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Principles of the whole person approach in medicine

By: Dr Mike Sheldon

This chapter describes the main principles of a whole person approach to medicine and health care

1 Centrality of the patient 2 A whole person anthropology 3 Definition of health
4 Telling the story 5 Making a diagnosis 6 Integration in health care
7 A healing relationship 8 Self help for the patient 9 Successful outcomes
10 Maturing in life Use of time Conclusion and references

As we seek to provide medical care in a whole person way we require a set of principles to guide our practice. The ten principles discussed in this chapter are not an exhaustive or complete list, but they demonstrate the range of changes needed when practising a whole person approach to health care and describes some of the implications of this whole person approach. If the spirit of these principles are adopted into our practice then we can be satisfied that we are whole person practitioners.

1  The centrality of the patient

It seems obvious to state that the patient must be at the centre of a health care system, it’s rather like saying “we believe in motherhood and apple pie”. Of course no-one is going to disagree. However as soon as the medical model begins to be practiced it’s amazing how quickly the patient slips out of this central position. In the bio-medical model guess what takes the place of the patient – the disease. Many doctors have been educated in a disease centred way. We are taught that the role of a competent doctor is to quickly establish the relevant symptoms, conduct an appropriate examination to elicit the physical signs, and know what investigations to order so that a competent diagnosis may be made and the disease process recognised and named. Then we have a clear idea of the prognosis and can institute the “evidence based” therapeutic intervention. If only it were this simple in real life.

Very quickly we enter a medical system that is built around specific diseases and body systems. For one aspect of your problem you may need to see a rheumatologist, who then refers you to a gastro-enterologist, who finds nothing wrong (in his system) and sends you off to a neurologist, who finally decides that you need to see a psychiatrist. This can go on indefinitely unless someone asks “What is happening to the patient?”

The illness that the patient brings is central to the whole exercise, and it is the patient’s experience of that illness, in its uniqueness as well as its similarities to the experience of other patients, which needs to hold centre-stage. At this point it is worthwhile distinguishing between Disease, Illness and Sickness.

Diseases are patho-physiological entities which are recognised to have known causes, a certain pathological action on the body’s anatomy and physiology, and a prognosis and treatment preferences. Thus we recognise Diabetes as a disorder of the pancreas gland in which not enough insulin is secreted which affects the way sugar is metabolised in the body. If left alone the patient could slip into a coma and die. The recognised treatment is to stimulate or give replacements for the deficient insulin.

Illness consists of the effects of a disease, or other health problem, experienced by the patient. Doctors refer to these as the symptoms, although the patient’s experience goes well beyond the normally recognised symptoms and may affect their relationships with others and their view of themselves.  Sickness is a role given to a person who is ill which confers certain benefits – such as being able to go to bed for the day and not work. Here it is society and immediate friends and family who confer this role onto the person. Thus it is possible to have a disease with no illness (such as early hypertension). It is possible to be ill without a disease (most women feel ill at some time in their menstrual cycle, but this is normal physiology). Lastly a person with no disease and no symptoms may attempt to adopt the sick role for other purposes – we normally call such a person a malingerer.

In order to ensure that the patient is central in the delivery of care the following seven actions are needed on the part of the doctor.

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A good doctor understands that whilst the next consultation may be just a job to him or her, to the patient it may be a matter of life and death. The good doctor takes a few moments to collect herself before each consultation in order to clear the mind of other patients, thoughts and tasks. Thus they are able to concentrate fully on the patient and reflect the importance of the consultation as experienced by the patient. Body language plays a large part in this process, as does the absence of continuous interruptions and the concerned attention which the good doctor adopts automatically. This demonstrates that the doctor respects the patient as a person with their own set of experiences, knowledge, anxieties and fears. As part of the consultation the doctor is prepared to spend some time exploring these beliefs and attitudes, and recognises the part they play in explaining why the patient has presented at this time and in this way.

Above all else the doctor must ensure that they hear the patient. Hearing implies attentive listening, providing feedback on what was heard in order to check that the correct message has been transmitted, and facilitating the patient’s telling of their story. The doctor has to establish a trusting relationship and demonstrate a satisfactory level of empathy and understanding of the patient. Next the doctor explores the patient’s context – their family, relationships, home situation and working practices. The wealth or poverty of the family will be taken into account along with any special factors which will affect the health and recovery of the patient. The needs of the patient cannot be considered in isolation. They have to be considered within the context of the whole of society. These needs are also inevitably tied up with other considerations such as education, finances, access to health care and the economic climate of the country.

