POEMs and PROMs

Practicing family physicians understand that taking the patient perspective into account is vital for good clinical care. This is a natural outcome of using the biopsychosocial model in the practice of medicine. Family medicine research should parallel this principle by including the patient experience when possible.

Medical research is constantly evolving. Much of the medical literature of the early 20^th century was essentially expert opinion and anecdote. As scientific methods improved, disease-oriented evidence (DOE) became the dominant form of publication beginning in the middle of the century.¹ Disease-oriented outcomes are very satisfying for physicians because they can generally be reliably measured and can be modified with readily available tools. From the physician’s perspective, a problem is identified, an intervention is made, and the problem improves.

Blood pressure can be easily measured and generally responds favorably to available medications. Let’s focus on blood pressure.

In the 1990’s, the evidence-based medicine revolution came onto the scene and the expectations for medical research outcomes changed rapidly.² As evidence-based medicine was embraced, researchers started to focus not just on what could be easily measured, but what was really important. This mandated novel research methods and outcome measures.³ In the late 1990s, the term patient-oriented evidence that matters (POEM) was introduced as a contrast to DOE.^4,5

Yes, blood pressure can be measured, and it can be lowered. But does lowering blood pressure result in fewer heart attacks and deaths?

POEMs keep patients at the center of medical research by asking questions that patients would want to know the answers to. This pattern paralleled the trend away from paternalism in clinical medicine and towards a shared-decision making approach to patient care.⁶ More recently, there has been a movement towards giving patients a direct voice in research outcomes.

Patient-reported outcome measures (PROMs) are research metrics that are measured by collecting responses from the patients who are actually experiencing the outcomes.⁷ Just like understanding the lived experience of patients is vital to the long-term practice of medicine, without the input of patients, we cannot understand the full implication of clinical research. Paying attention to PROMs, in general, results in overall higher patient satisfaction.⁸ It is simply realistic to state that an intervention that improves important clinical measures of health such as blood pressure, cholesterol levels, or even life expectancy will have limited efficacy if broadly rejected by patients (whatever their reasons might be).

How do patients feel about taking blood pressure medications? What side effects do they experience? Do they skip doses because of the side effects?

PROMs, then, are an important supplement to POEMs. What patients experience will clearly influence their behaviors regarding, for example, adherence to a medication regimen or accepting recommended vaccinations. PROMs generally come in two broad forms.^7,9 First are general types such as the SF-36 (36-Item Short Form Health Survey) that measures health globally. Then there are condition-specific measures such as the DiabPROM (Diabetes Patient-Related Outcome Measures).¹⁰ More tools for measuring PROMs are being developed every year and are now available for a surprising range of clinical scenarios.

JABFM has a long history of publishing papers that take the patient’s perspective into account. The frequency has increased over time, and the editorial team hopes to publish much more research with associated PROMs going forward.^8,11–14

Clinically, family physicians recognize the importance of taking the patient’s values and opinions into account before ordering tests or prescribing medications. Keeping patients at the center of clinical decisions is a pillar of family medicine. PROMs can keep patients at the center of family medicine research. Family medicine investigators are encouraged to consider the patient perspective as part of their research and, if their experience can be measured, include it as part of the larger project.