapists. As previous studies have demonstrated, experts in physical therapy make the patient the center of their clinical reasoning.1 Perhaps this is necessary because so much of what we do requires that patients voluntarily agree to changes in their own behavior in order to achieve success. Cohen speaks of certain professions as being practices of human improvement. He defines them as professions that seek to improve human minds, enrich human capacities, and change behavior. He goes on to say that unless the intended recipients of these improvements—be they student, patient, or client—embrace the changes being sought, then the changes are unachievable.2
In this section we strive to provide the reader with the necessary background to fully engage in this element of evidence based practice. The section begins with Chapter 6, "Bridging the Differences of Diversity: Communicating in the Borderlands," by Suzanne Gordon. This chapter describes how to communicate with our patients across the many cultural and social differences that might tend to separate us. Gordon reviews available knowledge about the therapeutic relationship and describes the communication skills necessary to create that relationship. She does this by focusing on the conditions needed to create a cross-cultural relationship, on the impact of differences in power and prestige, and on the complex interaction of our social identity with our personal identity.
John Coulehan and Marian Block follow that with Chapter 7, "The Patient Interview." They discuss the interview not only as the primary source of information that can help us understand patient values and circumstances and develop the therapeutic relationship but also as the primary source of information in the diagnostic process. They identify the attributes of the interview process that improve its effectiveness as the most powerful and important tool available to the clinician in his or her practice.
These background chapters are then followed by two chapters that lay out very clearly the specific issues related to patient ...