Whole Patient Care

My definition of whole patient care for the purposes of this article is providing a higher quality of traditional allopathic or osteopathic care to a patient utilizing the knowledge of that person’s complete medical history and examination, historical and cultural background, emotional and/or spiritual strength, family and community support combined with scientific medical evidence and being able to guide the patient properly in improving wellness as well as in treatment of illness, always with the whole patient’s best interests in mind.

This concept of "whole patient care" is not new and is only faintly similar in some respects to the newer philosophy of holistic medicine with regard to its emphasis on treating the whole patient not just the individual body parts, and on encompassing emotional and spiritual as well as physical aspects of the individual, but stops short of embracing alternative therapies without proper scientific support. I believe it is always important to keep an open mind about anything that may provide a benefit to any patient’s care, but always be aware of potential risks with unproven or unaccepted therapy.

I do believe that physicians, particularly those in the field of primary care, have the responsibility to know their whole patients inside and out and to use good judgment in advising proper care based on that knowledge.

Know and understand the whole patient for better, individualized care…

For example, say you have two patients admitted to the hospital with hip fractures.

The first patient, Mrs. X, is a 70 year-old female, who has been very active in her daily life - ambulating well, going shopping with friends frequently and has a healthy caring husband at home.

Mr. Y, on the other hand, is an 80 year-old widower, who lives alone, has no caring family member, and has been weak and unsteady for the past 2 years now.

These two people with the same diagnosis are going to get two very different approaches to their care and follow up because of the non-medical information that you know about them.

Mrs. X will most likely get a hemi-arthroplasty or total hip replacement with a long-lasting prosthesis. She will stay in the hospital 4 days and go home with physical therapy and 2 weeks of Coumadin as an outpatient and will be taken care of by her loving husband.

Mr. Y will most likely get a hip pinning, will stay in the hospital 5-6 or more days and then be transferred to a sub acute care facility, where it will probably take at least 3 weeks to get him ambulating on his own again. He will be at much greater risk of complications than Mrs. X, including things like pneumonia, pulmonary embolism, decubiti, muscle atrophy, repeated falling, malnutrition, etc. You will need to be aware of these things, prevent and treat accordingly. So now you're not just treating the hip. You're treating the whole patient.

Lifestyles

As another example, your whole-patient-care approach to a healthy athletic diabetic who is highly motivated to remain healthy and well and energetic for as long as s/he can is going to be different than it would be for an overweight smoking diabetic of the same age who doesn’t really want to know what a glucometer is, let alone use one. One is not a better person than the other. They just have different focuses in their lives and you have to adapt your style and approach to meet their needs while trying to help them both in the best way that you can knowing what their goals are and maybe trying to change goals when necessary. You are incorporating your knowledge of the patient’s goals and lifestyle to make the best plan of care to fit him or her.

Social Factors in Whole Patient Care

Patients who are illiterate (not as uncommon as one might think) don't take their prescriptions correctly because they can't read the label. Even more common are the patients who can't afford their prescriptions. How can you improve the health of a hypertensive, diabetic with hyperlipidemia, who can't afford the minimum of 3 drugs required to treat those problems? If you're not thinking about that when you see them and prescribe Januvia, for example, you can see where that might be a problem. If you didn't know the patient is a recovering alcoholic and you recommend an alcohol-based cough syrup, you may be doing him or her a great disservice. These are called contextual errors in medicine - mistakes made because we didn't consider the context of the particular patient situation or social environment.

Spiritual factors

An atheist approaching end-of-life issues will require a different approach than one who is very spiritual and religious. Knowing this may help guide you as you discuss these issues with your patient. It is important to always be respectful and non-judgmental as you are helping people deal with these problems.

Also, if a patient is inclined to use spirituality as a way of healing both physical and emotional stress, I would encourage it, not to the abandonment of good medical care, but definitely have them use it to the extent that it may help them feel better and may provide some peace of mind. It certainly can do no harm. In fact, I frequently advise those who need emotional and spiritual support through a difficult illness to seek the advice and counsel of their ministers and priests.

