So much emphasis has been placed in recent years on the concept of “whole person” care. Primary care providers are challenged to provide comprehensive preventative, diagnostic, and curative services spanning the full spectrum of both physical and behavioral health. Whole-person care has deep roots in the biopsychosocial model, which systematically considers biological, psychological, and social factors—and their complex interactions—in understanding health, illness, and health care delivery. Applying our contemporary sensibilities, this approach seems so appropriate and logical that it is hard to believe that historically the practice of medicine was anything but “whole person” in its focus.
The Mind Body Connection
The nature of the relationship between “mind” and “body” has been the center of centuries of debate among theologians, philosophers, physicians, and scientists. In the 17th century, Rene Descartes proposed the principles of Cartesian dualism. This theory postulated that the mind and body were two very distinct entities and that events in the body are very separate from events that happen in the mind. The widespread adoption of this approach solidified the separation of mind and body in the evolving science of medicine for the next 350 years.
Cartesian dualism also explains the evolution of the two distinct disciplines of behavioral health and physical health. This separation was further cemented because of the way each of these disciplines evolved. Physical medicine was buoyed by rapid discoveries and advances in biomedical sciences, while behavioral health and the treatment of mental illness struggled to meet the challenges posed by the mysteries of the brain and the complexities of the human psyche. During the Middle Ages, the mentally ill were believed to be possessed by demons and mental illness thus became stigmatized and feared. Thankfully, over the last 100 years there has been a steady de-stigmatization of mental illness along with the development of novel therapeutic modalities, such as talk therapies and highly effective psychiatric medications.
The Challenges of Whole Person Care
This historical perspective is essential to understanding some of the challenges faced by practicing primary care providers striving to provide “whole person” integrated care. The magnitude of the need for whole-person care can also not be underestimated. Data reveals that as many as 70% of primary care visits are driven by patients' psychological problems, such as anxiety, panic, depression, and stress. Revealingly, 40% of individuals who die by suicide had visited their primary care physician within the month before their suicide. There is also extensive evidence that an intricate bidirectional relationship exists between chronic conditions such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer, and psychological factors such as anxiety and depression. Psychological distress has even been found to weaken the immune system. In addition to the age-old afflictions of depression, anxiety, and stress disorders, primary care providers have been further challenged by a newer epidemic of opiate addiction that began in the mid 1990s with the introduction of synthetic and semi-synthetic opiates, such as OxyContin. An entire generation of primary care providers found themselves dealing with patients with severe addiction problems with little specific preparation or training.
Primary Care Is Well Positioned for SuccessSeveral factors position primary care providers to successfully offer whole-person care. The first, and likely the most important factor, is that primary care is practiced in the context of a unique long-term therapeutic relationship. This relationship is invaluable in today’s rather fragmented, fast-paced, transitory, virtualized care delivery system. It offers an emotional context in which over time patients develop trust and comfort as they are invited to share their whole story. A context in which psychological anguish is deemed as important and as honorable as physical symptoms and addiction can be viewed as a disease rather than a failure of character. The provider-patient relationship is, without a doubt, the foundation of whole-person medicine and a prerequisite for its success.
The second factor unique to primary care is the evolving integrated care models that are being implemented across the country in which primary care providers are creating rich partnerships with behavioral health professionals in either collaborative models or even co-located models. These partnerships allow patients to access a continuum of mind-body care seamlessly, benefitting from the sharing of patient-specific clinical data and insights between the two disciplines.
Some Barriers PersistIt is often assumed that the barriers to successfully providing whole-person care are solely the responsibility of the providers or the delivery system. It is important to recognize that patients bear some of the responsibility for these challenges as well. Patients sometimes strongly subscribe to the stigma of mental illness and will occasionally resist with all their might the notion that psychological, social, or spiritual factors play a role in their symptoms or condition. At times patients feel more comfortable and secure with Cartesian dualism because that is how they were brought up or how prior relationships with caretakers were structured.
Whole Patient Care is Positioned to Shine
There is mounting evidence that whole-person care improves patient outcomes, reduces costs, increases patient satisfaction, and is associated with less provider- and care-team burnout and higher role and job satisfaction. Medicine has come a long way from the dark days of Cartesian dualism, but it is important to realize that Descartes still casts a long shadow over patients, providers, and healthcare institutions alike. The COVID-19 pandemic has created an unprecedented increase in mental health difficulties as well as significantly challenged patients struggling with addictions. The silver lining in all of this might be that the whole-person care model will finally shine brightly enough to win out over the shadows of the past and see its day in the sun.
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