Wednesday, October 10, 2007

Does mainstream medicine treat the whole patient?

I have a certain hesitation in talking about the “whole patient”. As important as the notion is, in recent years it seems to have lost some of its meaning, at least in popular usage. That’s because it’s been hijacked by the boosters of alternative medicine who relentlessly accuse the mainstream of focusing on the disease and organ system at the expense of the person who has the disease. The American Medical Student Association, for example, in its promotional web page on Integrative, Complementary and Alternative Medicine, says this:

The above examples suggest that CAM fills a hole in conventional medicine. Michael Cohen describes the biomedical vs. holistic paradigms. Conventional medicine has almost perfected the biomedical approach. This system views the body as a machine and reduces the body to its components. The biomedical paradigm works well for emergency problems or diseases with one specific cause. The holistic paradigm, embraced by many CAM practitioners, sees the body as more than the sum of all of its parts. It emphasizes lifestyle changes, stress reduction and nutrition to enhance the patient's healing process. Biomedicine often falls short in treating chronic problems, while many patients with chronic problems find some relief with the holistic approach of CAM therapies.

Half truths and innuendo of this sort are pervasive in alternative medicine literature. Such “whole patient” promotions generally mislead and have the potential for great harm because they drive widespread uncritical acceptance of non-evidence based health claims.

But do they have a point? Has the mainstream become too reductionistic? The answer, in part, is that external barriers have caused a disconnect between real world practice and the teachings and ideals of mainstream medicine.

Mainstream medicine has always taught that doctors must treat the whole person. My favorite medical school mentor, the late Thomas E. Brittingham, pounded the notion into students’ heads. In his annual introductory letter to incoming third year students about to begin their medicine clerkship he wrote:

I expect you to spend time with each one of your patients after the initial workup in establishing rapport with him, obtaining an extensive personal history by indirect and easy means, and in showing the patient that you have a keen interest in him as a person and friend as well as a disease.

Dr. Brittingham wasn’t pushing some altie agenda. (There was no room for that in medical school in those days!). He was teaching the fundamentals of mainstream medicine. And despite the unfortunate fact that quackery is making its way into the curricula of MD granting schools today, the “mainstream” teachers in these schools still emphasize a comprehensive approach that treats the patient and not just the disease. One of our favorite “mainstream” bloggers, DB of DB’s Medical Rants, teaches this philosophy to students and house staff at the University of Alabama School of Medicine. For a sample of his writing on this subject check out his last two blog entries.

But, as I alluded to above, physicians encounter difficulty translating this principle into real world practice. Economic incentives force doctors to see too many patients in too little time. Perfunctory “quality” measures distract from things that really matter in patient care. The ever present threat of litigation makes the patient a potential adversary. These dehumanizing forces are significant obstacles to treating patients as whole persons.

There are no easy fixes, but at both the individual and the system level we in medicine must continually oppose these barriers to our professionalism. Without knowledge and skill in the humanistic dimensions of medicine we cannot be effective clinicians, but “integrative” medicine is not the answer. We can spend all the time in the world learning about the patient’s psychological make up, temperament and social interactions, but when we’re not grounded in the biomedical model we become incompetent.

We as doctors need to appreciate patients as people, but guess what? We also need to know about organs. And diseases. Our thought leaders do well to teach about the healing of whole persons. But they must also insist that the principles of Western science be rigorously applied to the healing of those persons.


Anonymous said...

emphasizes lifestyle changes, stress reduction and nutrition

Listening to people talk about their illnesses and doctor visits, nearly all mention that their doctors emphasized the above, in addition to whatever meds or other treatment he prescribed. The problem is, nearly all had excuses why they wouldn't/couldn't follow those directions. Do the alties have any better luck?

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