A multidimensional, integrated approach

Employing a multidimensional, integrated approach, rather than a biomedical reductionist model, was the dominant theme throughout the literature.

The literature emphasised that biopsychosocial, holistic and whole-person approaches must address multiple aspects of the person and their context, rather than being strictly biomedical.16 18 22 27 31 33 34 36 39–54 In a paper discussing the definition of holism, Freeman stated that:

An approach to health and medicine that is not reductionist is an implicit part of the comprehensive care provided by GPs. We are not doctors for particular diseases, or particular organs, or particular stages in the life cycle—we are doctors for people.18

Similarly, in a study on the perceived meaning of a (w)holistic view among GPs and district nurses in Sweden, Stranderg et al found that:

Biomedical attitude is not enough. There is a need for a multidimensional viewpoint including a bio-psychosocial attitude towards the patients.22

Which important aspects of the ‘whole’ to include in care varied. Biological, psychological and social factors were commonly identified.12 14 16 18 22 27 29 32 33 36 39–43 45–47 49 51 53–56 Some GPs argued for the importance of additional factors. Spirituality was prominent among these.14 29 33 34 37 39 40 42 44 48 50 54 57 58 Murray et al concluded from their study on GPs’ views on their role in providing spiritual care that:

The whole-person approach to medicine may be incomplete if it lacks consideration of the spiritual dimension.37

The patient’s ecological/environmental context was also emphasised by some GPs.14 59

The literature also emphasised that aspects of the person must be viewed in an integrated fashion.16 18 27–29 31–33 36 39 40 42–47 52 53 55 56 58 60 In their study on the meaning of an (w)holistic view, Strandberg et al found that:

The participants discussed the concepts ’the whole' versus ’parts of the whole'. Many meant that the whole actually is greater than the sum of all the parts…22

Similarly, Pietroni stated that a key principle of holistic medicine is that:

The human organism is a multidimensional being, possessing body, mind and spirit, all inextricably connected, each part affecting the and whole and the whole being greater than the sum of the parts.29

Sturmberg identified ‘understanding the interconnectedness of various illness aspects’ 53 as the second step in an approach to teaching holistic care.

One exception to this emphasis on a multidimensional, integrated approach was identified in O’Brien et al’s study.38 GPs in one practice in this study understood holism as caring for a patient’s multiple comorbidities and placed boundaries between ‘the medical’ and ‘the social’. Some authors also proposed a ‘split biopsychosocial model’ in which different components of care are selectively addressed depending on the patient’s presentation, though the utility of this approach was debated.43 60–62

Employing a multidimensional, integrated approach to care was the key theme characterising each of the biopsychosocial, holistic and whole person terminologies.16 18 22 27 29 31–34 36 39–56

Biopsychosocial terminology was the most specific of the terms in defining the aspects of care that it addressed (biological, psychological, social).36 41 43 46 Some GPs suggested the biopsychosocial approach was too narrow and should be expanded to a ‘biopsychosociospiritual’,34 39‘ecobiopsychosocial’59 or ‘psychosomatosociosemiotic’ model.53 63 Occasionally, the term biopsychosocial was used to incorporate these broader aspects.33 There was some debate regarding whether the biopsychosocial model employed an integrated approach, with some arguing that it remained dualistic.49 55 64

Whole person and holistic terminology were less specific than biopsychosocial in defining their domains of care, encompassing a varied and broad range of biological, psychological, social, spiritual and environmental/ecological aspects.16 18 27 34 39 40 42 44 47 48 51 54 Some models of WPC specifically distinguished between care of the person (body, soul, spirit) and external factors (social, environmental).39 47 However, these still addressed external factors in their overall approach to care. Emphasis on an integrated approach was strongest in holistic terminology, and also present in whole person terminology.16 18 27–29 31 32 39 40 44 45 52 53 55 56 58

Importance of the therapeutic relationship

The importance of the therapeutic relationship, a collaborative approach and characteristics of the doctor that fostered this relationship was emphasised.12 14 16 22 27–30 32 33 35 38 39 42 43 45 46 48 50 52 54 55 57 65–69

The therapeutic doctor–patient relationship was valued.12 28 29 50 Risdon and Edey stated that:

True healing and mending of brokenness is possible only within an authentic human relationship.50

Similarly, McWhinney argued that:

There is a growing body of scientific evidence that human relationships are an important factor in the favorable outcome of illness. Thus we have support for the ancient belief in the healing power of the physician.28

O’Brien et al included relationship as a suggested component in a whole person intervention.38 One GP in their study:

describ[ed] how she felt the essence of the GP (relationship, intuition, support and continuity) had been lost with the medical nuts & bolts of monitoring…, a view supported by her colleagues.

