For many years, I have advocated an integrated approach to medicine and health.
By integrated medicine, I mean the kind of care that integrates the best of new technology and current knowledge with ancient wisdom. More specifically, perhaps, it is an approach to care of the patient which includes mind, body and spirit and which maximises the potential of conventional, lifestyle and complementary approaches in the process of healing. Integrated health, on the other hand, represents an approach to individual and population health which respects and includes all health-related areas, such as the physical and social environment, education, agriculture and architecture. I know that this is a somewhat wider definition of integration than commonly used, but I want to argue that a successful health service needs to embrace this broader and more complex concept of integration.
I hasten to say that the point of this article is not to confront accepted medical wisdom, but merely to suggest that there is a case for reaching beyond it, and that is to explore how we might be able better to align the ambitions of patient and clinician within medicine and how we might maximize the ability of every professional and citizen to create better personal and community health outside of it.
Exactly thirty years ago, in a speech to the British Medical Association(1), I quoted George Engel, who wrote “A Modern Science of medicine still tends to be based on the notion of the body as a machine, of disease as the consequence of breakdown of the machine, and of the doctor's task as repair of the machine."
I fear that what was true thirty years ago remains equally true today. It is why for a rather long time now, and not without criticism from some quarters, I have been attempting to suggest that it might be beneficial to develop truly integrated systems of providing health and care. That is, not simply to treat the symptoms of disease, but actively to create health and to put the patient at the heart of this process by incorporating those core human elements of mind, body and spirit. To achieve this and there are many who support this I would suggest that medicine may sometimes need to become less literal in its interpretation of patient needs and more inclusive in terms of what treatment may be required in other words, to understand how symptoms may often simply be a metaphor for underlying dis-ease and unhappiness. It is also vital, it seems to me, to recognize that treatment may often be effective because of its symbolic meaning to the patient through effects that are now being increasingly understood by the science of psychoneuroimmunology.
In short, I suspect it will always be a struggle if we continue with an over-emphasis on mechanistic and technological approaches. Please don’t misunderstand me the best of science and technology constantly needs to be harnessed and deployed to obtain the best effect but, I would suggest, not at the expense of the human elements. These, after all, provide the whole rationale for medicine and healthcare going back to our roots.
The importance of those human elements is becoming all too apparent in contemporary medical science. Sir Michael Marmot has shown convincingly(2) that the health of employees is related to the extent to which they feel empowered to fulfil their role, according to their own judgement. Professor Blackburn, the Nobel Medicine Prize winner, has provided evidence(3) indicating that high levels of stress can result in shortened telomeres, the critical elements which bind chromosomes together. This in turn quickens the ageing process. With research of this kind, we can no longer continue to see mind and body as separate and occasionally interacting entities. That is because they are one and the same thing. Our scientific and therapeutic approach now needs, surely, to advance in a way that encourages and embraces a new understanding between patient hopes, perspective and belief and the workings of his or her body.
This whole area of work what I can only describe as an “integrated approach” in the U.K., or “integrative” in the United States - takes what we know about appropriate conventional, lifestyle and complementary approaches and applies them to patients. I can’t help feeling that we need to be prepared to offer the patient the “best of all worlds” according to a patient’s wishes, beliefs and needs. This requires modern science to understand, value and use patient perspective and belief rather than seeking to exclude them something which, in the view of many professionals in the field, occurs too often and too readily.
In the individual encounter between patient and clinician, we are led to believe that there is currently a “crisis in caring”. I am sure that this is not the case in many or most such encounters. Nevertheless, I am equally sure that there is much more that can be done to foster and enhance those age-old qualities of human kindness and compassion. The Media is full of instances where these have been palpably lacking, and I have heard of others speaking of the need to restore urgently a climate of care and compassion at the heart of our health services.
It is particularly surprising that so many appear to think there is a gap here, when we are told that those so called “soft skills” of caring can have a significant impact on the quality and pace of recovery among patients. This inevitably raises the question: “Are we doing enough to ensure there is sufficient empathy and compassion instilled throughout training in medical schools and in later hospital training?” Should we not, perhaps, be doing more to enhance the length of contact and continuity, when it comes to relationships between professionals and patients? It appears to many inside and outside the healthcare professions that our capacity for providing “the human touch” has steadily decreased as science and technology have improved. Surely, it should not be a case of “either/or”? Thus, it seems to me that good medicine should aim for a better balance between what science and technology may demand and what patients may actually want and need.
