In its customary use the term primary care refers to the ongoing basic health services provided by a primary care practitioner to a client. These services may include the care of acute and chronic medical problems, the organizing and orchestrating of complex multi-practitioner interventions, prevention and health promotion services, education, advise, and psychological counseling and support. It is the intent and hope that the primary care practitioner-client relationship will extend over many years, progressively developing both the trust and intimacy that characterizes a caring and healing relationship.
Today, primary care health services are predominantly provided by physicians within a contextual framework that emphasizes the authority and expertise of the practitioner, focuses on disease and disease categories, encourages episodic care, and promotes the underlying assumptions of the biomedical model: objectivism, determinism, and positivism. These assumptions, although unknown to most practitioners, exert a compelling influence on the practice of primary care.
In brief, objectivism asserts the unqualified and exclusive validity of sensory based observations that are considered to be untainted by subjectivity. The observer is believed to be independent of his observation and science is seen to be non-relativistic and extra-cultural. Determinism is the belief in a direct linear upward chain of causality linking a singular cause to its specific effect, the process of reductionism. This view underlies the “gold” standard in scientific research, the clinical controlled experiment in which a single variable is manipulated while all others are kept constant. Positivism is the view that the ongoing accumulation of data from sensory based experiments will provide us with a progressively more accurate and life enhancing understanding of nature.
It is the premise of this paper that the meaningful integration into our health care system of holistic principles and complementary healing practices will require a fundamental re-orientation of our current approach to primary care. To do otherwise would more than likely result in a distortion and corrosion of holistic principles, a reduction of complementary practices into disease oriented treatment modalities, and a corrupting influence on the alternative practitioner whose practice style would invariably fall under the hegemony of the reimbursement system and the biomedical world view. Complementary approaches will invariably be re-shaped to conform to the contextual framework of biomedicine rather than extending and expanding this framework. Stated in another way, the existing system will change the alternatives rather than the alternatives changing the system.
There are ample examples of this for us to draw upon. In the 1970s John Travis1 initiated the wellness movement. His conceptual model was educational in orientation and based on the principles of psycho/social/spiritual development. Immersed in the context of our scientific world view it was quickly reframed in a manner that exclusively emphasized its most physical and material aspects: smoking cessation, exercise, and nutritional changes. The core and soul of this model was lost through its integration into our contemporary context. Much the same can be said regarding the concept of holism. Holism, a concept which is based on an expansive view of the human experience, emphasizes the essential and irrevocable interaction of mind, body, and spirit.2 In the context of our cultural paradigm, the concept of holism has been distorted and mistaken for alternative treatment practices. Although a practice may derive from a conceptual framework that is more or less holistic, the actual practice, as integrated into our culture, is most often used as a reductive treatment practice oriented towards repair and restoration of function. Holism is not a practice. It is a perspective.
These concerns are hardly hypothetical. They are occurring now as alternative and complementary practitioners are progressively incorporated into managed care reimbursement plans. In general, conventional reimbursement systems do not reimburse for a specific approach, for example, chiropractic or acupuncture, but rather, for the treatment of a particular disease category: lower back pain in the case of chiropractic and chronic pain and addictive problems in the case of acupuncture. The existing biomedical context reduces these approaches to disease oriented treatments and jettisons their holistic context. Unknowingly, practitioners, appreciative of having accomplished their long sought after goal of acknowledgement and reimbursement through the health care insurance system, have failed to see the subtle and insidious distortion that lies in wait for them and their practices as they are “mainstreamed” by the insurance system, a fate only too well known to conventional medical practitioners.
No effort to transform and expand the current health care model can succeed without a shift in the underlying world view that drives our current medical model.3 The primary care practitioner who, as a result of managed care initiatives, is emerging as the initial contact point for clients, the “gatekeeper” for external medical resources, and, in participation with the client, the orchestrator of an individualized health and healing process, is the central figure in the changing medical paradigm. The perspectives and attitudes of this individual will largely determine the content and character of health care.
