We are probably all familiar with things that are tough to define, but that we recognize when we see them. No, I'm not planning on talking about that one...
The term I have in mind is: holistic.
I practice holistic medicine. Specifically, for the past decade, I have directed a rather unique clinic that provides what we call 'evidence-based integrative care.' We have published and presented details of the model.
People tend to have a strong sense of what holistic means, whether or not they can actually define it. Detractors see it as an indication of quackery-- without looking past the label. Proponents embrace it as an emblem of virtuous humanism. Holistic is good, and all else ... less so.
But if that is really true -- if holistic care is better (I'm among those who believes it is) -- then a workable definition is important. First, so that people who want to sign up for holistic care -- to give it, or receive it -- know what they are signing up for, exactly. And second, and more importantly, because you can't practice what you can't define. Unless we can say just what holistic care is, it can't be taught, tested, replicated, or improved.
The medical version of TheFreeDictionary tells us that holistic care is: "a system of comprehensive or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person; his or her response to illness; and the effect of the illness on the ability to meet self-care needs."
I am comfortable with this in theory, but not in practice. In practice, it begs the question: how, exactly, do you do that? What does considering 'physical, emotional, social, economic, and spiritual needs' look like in a doctor/patient encounter? What is a clinician actually supposed to do in a room with a patient so that the care that transpires between them is holistically concordant with this definition?
Let's acknowledge that platitudes don't really help. Of course, a holistic practitioner looks beyond a battered body part to the whole body; looks beyond the body to the mind and spirit; looks beyond the individual to the body politic of which they are an intimate part; and, if responsible, looks at the body of pertinent scientific evidence as well.
But a devotion to holism does not impart mystical prowess to clinician, or patient. No one gets a magic wand that allows for a complex array of medical problems to be fixed all at once. Holistic care is, in fact, most important when it's hardest to do -- when there is a lot that needs fixing. I suppose there may be a holistic way to suture the finger of a healthy, young person lacerated while dicing zucchini, but I doubt it would matter much. It does, however, matter a great deal in complex cases of chronic illness, attendant despair, social isolation, and hopelessness. And at such times, it's really hard!
Here's an illustration, based on any number of patients we've treated over the years. Consider a woman of roughly 70, who comes to the clinic ostensibly to get dietary advice because she wants to lose weight. She is, indeed, obese -- with a body mass index of 32. She has high blood pressure and type 2 diabetes, and is on medication for these. Her husband passed away 4 years ago, and she lives alone. She is lonely, tends toward sadness, and is always tired. She sleeps poorly.
She eats in part because she is often hungry, in part to get gratification she doesn't get from other sources. She does not exercise because she has arthritis that makes even walking painful. Her arthritis has worsened as her weight has gone up, putting more strain on already taxed hips and knees. Medication for her joint pains irritates her stomach, and worsens her hypertension. There's more, but you get the idea.
I regret to say that medical practice propagates its own uncouth vernacular, resorted to in part to relieve the pressure of 30 hour shifts and life and death crises. Much of the slang is too shameful to share, but one term is especially germane to a case such as the one above: circling the drain. A complex array of medical, emotional and social problems really can resemble a cascade in which each malady worsens another, and the net effect is a downward spiral into despondent disability. Circling the drain is crude, but apt.
I present the term here because it actually has hidden utility. If you can descend one degenerating spiral at a time, you can reverse engineer the process -- and ascend the same way! In my view, that is what holistic care -- in its practical details -- needs to be.
For the hypothetical case in question, and innumerable real people like her, reversing a descent begins with one well prioritized move in the other direction. So, for instance, it is likely that this woman has markedly impaired sleep, due perhaps to sleep apnea. A test and intervention to address this effectively may be the best first move for a number of reasons.
Poor sleep can cause, and/or compound depression; poor sleep invariably lowers pain thresholds, making things hurt that otherwise might not, and things that would hurt anyway, hurt more; poor sleep leads to unrestrained and emotional eating; poor sleep leads to hormonal imbalances that foster hypertension, insulin resistance, and weight gain; and poor sleep saps energy that might otherwise be used for everything from social interactions, to exercise.
Whether a focus on sleep is the right first step will vary with the patient, of course. But let's imagine that in this case it is a good choice, as I have found it to be on a number of occasions. So, we intervene accordingly -- just to improve sleep. So far, this doesn't sound defensibly holistic. But it does sound like something the patient might be able to tolerate.
But as soon as sleep does improve, the benefits start to accrue. Ms. Patient has a bit less pain, a bit more energy, and a slightly more hopeful outlook. So now that she has some more resources, we ask more of her. We now need her to invest these benefits back into herself! Let's use that energy to start a gentle exercise regimen (water-based if need be to avoid joint strain); initiate some social activity of interest to get some stimulation and purpose reintroduced; and perhaps begin the process of dietary improvements to address the weight loss goals initially espoused. We might also start a course of massage therapy or acupuncture to further alleviate joint pain, now that Ms. P believes feeling better is possible.
A little exercise further improves energy, and sleep, and self-esteem; and actually helps ease joint pain. Less pain further improves energy, sleep -- and willingness to exercise. Social engagement -- perhaps a church or civic group -- confers gratification that no longer needs to come from food. Hormonal rebalancing that occurs with restoration of circadian rhythms alleviates constant hunger. Diet improves. Medication doses are dialed down. Helpful supplements may be started.
Weight loss starts. Energy goes up. Joint pain improves some more. Physical activity becomes less and less problematic, and increases incrementally. Energy and sleep improve further, weight loss picks up. With more hope, and more opportunity to get out, Ms. P establishes, or reestablishes social contacts that restore friendship and love to their rightful place in her life. Her spirit rises, and with it, the energy she has to invest back into her own vitality.
And so on -- with many time consuming details left out, of course. This may sound like wishful thinking -- but it's a rewarding reality I have been privileged to help choreograph innumerable times over the past decade.
If the erosion of health is a degenerating spiral, then its reclamation is a spiral staircase.
Which leads to the good news, and bad, about holistic care, practically -- and practicably -- defined. The good news is that with real dedication and a commitment to one another and the process, almost every clinician and patient can find a way to ascend at least some distance toward the heights of holistic vitality. The bad news is that I've yet to see a helicopter fly in to get anyone there in one fell swoop. We all need to be realistic. The climb is made one step at a time.
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