Personal qualities of the doctor that fostered the therapeutic relationship were emphasised.18 27 29 32 38 39 46 52 55 57 60 61 65 67 69 These included characteristics such as being fully present, attentive to and interested in the patient, supportive (compassionate, empathetic, respectful, non-judgemental, etc) and possessing knowledge and understanding of the patient in addition to technical competence. Participants in Strandberg et al’s study identified that an important component of a holistic view was:

finding the patient’s hidden agenda and listening to what the patient is actually saying.22

Multiple sources emphasised a collaborative approach, with patients taking responsibility for their health.14 16 27 29 30 33 38 43 45 46 48 50 van Velden expressed this succinctly, stating that:

[in the] holistic bio-psycho-social model…the doctor–patient relationship changes from one of monologue to one of dialogue, with the doctor no longer instructing the patient but rather involved in negotiating with the latter. People start taking responsibility for personal choices rather than deferring to the rules of institutions.33

Illness may be viewed as an opportunity for personal growth. Borins stated that:

sometimes illness can be a creative opportunity for the patient to learn more about himself and the direction he is taking…Sometimes physical or emotional pain can inform a person that he must change his life and grow.14

Finally, some sources identified continuity as an important aspect of the doctor–patient relationship.22 42 54 66 One author specifically distinguished between holistic and WPC on the basis that continuity was a feature of whole person but not of holistic care.54 However, this distinction was not found elsewhere in the literature.

Emphasis on the doctor–patient relationship was prominent within whole person and holistic literature.14 16 27 29 30 32 35 38 39 42 45 48 50 52 54 55 57 66 67 69 Literature on the biopsychosocial approach was mixed, with the doctor–patient relationship emphasised in papers that specifically focused on the practical application of a biopsychosocial approach.46 61 65 An alternative view also existed, that considered the biopsychosocial model an ethically neutral scientific theory rather than an approach to care.41

Acknowledges the humanity of the doctor

The literature placed importance on acknowledgement of the doctor’s humanity. This encompasses self-awareness, a ‘physician heal thyself’ philosophy and the potential for personal growth of the doctor through the clinical interaction.12 14 16 29 31 32 39 42 44 48 58 61 65 68 69

Several sources argued for the importance of doctors’ self-awareness.12 32 50 61 65 68 Stewart stated that:

holistic care implied a set of values as well as behaviours on the part of the physician; this set would include…awareness of his own person…32

Epstein also implied the importance of self-reflection when discussing how to apply the biopsychosocial vision, suggesting that doctors ask themselves:

What parts of your self are you engaging in the care of this patient, right now?’ and then, ‘Does it have to be that way?65

A ‘physician heal thyself’ philosophy was emphasised.14 16 29 31 39 42 44 48 58 Brown stated that:

Holistic care means practitioners matter too. We need to look after ourselves, not only to be an example to our patients, but for our own well-being and that of our families.42

Similarly, Borins stated that:

An important concept of holistic medicine is that of ’Physician, heal thyself'. The more complete we are in our own spiritual, psychological and physical development, the easier it will be to help someone else on the path of positive growth.14

A minor subtheme is the potential for personal growth of the doctor through treating the patient.12 39 69 In reference to spiritual care, Anandarajah stated that:

physicians have the potential to heal and be healed through their clinical interactions, as clearly illustrated by numerous physician stories.39

Sawa stated that:

The practice of whole-person medicine increases the practitioner’s personal growth and develops his or her analytic skill and ability to think in terms of a complex web of contributing factors, rather than in terms of single chains of causal relationships.69

Recognising doctors’ humanity is a feature of biopsychosocial, holistic and whole person terminology, however the specific subthemes represented in these terminologies differed. Doctors’ self-awareness featured in literature describing all three terms.12 32 50 61 65 68 A ‘physician heal thyself’ philosophy primarily characterised holistic, and to a lesser extent WPC.14 16 29 31 39 42 44 48 58 Potential for personal growth of the doctor was a minor theme of some sources on holistic and WPC.12 39 69

Recognises the individual personhood of each patient

Recognition of the unique personhood of each patient within their individual context also characterised the literature.28 42 44 50 55 60 McWhinney stated that:

Understanding and treating illness in its context is what holistic medicine means to me…The natural (holistic) diagnostician tends to notice what is unique in each patient. He is reluctant to classify and label, and he does not separate the disease from the man or the man from his environment.28