An Integrated Healing Model
A re-orientation of primary care must begin with a shift in the existing world view of objectivism, determinism, and positivism. A reading of history, past and contemporary, and an understanding of current cultural trends clearly indicates that we are moving towards a new world view, a paradigm shift, that can be characterized by the emergence of a set of assumptions that are better matched to the needs of our time.4 These assumptions are: dynamism, holism, and purposefulness. In brief, dynamism is characterized by the view that human life is a vital process of growth and development resulting from the ongoing interaction and adaption of man to his changing environment. This perspective asserts that the human condition cannot be exclusively understood through the accumulation of static data which deny the influence and validity of psycho/social/spiritual and environmental influences. Holism is the term we use to designate the viewpoint that life is a natural, organized, and unfolding process that consists of constituent elements bound together from the very beginning in a unitary whole. Life cannot be constructed by the mere summation of its individual elements. Purposefulness express the view that intentionality and meaning can be found at all levels of the human experience.
Based on this world view we can devise an integrated healing model which can serve as the theoretical basis for a re-invention of the primary care process.5 This model, figure 1, is based on systems theory.6,7 It asserts that the human healing system is composed of four distinctive interactive sub-systems each with their own mechanisms, capacities, and resources. Taken together, these four sub-systems become the basis of a complete and vital healing system, qualities that resides in the total system rather than in any one of its constituent parts.
Fig. 1. Columns (read vertically) represent four distinct healing systems. Read horizontally, they incorporate the holistic perspective embedded in the model.
The homeostatic healing system is our most basic healing system. It is built-in, auto-regulating, and natural. This system evolved over millennia to support the living conditions of our primitive ancestors. Invariably, it breaks down when exposed to the conditions of urbanized life. Treatment systems are a reactive response to the failure of these natural healing mechanisms, and in the best scenario, should support our natural homeostatic mechanisms. Treatment systems are oriented towards the repair and the restoration of normal function. The authority and expertise lies with a professional whose practices usually involve external agents of one sort or another. The mind/body healing system is proactive, self-initiated, and directed towards the expansion of consciousness and the achievement of autonomy, an event that is heals both our psychology and physiology. Finally, the spiritual healing system relies on the emergence of a transcendent perspective which in and of itself can heal by spontaneously re-organizing both our psychology and physiology.
This inclusive and integrated model assists the primary care practitioner and his client in understanding and using both conventional and complementary approaches within a contextual framework that embodies a new and more expansive world view. Vertical movement within each healing sub-system extends the resources of that system, for example, the expansion of the treatment system with the addition of complementary therapies. Horizontal movement across the four sub-systems emphasizes the holistic perspective that is embedded in this model. Any of the sub-systems taken alone are inconsistent with the living process, taken together they constitute the essence of natural living system: dynamism, holism, and purposefulness.
The Primary Care Practitioner
As we re-consider the role of the primary care practitioner within the contextual framework of an integrated healing model, it becomes evident that there must be a defining shift in the relationships, perspectives, and practices that constitute the elements of primary care. This includes: a renewed emphasis on the quality and character of the diverse relationships related to the healing process – the relationship of the practitioner to himself, his client, other practitioners, and the community-at-large, and a careful balance between reductive and holistic perspectives. Primary care becomes more integrative and person-centered in contrast to fragmented and disease centered.
The diagnostic process expands to include a concern with psychological, spiritual, community, and environmental issues.(FIG. 2) In this manner the diagnostic process becomes inseparable from the substance of the practitioner-client relationship. The “medical history” is more a sketch of the unique story line of an individual’s life, than a standardized check list of symptoms. This reflects an acceptance of an concern with the subjectivity of each individual’s unique circumstance. The expanded practitioner-client relationship becomes a larger context within which the traditional diagnostic results are interpreted and acted upon. For the primary care practitioner the art of healing which is embodied in the healing relationship re-emerges to balance and provide a context for the technological and reductive aspects of healing.
This raises a most critical issue. Who shall be the future primary care practitioner? From the perspective of an integrated healing model there is no clear reason why this role requires the training of a physician. In fact, in the current medical setting nurse practitioners and physician assistants have often undertaken this role. Although it may be appropriate for the primary care practitioner to undergo training in a specific healing approach, it may not be essential that this be biomedicine. The rigors and intensity of a training process allows for a certain intellectual vitality, personal discipline and maturity which are essential qualities of a healer. But, an expertise in a particular perspective should be expanded to include a knowledge and understanding of the capacities, assets, and liabilities of other healing systems allowing the practitioner, irrespective of his healing approach, to appropriately use and relate to other practitioners and practices.
