Introduction

Historically, medicine has been considered the science and art of caring for the sick, and many authors consider medical ethics and morality to be part of the physician's behavior. Since the Roman culture, the concept of complete and honorable dedication of the physician to his patient has been accepted¹. In Aristotle's book Protrepticus, it is pointed out that medicine is fundamentally dedicated to preserving health and secondarily to caring for the sick, without mentioning diseases².

The Code of Ethics and Deontology of the Colegio Médico del Perú (CMP), version 2023, states: 'Medicine is oriented to respect for life, agony and death; as well as, to the achievement of the highest quality of life. It is a scientific and humanistic profession whose mission is to care for both individual and collective health, which implies promoting and preserving it, as well as preventing, treating, rehabilitating, relieving and comforting patients and their relatives, accompanying them respectfully and empathetically'³.

We note two positions regarding the practice of medicine, the first accepts the biomedical model (positivist) and the second supports the biopsychosocial vision of person-centered care; each has different arguments and characteristics. We postulate that the biopsychosocial model is the most adequate way of understanding the reality of the human being because it does not contradict the biomedical model, but rather complements it¹.

The British physician William Osler states 'A good physician treats the disease; the great physician treats the patient who has the disease'⁴.

More than 50 years ago, Karl Jaspers, physician and prominent philosopher, said: 'In modern medicine, everything seems to be in the best order. Day by day great results are achieved. But the astonishing thing is that dissatisfaction is growing among patients and physicians. There are now more high-level scientists and more science than at any other time, but it is also true that never before have there been so many problems and deteriorations in medical care derived from the negative influence of the dark side of technology, added to the persistent commercialization of medicine'⁴.

Gregorio Marañón's phrase 'there are no diseases, but sick people' is in truth a biopsychosocial model that considers not only the organic disease but also how the patient lives his own ailment and how it affects both his values and his family and social environment. It surpasses the paternalistic model of Hippocrates⁵.

Person-Centered Care (PCC) is now recognized as a fundamental intervention of high-quality health care because it results in numerous beneficial outcomes for patients, families and providers⁶. In addition, the practice of Person-Centered Medicine (PCM) provides solutions to other prevalent problems in health care including cost of services, improved chronic disease care, and legal litigation. Despite its profound ethical content, PCC is not well researched⁷.

Methodology

Due to the aforementioned positions, the author carried out a non-systematic bibliographic search on the subject of Medicine/Person Centered Care in various databases of the SciELO, Cochrane Library, PubMed, Scopus indexers, from which primary and secondary sources were collected in number of 1,576, selecting 67 to which 5 of direct access were added. This means that 72 references were finally used to prepare this trial. It was not necessary to request informed consent.

Definition

In Valero Rodriguez's thesis, William Osler's phrase is quoted as saying: 'Variability is the law of life, and just as no two faces are alike, no two bodies are alike, and no two individuals behave alike under the abnormal conditions we know as disease'⁸.

There is still no standard definition of PCM. The US National Academy of Medicine defines PCC as 'care that is planned, managed, delivered, and improved on an ongoing basis with the active participation of patients and their family or caregivers, in a manner that integrates the patient's preferences, values, and desired clinical outcomes'^1,9,10.

For WHO, PCC 'is an approach that incorporates the views and perspectives of people with a condition, caregivers, family members, and communities receiving that care. The health system is then organized around the comprehensive needs of people, rather than diseases'^11,12.

PCM is a very old and, at the same time, very current doctrine. It is a worldwide programmatic movement led by the International College of Person-Centered Medicine, based in New York^13-15.

The main objective of PCM is to improve the quality of people's health care^16,17, facilitating scientific and humanistic medical work with a solid ethical foundation⁹. Furthermore, PCM focuses medical action on the individual with a general holistic approach and not fragmented in all its biopsychosocial dimensions¹⁸, stimulates scientific research to generate the best clinical evidence and humanism as the essence of medicine¹⁴, offers care, support and treatment to the individual and the necessary information for the person to participate in his or her self-care^19-22.