One senior professional said to me that what seems to go missing all too easily is the art of thoroughly understanding the patient’s narrative. He said that we need to equip our health professionals with skills (and a desire) to listen and honour what is being said, and - importantly - what is not said to them. Only in this way can they develop a thorough understanding of the patient’s story. This understanding is necessary to develop healing empathy and help the patient find their own particular path towards better health. This should not only help the patient, but should also enable more health professionals to connect and engage in a much more meaningful and professionally satisfying way.
If, however, we are to create such a culture of better care, then we cannot depend forever upon “heroes” at the frontline. Better care and compassion require systems which support the caring ambition of every health service organization, every health service leader and every clinician. If we really want to change things, then we must better support and encourage those organizations, leaders and frontline clinicians, who are fully committed to going the last mile in the care of their patients.
But things should not begin and end with good professional care of the individual patient. There must surely be an enormous potential for more people to become concerned and caring of each other outside this professional encounter? In Burnley, where health inequalities have lowered life expectancy to among the worst levels in this country, up to a dozen of my Charities are working in partnership with local organizations trying to make a difference for the better in the fields of health, the built and natural environment, the Arts, education and business. Why? Because we know that alienated and uncaring communities adversely affect the health and wellbeing of those living in them(4,5). Conversely, current evidence suggests that if you try to tackle some of these admittedly deep-seated problems, not only do you begin to witness improvements in health and other inequalities, but this can lead to improvements in the overall cost-efficiency and effectiveness of local services(6).
In summary then, we are beginning to know more about the causes of unhappiness and poor health. We also know the importance of the patient/professional relationship and the therapeutic potential of relationships in general. There are “a priori” reasons to suspect that we could improve health through a range of better integrated interventions and programmes. We now desperately need to produce more of the right kind of research to strengthen these hypotheses.
This wider role for medicine is supported by traditional wisdom which sees illness as a disorder of the whole person, involving not only the patient’s body, but his mind, his self image, his dependence on the physical and social environment, as well as his relation to the cosmos. Perhaps we should also invoke ancient wisdom in dealing with this model of disease. In that same speech to the BMA in 1982, I quoted Paracelsus, the 16th Century healer, who said that the doctor “Must be intimate with Nature. He must have the intuition which is necessary to understand the patient, his body, his disease. He must have the ‘feel’ and the ‘touch’ which make it possible for him to be in sympathetic communication with the patient’s spirits.” Paracelsus also believed that the good doctor’s therapeutic success largely depends on his ability to inspire the patient with confidence and to mobilize his will to health. These ideas, which were close to heresy in 1982, appear to be more acceptable to some in 2012. Postmodern medicine, I believe, will need to embrace them in its science and alongside its technology if it is to maximise its impact and remain sustainable.
Clinicians, of course, have the huge responsibility of taking these things seriously and finding a way forward that is best for patients and for local populations. Surely, there can never have been a better time for all clinicians to emphasise the value of caring, continuing relationships and of adopting a more holistic approach to health and disease - a human approach, if you like, which maximizes the potential of the physical and social environment, so that healing and better health can thrive?
Now, surely, is the time for us all to concentrate some real effort in these areas. We will need to do so by deploying approaches which, at their heart, retain the crucial bedrock elements of traditional and modern civilized healthcare - of empathy, compassion and the enduring values of the caring professions.
- Speech to the British Medical Association on 14th December 1982
- Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease. Lancet 1997; 350: 235-40.
- Daubenmier, J., Lin, J., Blackburn, E., Hecht, F.M., Kristeller, J., Maninger, N., Kuwata, M., Bacchetti, P., Havel, P., & Epel, E. Changes in stress, eating, and metabolic factors are related to changes in telomerase activity in a randomized mindfulness intervention pilot study. Psychoneuroendocrinology. 2012 Jul; 37(7): 917-28. Epub 2011 Dec 14.
- Propper, C., Jones, K., Bolster, A., Burgess, S., Johnston, R. and Sarker, R. (2005), ‘‘Local neighbourhood and mental health: evidence from the UK’’, Social Science & Medicine, Vol. 61 No. 10, pp. 2065-83.
- Ross, C.E., Mirowsky, J. and Pribesh, S. (2001), ‘‘Powerlessness and the amplification of threat: neighborhood disadvantage, disorder, and mistrust’’, American Sociological Review, Vol. 66 No. 4, pp. 568-91.
- Friedli L: Mental Health, Resilience and Inequalities (2009); WHO