Emotional factors

Another important point in the concept of whole patient care is that treatment of various illnesses often requires a multidisciplined approach – i.e., not just treating the illness but also treating any underlying emotional stresses that may be aggravating the illness. Treating the physical illness by itself may not work well unless you treat the other aggravating components of the illness as well. If an emotional problem like anxiety, depression or grief reaction is what’s causing or contributing to the symptoms, then you have to address these issues with same compassion, concern and thoroughness that you would with any physical illness.

Consider the patient who comes to a doctor with abdominal pain for example and after careful study, the physician determines that the problem is anxiety-related irritable bowel syndrome; the doctor should explain this carefully and provide a treatment plan that helps the patient deal with the underlying anxiety as well as the abdominal pain, including some type of counseling by the physician or by some outside psychological support, and then close follow up.

Some doctors tend to leave those patients who need psych support hanging with no other options available to them after the diagnosis is made and after they have failed symptomatic treatment. This is probably how the entire holistic movement got started or became popular in the first place. The medical establishment failed many patients with these kinds of illnesses, so they sought “alternative” therapies that provided at least some acknowledgment of their suffering by compassionate, caring people and also some intensive and ongoing attempts to help improve their symptoms even if they weren’t evidence-based.

No doubt, sometimes these alternative approaches help, and people do feel better, and their emotional and physical needs are met. I am not against this at all if it helps and as long as it’s safe. But I think it brings up the point that traditional medicine has somehow failed these people or at least that is their perception; and that has downgraded our reputations as healers and caregivers somewhat.

As physicians and nurses, we can treat respiratory failure and congestive heart failure pretty well, but we fail miserably when the problems are associated with emotional stress. Most of us seem to want to ignore these problems and walk away from them even though they are real and create great suffering for patients.

Interestingly, many of these patients respond very well and are eternally grateful to the one physician, or any other health care professional for that matter, who will actually sit down and listen to them and take them seriously. Unfortunately, this requires some time, which many of us don’t have, but if we want these people to do well, we have to make the time, or find someone who will. And sadly don’t look to your average psychiatrist to help you with this, unless you can find a psychoanalyst. Because of societal economics, most psychiatrists are relegated to 10-15 minute med checks rather than actual psychotherapy. If you want someone to provide psychological support for your patient besides yourself or clergy, you will have to look towards a licensed clinical social worker in most cases, and the patient is lucky if their insurance will cover ½ the fee. These are serious deficiencies in a country that spends more dollars per capita for health care than almost any other country in the world. Unfortunately, the economic incentives in this current health care system are not supportive of the concept of whole patient care. I am hopeful they are starting to move in that direction a little however.

Piecemeal care

One final aspect of this topic of whole-patient-care relates to piecemeal health care that many patients get if they don’t have a primary care physician. Some patients will go to a gastroenterologist for their abdominal pain and get a prescription for omeprazole, then will see their cardiologist and get simvistatin and Plavix , and then will go to an urgent care center and get erythromycin for their upper respiratory infection, not realizing that all of these medications taken together could have potentially serious interactions. If the patient had one physician who has all the information about that patient and knows who is prescribing what medicine and why, the patient has a much better chance of staying healthy and avoiding medical errors.

* * * * *

Again, one size almost never fits all in real clinical medicine and whole patient care. Medical care has to be personalized for the particular patient involved. In order to do this properly, the physician must always learn about and use the knowledge about the patient’s background, culture, occupation, family, living conditions, sexual orientation, goals, spiritual and emotional factors, and anything else the patient is willing to tell you along with the information that you can obtain from old charts and other consultants the patient has seen to help guide you and your patient to make the best possible decisions in his/her individual medical care.

And always provide close attention and follow up for patients with continuing symptoms. You may discover something important on a follow up visit that will lead you and your patient in a better direction. Listen carefully to what they are saying. Retake the history several times if necessary. Be aware of potential emotional stresses that may be complicating their situations, and don’t be afraid to provide psychological support or at least a listening ear when necessary. On the other hand, don't be too quick to attribute symptoms you don't understand to a psychological illness, even if the patient is overtly emotionally stressed. Study, understand and treat the whole patient, not just the easy parts.

This page on Whole Patient Care was last updated on October 10, 2010.

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