History

PCM can be found in ancient Eastern civilizations, such as Chinese and Ayurvedic, as well as Western civilizations, particularly ancient Greece, which understand health broadly and holistically. These traditions are oriented towards health as a whole human being rather than disease¹⁹.

In ancient Greece, the physicians of Cos did not differentiate the disease from the person nor the person from his environment; and those of Cnidus sought to find the patient's picture according to a taxonomy of diseases. During the Renaissance, both schools of thought were expressed through the controversy between the followers of Hippocrates and those of Galen. In the 17th century, the physician Thomas Sydenham constructed a model of objective clinical observations, describing the symptoms, course and outcome of the disease over time and thus created a new nosography. One hundred years later, with the French Revolution, foundational ideas of the modern clinical method appeared²³.

From a very young age, Pedro Laín Entralgo developed an integrative style of the scientific and the humanistic, as well as the treatment of the patient understood as a subject who seeks his or her personal wellbeing. Regarding the ethics between the doctor and the patient, he shows his commitment to the recovery of a professional with a soul. C. Gustav Jung advised health professionals: 'know all the theories, master all the techniques, but when touching a human soul, be just another human soul'¹⁰.

Carl R. Rogers incorporated several disciplines related to the human being: social sciences, medicine, organizational psychology, economics, ecology, philosophy of science, theology, ethics, sports, art, culture, and race^24,25. The term 'patient-centered medicine' was introduced by the British psychoanalyst Michael Balint in 1970, who contrasted it with 'disease-centered medicine'^5,26. In recent years, in the face of increasing technology and specialization, the concept of person-centered medicine has been introduced, which emphasizes individual attention to the sick as subjects with a holistic, general, non-fragmented approach, analyzing the person in all his/her biopsychosocial dimensions²⁷; it rescues Ortega y Gasset's expression "I am I and my circumstances"²⁶. PCM has become a worldwide movement led by the International College of Person-Centered Medicine founded by the Peruvian psychiatrist Dr. Juan Mezzich. It has only recently entered Latin America^14,28.

PCM has developed predominantly in psychiatry and especially in family medicine²⁹ and seeks to apply a personalized, integrated, and contextualized model of clinical practice, so that the biomedical approach and technological advances can be delivered to patients within a humanistic planning³⁰.

In recent years, interesting national, Latin American and world events have been held with the purpose of promoting this new current in the practice of medicine. Mezzich points out that the WHO has already convened several international conferences to deal with the obvious: people-centered medicine³¹. In our country, the National Academy of Medicine has conducted several events on the subject, including a Latin American meeting that was followed by an important pronouncement. The Peruvian Association of Medical Schools (ASPEFAM, for its acronym in English) indicates that this approach not only seeks to place the human person at the center of health care, but also to continue humanizing the doctor-patient relationship³². This pronouncement is extremely important to ensure the training of human resources who can apply the new orientation of medicine³³, different from the one that Abraham Flexner gave it and that he himself remarked years later that 'intensely cultivating a scientific medicine brought with it the risk of losing the best judgment and the broad culture of previous generations'³⁴. It will first be necessary to train teachers to impart teaching-learning of this current of medical thought, given that 'no one can give what he does not have, since in order to teach how to be a person one must first be a person'¹³.

We have stated that PCM has been developed in psychiatry, in family medicine -particularly in primary care- and has been extended to surgery, and we obviously aspire to its application in the specialty of obstetrics and gynecology^35,36.

How do we understand pcm?

According to the National Academy of Sciences, Engineering and Medicine of the United States, PCM is understood as 'the medical practice that is based on the respect and monitoring of the patient's preferences, needs and values, elements that should guide all clinical decisions',³⁷. It should consider the patient's cultural traditions, personal preferences and values, family situation and lifestyle³⁸.

JM Ceriane tells us: 'we are in an era of medicine in which biological science, information, no tolerance for uncertainty, commercialism, scarce empathy, utilitarianism, and technology predominate. These aspects displace humanism, one of the pillars of medicine since time immemorial. Doctors and patients are dissatisfied'³⁹. There are patients who show the same symptoms, and even the same laboratory tests, but their ailments are very personal to each one, depending on the circumstances surrounding them⁴⁰.