Each person is unique in the way they respond to disease processes and to the treatment given to help them. Illness is the patient’s experience of the disease and other health processes working within them. These symptoms are interpreted by the patient and affect the way they live. Each person is unique in the way they respond to pain, that which one person would shrug off as they continued working may force their neighbour to stop work and retire to bed. It is important that each patient is encouraged to participate as fully as possible in any decision making around their own health care. The doctor as educator needs to evaluate the patient’s competence and desires to be involved and then encourage them to participate in the decision making process to the fullest possible extent.

Finally the whole person doctor encourages self-help in the patient. It is their health that is at stake, and the doctor must help the patient as much as possible to play their part in becoming and staying healthy. Each person’s health story is different, but in the whole-person approach we validate the patient’s story by listening carefully and actively to it. We then help them to understand its complexity and seek to give them the power to change their story to one that is healthier – that is enabling them to function more effectively than before. Above all else in the whole person approach we seek to maximise the person’s ability to understand their own health story and so participate fully in the process of becoming healthy again.

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2 A whole-person model of man (anthropology)

Any model of medical care starts with an anthropology, the understanding of how men and women are made and how they function. The current western medical model is largely based on a scientific humanistic anthropology where mankind is considered as a superior kind of animal with highly developed intellectual, emotional and social components. Thus the model of medicine practised majors on the physical components of the problem whilst acknowledging the influence of psychological, emotional and social factors on the process of recovery to full health.

A whole-person understanding of anthropology accepts that the physical component of men and women has many similarities to the animal kingdom, but the person-hood side is well developed into a psyche (mind and emotions) and spirit. Thus any understanding of ill-health demands a description of the problem in physical, psychological, social and spiritual terms. The physical approach is much the same as in the so called “western model” of medicine although there is a greater understanding of the interaction between the physical components of the person and their mind and spirit.

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The psycho-social aspect of the person combines an understanding of the importance and the interaction between the social background of the patient along with their intellect and emotions. Finally the spiritual dimension acts as the foundation of the person and supplies will, meaning, love, hope and faith without which we drift along and are prey to any harm the environment decides to throw at us. We could explore aspects of the “locus of control” model and understand that the person with a strong spirit will have a more developed internal locus of control and so be able to take actions themselves to improve their health. (This needs expansion and explanation).

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3 Definition of Health  and illness involves the whole person

We can no longer define health as the absence of disease. Genetic science has opened our eyes to the fact that most of us are “diseased” before birth, or at least have the potential for developing certain diseases. When any person is examined closely you can find some evidence of disease within them - that is there is evidence of a patho-physiological process which has already, or will in the near future, cause ill-health. Nor can we use a definition that talks of freedom from symptoms and suffering – for studies have shown that we all have some pain or physical symptoms of dysfunction almost every day. Rather we need to begin to consider health as the way we adapt and cope with our internal and external environments. Being healthy is more about managing the health problems we have rather than seeking for a state in which there are no problems.

Health is therefore a dynamic in which we grow and mature throughout our lives, and is the strength we have to enable us to live life to the full and complete the tasks which are important for our self-fulfillment. It involves creating an equilibrium between ourselves and the world around us, which is based on right relationships and values such as respect and loving kindness. Health is a therefore a journey through life and into death where we always seek to adapt to disability and suffering and cope with pain and difficulties in a way which matures us as whole people.

Following the fuller examination of health in the previous chapter we can conclude that health may be summed up in the following table.

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4 The importance of narrative – telling the true health story

The narrative approach to medicine has emphasised the importance of the patient’s experience and understanding of their health problems. The story they tell reflects their beliefs about health and their understanding of how they came to be ill. It is in the telling of their story that the patient comes to realise how they got to where they are, and should enable them, with appropriate professional help, to re-write their future story to one that is healthier. An understanding of the true health story is an essential first requirement for going on to change that story. The understanding of the patient comes mainly through the telling of their story to the listening health professional who can help the patient reflect on the events and situations which led up to the problem, and the likely factors which will keep the person in ill-health if they are not changed.

Taking a “history” from the patient is an essential component of the medical encounter. An old school physician who taught me at medical school used to say “let the patient talk for long enough and they will tell you what is wrong”. That attitude has slowly changed over the intervening years to one of putting less value on the story told by the patient whilst relying more on the results of images and investigations which are believed to give a more accurate picture of what is happening to the patient. This approach may confer benefits in a strictly patho-physiological model of health but does not apply when the person himself is part of the problem – as is invariably the case.

In the next chapter we concentrate on this process of history taking, or as I prefer to label it “taking a herstory”, to emphasise that the whole story includes the emotions, thoughts and beliefs of the patient. But what is the true health care story? In legal circles great importance is laid on the very first account given by the witness, and later changes to this story are taken to be false accounts which can demonstrate the reliability of the person as a witness. In health care I believe that the opposite is true. The more times the patient attempts to tell their health story, so the nearer it comes to the true situation.