Fig. 2. Implications of an expanded healing model
Primary Care Practice
Let’s examine how the primary practitioner will actually handle his/her task. In the ideal and preferred circumstance the practitioner-client relationship develops over an extended period of time and emphasizes disease prevention and the attainment of full health. However, given our present cultural practices, practitioners and clients usually forge their relationship in the context of an illness setting. Beginning with the first encounter, an emphasis will be placed on1 eliciting an expanded biographical history, one that encompasses the orientation of the four healing systems and is therefore bio/psycho/social/spiritual in perspective (see figure 2), and2 developing an empathic, person-centered relationship. The nature and severity of the initial concern, the age and maturity of the client, and the details of the history will assist in sorting out the primary factors to be considered in each circumstance. For example, a transient upper respiratory infection may call for specific treatment and limited advice whereas the onset of atherosclerotic heart disease will certainty require that all of the healing systems be addressed within the context of a rapidly developing healing relationship.
As depicted in figure 3, the initial and ongoing efforts at establishing an historical database will expand from its previous and exclusive focus on disease to one that seeks a comprehensive understanding of the multidimensional factors that together compose an individual’s life; personal history, attitudes, lifestyles, social and work relationships, environmental elements, and spiritual perspectives. Rather than converging towards a physiologic based diagnosis, the practitioner first diverges towards a holistic vision of the individual. This is an individualized approach mandated by the circumstances af a unique individual in contrast to an approach that is dictated by the presenting signs and symptoms and the need to converge, as soon as possible, towards a disease related diagnosis. As stated by the famed internist Sir William Osler, “It is better to know the patient that has the disease than the disease that has the patient”.
Fig. 3. Multidimensional Healing: the clinical process
The objective of treatment modality, whether it be conventional or alternative is to repair the abnormality and restore, as best as possible, normal function. The objective of our new primary care practitioner is broader, a summation of the objectives of the individual healing systems which include: (1) the maintenance of an internal/external balance, (2) the repair of abnormalities and the restoration of normal function, (3) the development of personal autonomy and the expansion of self-awareness, personal capacities, and resources, and (4) the achievement of wholeness as signified by a spiritual perspective that conveys meaning and purpose to life.
Although the practitioner is frequently placed in the position of reacting to the presentation of the signs and symptoms of illness, it is essential that he/she learns to maintain and promote a proactive perspective. The practitioner must “hold”, often initially for himself and his client, the vision that I believe was best stated by C.G.Jung, “… disease is the beginning of a natural healing process”. Further, the practitioner must view health more as a verb than a noun, a life long orientation rather than a static condition, one that is expressed through attitudes, choices, and actions. This conceptual expansion and re-definition of our ideas about health and disease is the primary factor in the shift from a reactive approach to one that is proactive. It is understandable that the ill client is primarily focused on disease. It is the role of the new primary care practitioner to meet this need while at the same time placing it in a far larger context, “using” it as a vehicle through which to assist the individual in expanding his more limited view of health and healing.
The Practitioner – Client Relationship
It is in this area that we seek to achieve one the most significant differences between the old style of practicing primary care and the re-designed role that I am suggesting.8 Professionalism is a recent development in human history. It is based on the proliferation of information and technology, the related need for specialization, and the cultural practice of restricting, through licensing, the practice of a particular social role. Professionalism is inseparable from the dominant – dependent relationship that is built into the idea of professionalism and expertise. The client is placed in a relative position of powerlessness and helplessness as he defers responsibility for recovery and health to the professional expert. The practitioner-client relationship is seen as merely a vehicle with which to carry forth the prescribed functions of the professional role.
The consequences of the rise of professionalism, a loss of personal autonomy and a diminshed capacity for self-care, are not restricted to the disease process. The medicalization of our lives now extends to include the most essential existential issues of life: pain and suffering, ageing, and death. These experiences, ones which are necessary for personal development and the expansion of consciousness, are expropriated from our personal domain.9 The unbridled exercise of professionalism and expertise (conventional and alternative practitioners included) destroys the potential for full health and diminishes the autonomy and dignity of the individual.
The new primary care practitioner must see himself engaged in a partnership with the client in which responsibility must at all times move towards the individual and away from the professional, and in which the relationship is seen as the primary and enduring context within which recovery, healing, and health initiatives take place. As we each become more fluent with the extensive resources that are now available through the Internet and other online services, access to information will cease to be an important distinction separating the practitioner from his client.10,11
Imagine a client accessing the data bank of the Cochrane Collaboration, an international effort to perform, update, and disseminate systematic reviews of clinical trials.12 Or, consider him entering information on his illness and reviewing the output of disease specific information, seeking information on particular alternative practices, or contacting other individuals with his precise problem to determine the results of their efforts while at the same time establishing a supportive and healing relationship. Perhaps our client can even speak online with one or more “experts”.