Characteristics

Mezzich summarizes the 8 essential characteristics of CCM¹⁸:

The PCM emphasizes individual care of the sick as subjects, with a holistic, general - and not fragmented - approach to the human being in all its dimensions"¹⁸.

Cárdenas, in his doctoral thesis, found that the most frequent violation of the Code of Ethics was 'careless, superficial, incomplete care'. Such a finding justifies one of the many reasons why the practice of PCM should be encouraged in Peru within a strict adherence to ethical aspects⁴¹.

With Alvarez-Romero we can add that this paradigm understands the person from five factors: biological, psychological, sociological, ecological, and spiritual. He adds: 'Doctors are useful, not because they make us swallow all kinds of harmful substances, but because they correspond to a psychic need of the patient and his relatives, the eternal need for hope, sympathy and help that only a suffering being is capable of experiencing' (Leo Tolstoy)²⁰.

Finally, we can say that the South London Health Innovation Network states that 'PCC includes: - Respecting people's values - Taking into account people's preferences and needs - Coordinating and integrating care - Working together to be sure there is good communication, information and education - Being sure the person is physically comfortable and safe - Giving emotional support - Involving family and friends - Being sure there is continuity within services - Ensuring that people have access to care when they need it'⁴³.

Advantages^{1,4,7,33,43,45,46}

Barriers

Woman-centered obstetric care

Obstetrics and gynecology provides care for women throughout their lives, including pregnancy and childbirth, as well as diagnosis and treatment for diseases of the female reproductive organs⁹. Professor Mamhoud Fatalha proposed in 1997 to change the name to Women's Health. In Latin America there is evidence on the humanization of gynecological-obstetric care, but the studies report from the review of compliance with WHO recommendations to the assessment of inadequate care⁴⁷.

Traditionally, women have been attended and supported by other women during childbirth. Today, in hospitals around the world, continuous support during childbirth is often the exception. Currently, women deliver unaccompanied in a private setting, a situation that needs to change according to the evidence⁴⁸. WHO recommends maternal care that respects dignity, confidentiality, ensures no harm and no abuse, and proposes informed choice and continuous support during labor and delivery⁴⁹.

A study in Ireland on person-centered obstetric care found that respect, participation in decisions, communication, educational impact, continuity of service, continuity, availability and competence of staff, genuine choice, promotion of autonomy, individualized care, and organization of practice improve outcomes⁵⁰.

A paradigm shift is essential to provide care that is more inclusive of the needs and priorities of pregnant women in different aspects of their health. PCC respects gender equity by involving women in self-care, tailoring care to their needs and values, and eliminating discrimination of all kinds⁵¹. Poor quality maternity care leads to delays in care and adverse outcomes for the pregnant woman and newborn, including perinatal mortality. A quasi-experimental study in India showed that PCC improved outcomes⁵².

Recommendations

The following recommendations emerge from this review:

• Change the paradigm in health policies, strengthen the first level of care to rescue primary care in accordance with the conclusions of Alma Ata and provide person-centered care^52,65-68.

• Improve the physical plant and equipment of health facilities to provide adequate, timely and dignified care to pregnant women, women in labor and newborns^9,21,49.

• Build an integral health system, with biopsychosocial, cultural, spiritual, and energetic dimensions duly harmonized and balanced, based on the right to health and with the intersectoral participation of the entire State, building the defense of the health of individuals, the family and the community^13,19.

• Educate health personnel and train tutors in people-centered medicine at the undergraduate, postgraduate, and continuing medical education levels, in order to strengthen attitudes^{9,19,32,35,56,69,70,71}.

• To build a participative and consensual health, between caregivers and care, with unrestricted respect for the ideas of all¹⁸.

• Use evidence-based medicine to strengthen PCM^{14,20,30,30,39,72}.

• Promote research on person-centered obstetric care^7,14,18.

• Strengthen family and community involvement in person-centered care^4,12,65.

• Update the National Guidelines for Comprehensive Sexual and Reproductive Health Care^53,54.