 

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As we listen to people telling their health stories we need to remember that the more the story is rehearsed, then the closer it can come to the “real” story. This telling is also partly dependent on the reaction and questioning of the doctor listening to the story. I had to learn this lesson the hard way whilst a medical student. We were attached to the Accident and Emergency Department whilst on a surgical firm to be the first point of contact with new patients, and so be the first to take a history. One night I “clerked” a gentleman with abdominal pain who was then admitted. Later, probably whilst I was asleep or relaxing in a local tavern, further histories were being taken by the house officer, the junior registrar, the senior registrar and finally the consultant. The next day was the grand consultant round and as we came to the gentleman’s bed the consultant invited me to give the patient’s history. I started off confidently only to find that after a few sentences the patient kept interrupting me to correct my version of his story. The final version he told of his problem was quite different to the one he had given me the previous night. Following repeated questioning and interaction with more senior doctors, he better understood which of his symptoms related to his illness and which were unrelated. The previous night he had told me the “raw” story as he saw it, and now he was able to tell the “real” story as demanded by the medical model. By this time the patient also felt better and so was able to think more clearly. The wise doctor always comes back and takes a second or third bite at the history, and this use of time to clarify matters is one of the tricks of the General Practitioner who uses a time interval to help sort out the “wheat from the chaff” in the patient’s account.

Of course all stories are told within a relationship. The trust and rapport between the two participants will influence how much of the story is told. The “listener” plays an active part in the story and we need to recognise how both the internal experience of telling the story and the external experience of listening to a story can affect both what is said and how it is said.

Internal experience of the patient
Several factors are important within the person telling the health story:

  • Importance of language – how fluent is the patient, how many technical words do they know, how good are they at expressing themselves.
  • Emotions and feelings affect the telling of the story
  • The reactions of the listener will encourage or discourage the patient and so alter details and may make them forget important facts.
  • The authority of the listener also has an effect – most of us come away from a medical consultation realising that we have forgotten to mention something that we had thought about beforehand. The power aspect of the relationship is important.
  • It is only as we verbalise our thoughts that we begin to order and understand them. In order to fully understand your own story you need to tell it to someone else.
  • Talking opens up the door to our memory, and on further tellings more details may be remembered.

External Observation of the story-teller
The listener plays an active part in the process as they:

  • Walk alongside the person through the story, helping them to tell of their experiences.
  • Demonstrate genuine interest in the patient, allowing them to expose their vulnerability.
  • Asking further questions to draw out aspects the person had forgotten or not thought important.
  • Seek to understand the emotions felt by the patient as the story is told.
  • Provide a feedback loop to increase the patient’s understanding of the story they have told.

Whole-person Story Listening
And so to summarise the differences between a routine history taking and that required in a whole person approach – in a whole person model, the doctor:

  • Concentrates on the person telling the story, entering into the story in order to gain a greater degree of understanding
  • Learns to observe how the patient tells the story to discover emotions and beliefs.
  • At the right time, and in the right way, asks the right questions which draw out the true story
  • Exhibits empathy – not trying to identify with the person but recognising and validating the suffering that they are going through.
  • Walks alongside them, trying to see things from their point of view.

This approach is not new, but rather a re-statement of the “old fashioned” approach to the patient’s story that good physicians have always understood.

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5 Making a diagnosis in whole person terms

In the bio-medical model the diagnosis is usually made in patho-physiological terms. Thus the observed alterations in tissues, organs and physiological functions are used to name the condition the patient has. In a patient-centred approach the illness is more usually described in terms of health problems, recognising that some of these problems may have a biological basis, whilst others are psychological or social problems. The whole person approach goes one step further and recognises the complex, multi-factorial nature of the causes of ill-health. Thus a history of headache, whilst having a common final physical pathway, may be caused by a physical disease (a tumour), or a psychological condition (depression), or a social condition (stress due to over-work) or finally a spiritual condition (a broken relationship due to hurt and unforgiveness). It seems obvious to state that the treatment follows on from the diagnosis, so it is important to unravel the causes of the problem, especially when several co-exist, so that treatment may be effective.

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This is more fully discussed in a later chapter.

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6 The integrated therapeutic team

The doctor is no longer a “single-handed” healing professional but one of a growing team with a wide variety of skills and training. The doctor may still be at the centre of this team but he or she must no longer act alone. An integrated team including nurses, counsellors, carers and other therapists are needed to help patients regain their health. An integrated team demands good communication and support between the professionals, carers and patient.

wholeperson text box 6

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7 Healing therapeutic relationships

Much research has centred on the value of a trusting and continuing doctor/patient relationship, with the person of the doctor being seen in the role of healer. Perhaps we need to talk of the relationship between the patient and all the people involved in caring for them. Therapist is a term which can cover doctor, physician, nurse, counsellor, physiotherapist and all others including carers. It therefore seems best to reduce the use of the individual terms like doctor, nurse, chaplain and counsellor and assume that everyone who enters into a “healing relationship” with a patient is a therapist for that time and encounter. We therefore make an immediate assumption that no one person can be “the therapist” for a patient as so many different skills will be needed in a whole-person approach. However we do also need to recognise the individual skills and training required in a therapeutic relationship and so retain the well known titles except when talking generally.