Focus was placed on the person rather than the disease.14 27 31 33 38 In a study exploring how GPs who practised complementary therapies understood the term ‘holism’, Adams identified that they viewed:

holism in terms of treating a person rather than simply a patient. These doctors suggest that treating an individual as a patient leads to ‘unhealthy’ focus upon disease and a failure to acknowledge what they see as the complex and multilayered nature of illness.27

Some papers distinguished between disease and illness.22 27 50 Strandberg et al’s study identified that to have a holistic view:

GPs and nurses have to deal with the gap between ’illness' and ’disease', that is, what the patient experiences and what is the medical problem.22

Recognising patients’ individual personhood primarily characterised whole person and holistic terminology.22 27 28 31 38 40 42 44 50 55 Variations on this theme were occasionally present in biopsychosocial literature.33 60

Health as more than absence of disease

Papers incorporating this theme viewed health as more than absence of disease.33 40 van Velden stated that:

Optimal health is therefore much more than the absence of disease or infirmity. It is the conscious pursuit of the highest qualities of the spiritual, mental, emotional, physical, environmental, occupational and social aspects of the human experience, as illustrated in the bio-psycho-social model.33

Some sources conceptualised disease as a state of ‘imbalance’ and healing as restoring the balance of health.29 33 53 69 Pietroni, for example, stated that:

Disease or ill-health arises as a result of a state of imbalance, either from within the human being or because of some external force in the environment….29

Preventive health measures were also emphasised.14 31 32 35 40 52 66

Aspects of this theme were included in whole person, holistic and biopsychosocial care.14 29 31–33 35 40 52 53 66 69 However, it was most pronounced in the holistic literature.14 29 31 32 40 52 53 66

Employs a range of treatment modalities

Using a wide range of treatment modalities was the final theme identified.14 16 18 27 31 33 39 48 53 58

Examples include Anandarajah’s suggestion of treatment modalities in her body, mind, spirit, environment, social, transcendent model of WPC.39 These ranged from medication, surgery and physical therapy, to counselling and cognitive therapy, spiritual counselling, compassion, presence and connection. Margalit et al’s study on the practical application of the biopsychosocial model identified that offering not only medication, but also advice on health promotion and managing emotions characterised a biopsychosocial doctor–patient encounter.46

A subset of literature using holistic terminology specifically included the use of complementary and alternative medicine (CAM).18 27 29 31 34 40 48 58 Pietroni stated that:

An holistic approach…involves a willingness to use a wide range of interventions—traditional medical interventions, alternative approaches and self-help measures.48

However, the literature consistently emphasised that CAM is not holistic if used in isolation.14 16 18 22 27–31 35 48 Pietroni stated that:

Holism is more than a pot-pourri of therapies. It is an approach to health and disease that transcends any particular therapy…Holism should not be confused with the positive-health movement nor with the complementary medicine movement. Many complementary practitioners do not have an holistic approach and use their therapies in the traditional reductive manner. Conversely, many doctors who know nothing of homeopathy or acupuncture adopt a whole-person approach to their work and have done even before the word holistic became current.30

Similarly, in his study on GPs who practise complementary therapies, Adams found that:

Many of the GPs are keen to stress that a holistic approach does not evolve simply with their development of complementary practice. They talk of always having been holistic and how holism is not confined to complementary medicines.27

Additionally, McWhinney wrote that:

There is nothing unorthodox about holistic medicine. Unfortunately, the term has been used so much by unorthodox groups of healers, that it is in danger of losing some of its meaning for us. I do not wish to suggest that we should ignore the contribution which unorthodox methods can make to healing. Let us remember, however, that the holistic approach has a long and distinguished history in orthodox medicine itself.28

The use of a wide range of treatment modalities characterised whole person, holistic and biopsychosocial care.14 16 18 27 31 33 39 48 53 58 However, the inclusion of CAM was a specific characteristic of holistic terminology.18 27 29 31 34 40 48 58 A distinction was found between various ‘holistic’ terms in this respect. Sources that discussed ‘holistic medicine’ or ‘holistic health’ frequently incorporated CAM, with the exception of McWhinney’s paper describing holistic medicine.14 16 27–29 31 58 Conversely, sources discussing ‘holistic care’ rarely referred to the use of CAM. This suggests that the term ‘holistic care’ does not necessarily imply incorporation of complementary approaches within the GP context. The terms ‘holism’, ‘holistic approach’ and ‘holistic view’ were more varied in this respect, making these terms somewhat more ambiguous.18 27 28 30 34 36 38 48 55 66