Paradoxically, what will distinctively remain the domain of the practitioner will not be his fluency in information and technology, but his art as a healer and his capacity to develop and participate in healing relationships. In T.S. Eliot’s words from the Four Quartets we will “… arrive where we started, And know the place for the first time.” The art will return to medicine. And what exactly is this art of medicine? It is the creative capacity to enter into the experience of another human being, understand from the clients perspective the nature of his life and its forces, what can be called empathic listening, and participate with this individual in the composing of a healthy life, a composition that involves recovery, healing, and health – the fully lived life.
The Practitioner-Practitioner Relationship
The full capacity to use all of the potentially valuable healing modalities, whether they are conventional or alternative, is based on the understanding and relationship that develops among practitioners. This understanding must include an acceptance of the fact that there are many complementary approaches to healing each of which developed in a cultural context. No one approach or technique has sole ownership of a singular truth. There is more than one way to heal.
Similar to how we as individuals learn to move beyond our biased judgements of another person by listening to and getting to know that person, as practitioners we must we willing to study and understand cross cultural healing traditions. The more we understand about a healing tradition, the more capable we become of using, when appropriate, the resources of that approach, and relating to and understanding the perspective and practices of the practitioner. It then becomes possible to establish a working relationship with a community of professionals that share a multiplicity of approaches to healing each of which can contribute to our expanded approach to health and healing.
In the practitioner-client relationship we are called upon to be sufficiently self aware and knowledgeable that we can move beyond our own perspectives to encompass those of our client – from the perspective of our client. In the practitioner-practitioner relationship we are asked to do much the same. Underlying each of these tasks is a maturing of ourselves and our consciousness, a maturing that can appreciate and value the relativity and subjectivity of all perspectives, seeing within this diversity a larger unity. This is difficult for all practitioners, conventional and alternative.
The Education of the Primary Care Practitioner
Science is the development of a systematized knowledge which is derived from observation, study and experimentation, and is directed towards achieving a cohesive and durable understanding of the natural world. Biomedicine is only one expression of the scientific ethic, but it is the only one that is taught to today’s primary car practitioners. Although biomedicine, as a reductive branch of science, has provided us with a very powerful understanding of basic physiology and a highly effective technology that can be applied to a specific set of circumstances, like all branches of science, it is limited. The primary care practitioner of the future must be taught a broader based science which incorporates the psycho/social/spiritual dimensions of life.
System’s theory and integrative studies provide the backbone for such a science. The whole healing model presented above contains within its structure sufficient latitude to embrace both reductive and holistic approaches, conventional and alternative. The primary care practitioner of tomorrow must be capable of carrying out his activities with an attention to the multi-factor influences on disease and health, and the full array of potential approaches to healing. This is best accomplished through an educational process that promotes a scientific perspective which includes an observational process that extends from the laboratory to the “bedside” and from there out to the family, community, and environment. Such a broad based science views the human experience from an ecological perspective rather than exclusively focusing on a reductive physiology-centered perspective. With such a background it becomes possible to both focus out in an ecologic manner and focus in with an analytic and reductive perspective.
It either instance, it is the eyes and ears that make both a good scientist, and also a good caretaker. The former allows for accurate outer observations and the latter for empathic listening, the essential component of a healing relationship. Empathic listening is the capacity of the listener to silence his own inner dialogue, which is invariably cluttered with personal perspectives, for the purpose of fully and non-judgmentally entering the experience of his client. This serves two purposes. First, given the limits of the human experience, it allows for the most accurate interview that is possible, as the practitioner is hearing the experience of the client spoken from the client’s unique world view. Second, empathic listening is the basis of the trust and acknowledgement that are the cornerstones of a healing relationship. Empathic listening is a teachable skill, and in addition to training the practitioner in listening to others, it bestows a further gift, the capacity of the practitioner to listen to his own experience, an encounter which as a holographic microcosm provides him with a direct and highly empathic understanding of life outside of the boundaries of his skin.