These healing relationships require a level of trust to overcome the vulnerability felt by patients as they share intimate details of their life experience. This trust depends on acceptance, respect and affirmation from the therapist. Each therapist needs to concentrate on the patient and participate in their narrative as an informed and supportive friend on the journey.

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The importance of the doctor relating to the patient as a human being who is suffering, confused, anxious, fearful and ill.
Quotes from Anatole Broyard  “Intoxicated by my illness” pp 44-45
“I see no reason or need for my doctor to love me – nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time: I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind, just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way. …. I’d like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness”.

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8 Self-help for the patient

A vital part of empowering patients to become healthier is the provision of tools and methods which the patient can use themselves to improve their health. There will be times when the patient needs to have a level of dependence on therapists and carers, however at all times we should seek to involve the patient, encourage and empower them to be fully involved in the process of becoming healthier.

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9 Successful outcomes

The obvious first successful outcome is that the person is healthier, although the extended definition of health is needed (as outlined in section 3 above). Thus the patient has increased self-awareness and power to change their health story. They have a greater ability to help themselves in therapeutic terms and also the ability to help others. They will have matured in their ability to cope with distressing situations and also learned to adapt themselves and their environment. Finally they have more courage and security to face life’s challenges.

We can summarise the benefits of this whole-person approach as the following key outcomes would be sought.
wholeperson text box 9
(To be expanded and worked on)

By the patient

  • Recognition of the Wholistic nature of the person, where the patient can acknowledge that their thinking, feeling and values does influence their state of health
  • Recognition of the role of relationships, and the effect these have on life in general, and ill-health in particular
  • Understanding the separation possible between “me” and the disease processes going on in the body
  • Greater self-acceptance, understanding strengths and weaknesses
  • Understanding of how stress works in their lives to reduce health status
  • Understanding of what health is – not absence of disease and symptoms
  • Learning about coping mechanisms, and what methods the patient uses to cope with stress and illness

wholeperson text box 9b


By the doctor

  • Seeing the whole-person, their fears, hopes and values
  • Seeing how to support and strengthen weak areas within their coping strategies
  • Seeing how to provide help in dealing with relationships, past hurts and wrong understandings which impact health and health behaviour
  • Fitting in therapy to the individual, so increasing compliance and patient cooperation with therapy
  •  
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10 Health, peace and well-being – maturing in health

Finally we need to recognise that good health is not an end in itself, but a part of the rich tapestry of life. Many people have chronic illness and disabilities, yet patients with each of these can still maximise their health status. It is the main objective of a whole-person approach that each patient can arrive at a place of inner peace (Shalom) and well-being. The process of health care therefore lasts until death, and the right balance needs to be struck to avoid the danger of over-medicalising life’s problems, and on the other hand ignoring hidden health issues which reduce the quality of life.

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Doctor-patient interaction – the use of time

(This section may need to be elsewhere)
Value of continuity of care
Reasons why this may not produce the required understanding
Continuity does not necessarily lead to greater understanding because:

  • The interaction is based around the doctor-patient consultation, so is always on the doctor’s home ground, and conducted on his terms
  • The story developed is one around the relationship itself, which cannot help but be partly paternalistic
  • Five ten minute appointments are not the same as one whole hour with the patient. Value of giving time for patient to develop their story
  • Familiarity can lead to assumptions being made rather than digging deeper to discover underlying issues
  • Each consultation tends to be focused around presenting symptoms, and the general background context is not explored because of lack of time
  • Danger of forming opinions too quickly in order to manage the consultation, so allowing bias and pre-formed notions to influence the judgment
  • Only one person hearing the patient’s story, so limiting the effectiveness of the interaction due to personal biases

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Conclusions and summary

SUMMARY
All of the above may be summed up in 3 simple rules

  • be patient centred

put the patient and carers at the centre of the health care process

  • be committed

stay with the patient through to the point where they have achieved the maximal health status

  • be integrated

involve all appropriate members of the health care team.

And as with all sets of simple rules there is another which can be added -

  • be appropriate

don’t attempt to take the patient further than they can go, be realistic in objectives having regard to internal and external resources

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  Updated October 19, 2011   Home > Handbook Index > Handbook Chapter 10