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Is evidence-based medicine patient-centered and is patient-centered care evidence-based?

Are achieving evidence-based medicine (EBM) and cultural competence in medicine (CCM) contradictory goals? In some ways, EBM and CCM are complementary means to improve quality; but it can also appear that, by virtue of their methods of changing medical practice, they are fundamentally at odds. Yet each is an important area for exploration in health services research and both are evolving from marginal to mainstream considerations in changing health policy and as potential strategies to improve quality. It is, therefore, critical that we understand how and when these emerging subfields might be perceived as conflicting and when they can work together. 
 
We begin with definitions: Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence, primarily from clinical trials, in making decisions about the care of individual patients. In general, the goal of EBM has been to improve quality through the standardization of medical care. Indeed, EBM has typically been implemented through clinical guidelines, protocols, or best practices, all which are used to standardize, not individualize, patient care. More recently, however, efforts have been made to incorporate individual circumstances and preferences into EBM decision protocols. Ideally, some leaders of the field now say, medical practice using EBM should allow for integrating individual clinical expertise with the best available data from population-based research. 
 
Cultural competence in medicine, by contrast, is the delivery of health services that acknowledges and understands cultural diversity in the clinical setting and respects individuals' health beliefs, values, and behaviors. It started with rather simplistic attempts to teach doctors about population groups, their cultural norms, and especially cultural peculiarities regarding health and health care. More recently although, it has evolved into something more akin to patient-centered care (Betancourt 2004). Cultural competence has progressed into using the foundations of narrative medicine to better understand the patient's story and integrate what is important to them into decisions about their health care. In essence, CCM aims to improve quality by individualizing, rather than standardizing, health care interactions. 
 
Even this very brief summary suggests that, like many new ideas, both EBM and CCM were first applied in overly simplistic ways. This problem was exacerbated by the fact that both base their recommendations on modal information derived from populations or subgroups. EBM guidelines are derived from population-based studies, while early teaching modules on CCM were based on general, or average, health beliefs among subpopulations. For this reason, however, both EBM and CCM have been accused of fostering stereotypes and have therefore suffered some degree of backlash. EBM experienced a backlash over fears of “cookbook medicine,” or clinical stereotyping, while CCM experienced a backlash over fears of cultural stereotyping. 
 
Perhaps as a result of this backlash, both fields have gone through somewhat of a reinvention and both now proclaim to focus their goals on improving quality by providing patient-centered care. But their methods remain, on face-value, at odds. EBM still fundamentally aims to improve quality through standardization, while CCM aims to improve quality through individualization of care. Ultimately, for EBM and CCM to work together, we will need evidence that EBM can be patient-centered and that CCM can demonstrably improve health outcomes. For example, do patients feel that implementation of EBM, in practice, makes them feel more listened to, empowered and respected? And does CCM lead to fewer medical errors and better health outcomes?