Empathic listening requires self awareness and self-understanding, qualities that only arise from inner reflection. The image of the wise healer is an ancient one which existed long before the very recent emergence and dominance of the “wisdom” of the laboratory sciences. An educational process that devalues humanistic and aesthetic studies, emphasizes the rapid and unquestioned assimilation of technical knowledge, and promotes long an excessive hours in clinical training and practice does not leave time for the self reflection and personal maturation that characterize the wise healer. This has been a great loss for all of us, personally and professionally. The educational process of a practitioner must encourage a life long process of self-study that should occur within the context of a broader and more liberal education.
Thus far I have spoken of two important facets of the training of the new primary care practitioner: a knowledge of system’s theory as it applies to issues of disease and health, and the capacity to mature with each client a healing relationship based on the trust and acknowledgement resulting from empathic listening. There is also the core content of the elements of clinical practice. For the physician, this resides in the skills and capacities related to an expanded biomedical model. For other practitioners the content will differ. As I have stated, each practitioner must learn that his approach is relativistic and culture based and therefore has “proprietorship”, over only one segment of reality.
Given the array of healing modalities it becomes necessary for the primary care practitioner to have a large, accurate, and up-to-date information base at his “fingertips”. As I have noted previously both the upsurge in interest in acquiring reliable research data on alternative approaches and the availability of online information will allow the primary care practitioner ready access to the information he needs. A fluency in online information gathering will invariably be a part of the future educational process.
I have mentioned a few of the key elements in the education and training of the new primary care practitioner. In many instance these elements were clearly seen and recommended by Abraham Flexner in his 1910 report on medical education, a report which re-shaped the character of medical education. Many have seen this report as the primary factor in the development of a medical curriculum that emphasizes reductionism. As George Engel points out, Flexner spoke for a broader based science whose essence has yet to be incorporated into medical training.13,14 The recent publication of the Pew-Fetzer Task Force Report on Advancing Psychosocial Education has providing us with further insights into the dynamics of a revised approach to the training of medical practitioners, one that unlike the Flexner report, a report which emphasized the importance of the clinical and laboratory sciences, re-asserts the primacy of the client-practitioner relationship.15
Reclaiming The Passion and Spirit of Healing
Rene Descartes, much as is our circumstance today, lived at a time of great change. When he published his Discourse on Method in 1637 the medieval world was disintegrating and a new world, a modern world of enlightenment and progress was slowly emerging. Although his firm believe in reason as the most reliable path to truth must be understood in the historical context of his time, it nevertheless resulted in the mind being split off from body, subject from object, and matter from spirit. Life was devitalized and the multi-demensional living process was no longer seen as a legitimate area of study or research.
There are two great streams of knowledge available to the human mind: (1) sensory based knowledge, and (2) intutive knowledge. When one way of knowing becomes over dominant its counterpart rises to restore balance. Descartes emphasis on the intellectual and sensory based observations was a necessary historical response to the over dominance of the preceding religious perspectives. We now discover that history has come full circle again. The dominance of sensory based knowledge has left us with a devitalized world, one that lacks meaning, purpose, and direction. It is in such circumstances that the human psyche constellates the opposing tendency, and we begin to become aware of the rise of intuitive knowledge and empathic understanding – the second great stream of knowledge.
It is only when these two streams of knowledge intersect that we feel, personally and culturally, the full creative potential of life. This is occurring in our time. For example, the rise in feminist principles, hologographic and chaos theories, the ecological movement, and the effort to bring a holistic viewpoint into medicine each share a common core, a resurgence of intuitive knowlege and empathic understanding which, in contrast to an intellectual sensory based knowledge, conveys a knowledge of patterns, relationships, and wholes. It is in the convergence and balanced use of these two ways of knowing that passion and spirit is fully released.
As healers begin to again approach their clients and the healing process using both their intellectual sensory based knowledge and their empathic intuitive knowledge the practice of medicine will be re-vitalized. Every individual will become another experiment, an anomaly to be studied, a unique expression of life. Each client will teach us something new about ourselves, expand our personal and professional horizons, and force us to approach healing with a mind that is emptied of standardized views of disease, health, and the human condition. We will be able to tap into our extraordinary technical and sensory based knowledge and apply it within the context of the meaning and purpose conveyed by an intuitive and empathic understanding of the circumstances of a unique individual life. We will be fully engaged, and our art will be fully restored.
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15. See citation # 8 above.
16. Needleman, J. The Way of the Physician. San Francisco. Harper and Row. 1985.