Holistic health — caring for the whole person

The holistic model is traced back to the Hippocratic school of medicine (circa 400 BC) and the oath of Maimoides (circa the 12th century AD) which have fashioned and defined the unique obligations that clinicians have toward their patients and their medical practices. Disease and illness was viewed as an ‘effect’ from imbalance and explored causes of disease from the environment and natural phenomena such as air, water, and food. Early health practitioners used the term vis medicatrix naturae, meaning the healing power of nature, to describe the body’s ability to heal itself. Furthermore, the Hippocratic oath states: ‘first, do no harm’. It is important despite which style of medicine we use, whether it is a pharmaceutical agent, surgical approach or a natural therapy, that we do no harm to patients.

The World Health Organization (WHO) definition for optimal health suggests this should be inclusive of physical, social, psychological, emotional and spiritual wellbeing. The holistic or health model looks at maximising or supporting all aspects of a person’s health, which will then lead to the disease being healed by the body.

The health practitioner’s aim is to help empower patients to be active participants in their own healing process and to encourage personal responsibility for their health to improve quality of care and quality of life. The goal is not just to treat the illness, but to focus on promoting health and wellness.

Establishing and maintaining optimal health and balance is vital to prevention and treatment. Wellness is a state of being healthy characterised by positive emotions, thoughts and actions. Wellness is inherent in everyone, no matter what ‘disease’ is present. If wellness is truly recognised, focused upon and experienced, the individual will heal more quickly, not just through direct treatment of the ‘disease’ alone.

Holistic medicine also includes the integration of various safe, evidence-based complementary therapies and medicines that may provide a gentler, safer and, in some cases, more empowering approach to health care. Many medical and health practitioners worldwide are integrating various ethical non-pharmaceutical modalities into their clinical practice as part of the holistic approach. These forms of therapies aim to enhance a healthy lifestyle, work with the natural healing process, empower patients to be active participants in their own healing process and nurture the whole person. Where such therapies can be safely used, they include counselling, meditation and relaxation therapies, hypnosis, primary preventative medicine and lifestyle management, acupuncture, nutritional medicine, herbal medicine, environmental medicine, and physical and manipulative medicine. These therapies work in harmony with the natural healing processes of the body. Natural medicines, when used properly, generally are well tolerated and rarely cause side-effects. They generally support the body’s healing mechanisms, rather than take over the body’s processes.⁶

It is important to remain open-minded and flexible, both philosophically and in research methodology, with such an approach to treating individuals. We must recognise that healing primarily comes from the individual and mostly depends on their motivation level.

Integrative medicine

Integrative medicine (IM) refers to the blending of conventional and complementary medicines and therapies with the aim of using the most appropriate of either or both modalities to care for the patient as a whole.⁷

This closely reflects both the Hippocratic oath and the WHO definition discussed above. However, although some may view IM as synonymous with CAM, this was never so, nor was it ever the case. CAM comprises many therapeutic modalities that are not taught in a conventional medical syllabus, based on the ideas that range from those that are sensible and worth including in mainstream medicine to those that are extremely imprudent and a few that are very perilous. Neither the word alternative nor complementary captures the essence of IM.⁸ The former suggests a replacement of conventional therapies by others whereas the latter suggests therapies of varying value that may be used as adjuncts.

IM embraces a holistic approach to clinical practice encouraging patient involvement in self-health care, prevention and interventions that focus on health maintenance by paying attention to all relative components of lifestyle, including diet, exercise, stress management, and the emotional wellbeing of the patient. IM also integrates evidence-based complementary medicines that are safe and may positively impact on the healing process and quality of life for the patient.

IM does not reject or compete with conventional health care but rather seeks to broaden conventional health care by providing the health practitioner, doctor and patient with options to improve health that can work alongside conventional health care.

IM emphasises a number of issues including:⁹

When considering any therapy it is important to balance the risks, the benefits, the evidence, the costs, and the alternatives, such as other therapies or doing nothing.

Complementary and alternative medicine (CAM)

Complementary and alternative medicine, as defined by the National Centre for Complementary and Alternative Medicine (NCCAM), is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (see Table 1.1).¹⁰

Table 1.1 NCCAM classifications ¹⁰

As the evidence-base for some CAM increases, medical practitioners have a legal obligation to inform patients of the efficacy of relevant complementary therapies as treatment options, and to simultaneously be aware of the potential for adverse events and interactions that CAMs, such as nutritional and herbal supplements, may have when co-administered with pharmaceutical drugs or when a patient denies good orthodox care for any unproven CAM.¹¹ Knowledge in the efficacy of a complementary medicine or therapy is essential when making clinical decisions for patient care to help weigh against potential risks, such as adverse reactions or delays in useful conventional treatment. This highlights the importance of medical practitioners having at least basic education in the area of CAM to enable them to communicate and inform patients about what therapies are appropriate to the individual. Education on potential risks such as nutrient toxicity, especially with single nutrient use, and any potential interactions with pharmaceuticals is also essential.

Popularity of IM and CAM

Worldwide reports demonstrate that a large proportion of the public are using CAM and its popularity is increasing. For example, in Australia up to 70% of the population are using CAM.¹² In the United States, up to 62% of adults use CAM.¹³ It is therefore vital that health and medical practitioners are well informed about the evidence in these areas.

In many respects, the enthusiasm to use CAM is largely driven by the public. The community has greater access to information and various complementary medicine practitioners and therapies. There are often various reasons why a patient will want to trial CAM. These include philosophical and cultural reasons — wanting a more holistic approach to health care, when there are no longer any other orthodox approaches to assist in their health care, especially if they have suffered any adverse events from orthodox treatments. Generally, patients who use CAM are not rejecting orthodox medicine but are looking for options to improve wellbeing. Unfortunately, medical practitioners underestimate the extent of use of CAM by patients.^{14, 15} This is of great concern, considering the potential for adverse events such as herb–drug interactions and coordinating the overall management of the patient.

IM strategies and healing

A holistic approach to health care involves giving comprehensive lifestyle advice that is inclusive of physical, social, psychological, emotional and spiritual wellbeing. In this way, we are encouraging and promoting our patients to take personal responsibility and be active participants for their own health. The focus needs to be on wellness, and not specifically on the disease. Positive lifestyle changes and a typical integrative approach to assist healing that can work alongside conventional medicine to improve health outcome or quality of life are listed in Table 1.2.

Table 1.2 Summary of lifestyle and IM strategies

Health practitioner/doctor and patient satisfaction

Holistic health care offers an enormous amount of satisfaction and joy to the health practitioner, working with patients to help restore good health. The patients are often satisfied with this style of medicine and this, in turn, equally satisfies the doctors practising holistic health care. It empowers patients by providing them individually prescribed options for treating their health condition. Failure to treat or cure patients may occur due to a number of factors, such as lack of motivation, not changing lifestyle, choosing the wrong therapy, lack of commitment to the therapy for various reasons (e.g. financial, lack of support, peer pressure, non-believers etc). It is important to be aware and sensitive to these factors by being intuitive and listening to patients’ needs carefully, and with clinical experience fine tune treatment modalities accordingly.

Furthermore, patients and doctors need to have access to quality information about complementary medicine to make well-informed decisions.

The health practitioner(HP)/doctor–patient relationship is precious, patient–centred and can result in a positive therapeutic outcome. It positively affects medical care and patient satisfaction. The HP/doctor–patient relationship is based on:

Most studies actually indicate that over 80% of patients are satisfied with their general practitioner especially if they see the same doctor frequently.¹⁸ A questionnaire of 869 patients demonstrated that trust and commitment was positively associated with adherence to treatment. Positive relationships were also associated with adherence to treatment and commitment, and between trust and commitment, that led to positive lifestyle choices, such as healthy eating habits.¹⁹ The researchers concluded:

It is also vital that patients are encouraged to take responsibility for their health and be well informed about all treatments (conventional or complementary) that are safe and suitable for their health care (see Tables 1.3 and 1.4).

Table 1.3 Encourage patient responsibility

Table 1.4 The well-informed patient

Respect for the patient and their choice of treatment, compassion, trust and empathetic understanding all positively influence the HP/doctor–patient relationship, and help adherence to therapeutic regimens (see Table 1.5).^{20, 21, 22}

Other factors that influence the HP/doctor–patient relationship:

HP/doctor–patient relationship and the ‘doctor’ as the teacher

The doctor–patient relationship also refers here to the health practitioner–patient relationship as the basic principles of care are similar. Interestingly, the original meaning of the word ‘doctore’ is teacher. Thus as doctor’s we are also educator’s for lifestyle and health. Patient needs vary from one patient to another. Therefore, it is mandatory to remain flexible and vary approaches using treatment according to an individual’s needs at the time. Many studies demonstrate that active listening, spending time with a patient, displaying a sympathetic, understanding, caring and warm attitude not only helps to develop patient trust, but also enhances the healing response (also known as placebo). To achieve all of this requires longer consultations.

The plant analogy

If given the ‘right conditions’, the body has an innate capacity to heal. The body is equipped with natural healing mechanisms. A good analogy of this is the sick plant. Most gardeners know that plants can thrive well by providing the ‘right conditions’, such as: the right amount of sunlight; fresh air; nutrient-dense soil (occasionally supplementing with nutrients through fertilising); a stable, nurturing environment free of chemicals; and adequate water. Even if a plant appears unwell, changing any of these conditions can aid the recovery of the plant. If we apply this concept to the unwell person, their needs are very similar. Human needs for maintaining and restoring good health include: plenty of fresh air; exercise; adequate water; sunlight; good nutritious unprocessed foods; a peaceful environment free of chemicals, excessive noise and light; good quality sleep; contact with nature and people; meaning and joy in our lives; and minimising psychological stress.

Dis–ease

The term dis–ease literally means the person is not at ease and illness is the body’s expression of imbalance that requires the necessary fundamental changes to bring about balance, ease and wellness. It is important for the patient to recognise that their current circumstances and lifestyle have contributed to their current health situation. Therefore, if patients are expected to gain maximum benefit from treatment, they need to fully commit themselves to a number of positive lifestyle changes. The illness, therefore, should be viewed as positive, as it is the body’s expression that changes are necessary and this is the opportunity to change one’s life and adopt healthier behaviour patterns to allow this to occur.

Stress

Most illnesses have a psychological component as a precipitator and/or as a consequence of the illness. Stress plays a major role in most diseases and stress management should be regularly prescribed to our patients. A common question one should ask patients is:

What was happening in your life at the onset of your illness?

This question often gives us a good clue as to what major stressors may have contributed to the onset or aggravation of the illness. Providing the time to listen to patients and ‘hearing their stories’ can have profound healing effects on them.

It is important to emphasise to patients to listen to their bodies, follow their own intuition and learn to love oneself. If people are stressed and don’t care for themselves, they won’t follow our advice to exercise, eat right, to not smoke or drink alcohol. As health practitioners, we can play a vital role in helping to guide our patients towards better health, positive lifestyle changes and behaviour patterns through guidance, appropriate counselling and being suitable role models.

Communication with allied and CAM practitioners

It is well established that patients are not communicating with medical practitioners about the use of CAM.^{25, 26} What is not so well established is to what degree the CAM practitioners and regular doctors are communicating. Medical practitioners (MPs) have an established tradition of communicating with each other e.g. specialists (consultants) with general practitioners (GPs). A specialist knows that in general the GP will have some idea about the content of what they are communicating, as medical graduates would have had at least some exposure to do with the various medical specialties during their medical courses and postgraduate training. If a homeopath was to communicate with a GP there are major difficulties as most GPs would either have no or little knowledge or understanding of homeopathy and the language behind it. Many patients do not communicate with their regular doctor about CAM use for fear of being misunderstood or jeopardising their doctor–patient relationship. However, studies indicate that patients prefer that GPs were more educated about the CAMs they use, so that they can then better communicate with their doctors about their use of CAMs.¹²

There is a greater need to have more interaction between CAM and doctors when the patient chooses to see a CAM practitioner. An increasing number of medical practices include MPs plus various non-medical CAM practitioners and they are proving to be very popular with patients. Many of these medical practices have routine meetings to discuss the management of the patient. Other means of improving communication include letter writing, emails or phone discussions, especially with CAM practitioners at other clinics.

Referrals to regulated CAM practitioners such as osteopaths, chiropractors (in most states and territories of Australia) and TCM practitioners (Australia), reduces the risk of incompetent management. If the CAM practitioner is a member of a professional body this can provide evidence of at least some training, standards and guidelines for safe practise.

It is also reassuring to the MP if it is known that the CAM practitioner has adequate experience and in particular is aware of their limitations and knows when to refer back to a MP. The MP should initially be involved if a diagnosis has to be made but this would not be necessary if a patient wanted, for example, dietary advice or wanted to learn relaxation techniques which could be obtained from a CAM practitioner. As a ground rule, MPs differentiate between medical and CAM practitioners and have expressed greater confidence in medical colleagues who practice complementary medicine.^{27, 28}

There are unresolved issues to do with referrals by MPs to CAM practitioners and these include:²⁹

Ethical and legal Issues

A report on ethical and legal issues at the interface of CAM and conventional medicine suggests that when MPs are faced with patients wanting to trial CAM they should:³⁰

The abovementioned points serve as useful guidelines for MPs in consultations involving CAM.

Evidence-based medicine (EBM)

The definition of evidence-based medicine (EBM) is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’.³¹ EBM integrates the best external evidence with individual clinical expertise and patients’ choice. Furthermore it is noted that absence of evidence does not mean a therapy does not work.³²

EBM is a common term described as:

This definition emphasises that whilst scientific evidence is important in clinical judgment, clinical experience and expertise also play a major role in the care and choice of treatment for a patient.

EBM encourages doctors to look for well-structured, randomised placebo-controlled prospective studies (Level II evidence) and systematic reviews of such studies (Level I evidence) to support clinical practice, but as yet there are few of these for the majority of CAMs.

‘Outcome studies’ may be more appropriate for holistic models of health, such as TCM and traditional Ayurveda medicine, where a more individualised and holistic approach to treatment occurs. Randomised control trials (RCTs) may be suitable for the holistic approaches but need to be creative but still technically possible. Very little good quality research exists for these therapies. Lack of evidence is not necessarily associated with lack of patient benefit.

Conclusion

The use of CAM should have certain boundaries. Its use should not be to the exclusion of a clearly indicated, safe, effective and superior orthodox therapy. In making choices patients need to be informed about the range of reasonable options of orthodox and complementary therapies. Based on clear information patients should then be allowed to make their choices as to what treatment they wish to pursue if they are low risk and have some proven efficacy. It is easier to recommend CAMs when they have evidence for safety and efficacy. There is now a growing body of scientific evidence to support CAMs such as some herbal medicines, acupuncture, nutritional medicine, and stress management techniques which work with the natural healing process of the body.

The basic principles of holistic health care include:

This book summarises the key scientific and management strategies using an IM approach to treat common health problems faced by medical and health practitioners in everyday medical practices.