Whole person care: encompassing the two faces of medicine

Essay
Whole person care: encompassing the two faces of medicine
Tom A. Hutchinson, MB, Nora Hutchinson, BA and Antonia Arnaert, PhD

Director, McGill Programs in Whole Person Care
Faculty of Medicine, Class of 2012
Assistant Professor, School of Nursing McGill University Montréal, Quebec

"I would go without shirt or shoe
Friend, tobacco or bread,
Sooner than lose for a minute the two
Separate sides of my head!"
— Rudyard Kipling, The Two-Sided Man

Figure 124
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FIGURE. Janus, the Roman god of doorways, looks in 2 directions. Likewise, physicians are charged with looking toward both healing and curing. (Bronze coin of Janus, 211 BC.) Image courtesy of: The Art Archive / British Museum

What is Kipling talking about and what, if anything, does it have to do with medicine? Actually, it lies at the heart of our current problems and opportunities in medicine: we have lost and are trying to regain one of the sides of our medical heads. That is what physicians Michael Kearney and Balfour Mount1,2 are pointing out when they ask us to reincorporate healing into the medical mandate. But we have not yet explored adequately and don’t yet understand fully the difficulty of what they are calling on us to do. Curing and healing are like the 2 faces of Janus, the Roman god of gateways and new beginnings. They are antipodes and yet both are simultaneously essential to excellent medical care.

Curing is an action carried out by the health care practitioner to eradicate disease or correct a problem,3 while healing is a process leading to a greater sense of integrity and wholeness in response to an injury or disease that occurs within the patient, which can be facilitated by the health care practitioner.2 The roles of the patient and of the health care practitioner in curing versus healing are not just different, they are diametrically opposed.

The goal of the patient in the curing mode is survival. This is not limited to physical survival; rather it extends to survival of all that the patient has learned to identify as himself, including physical appearance, lifestyle, relationships and everything else that makes up a life. In other words, the goal is to avoid change. Healing, on the other hand, comes from the acceptance of change. This acceptance allows the patient to grow to a new sense of himself as a person (perhaps with disease) with a new experience of integrity and wholeness that is different than the old status quo. In curing, the patient depends on the expertise of the practitioner to control disease; in healing, the patient begins to realize that it is his or her own resources that will finally lead to growth and that he or she is responsible for managing those resources.

The contrast in the health care worker’s roles in curing and healing are equally striking. In the curing mode, the physician, through his knowledge and expertise concerning disease, clearly has more power. That is why the patient consulted him in the first place. In the healing mode the power shifts toward the patient. It is within the patient that healing will occur and it is the patient who will make the healing journey. The physician’s role is accompaniment. To do this effectively the physician needs to be able to put part of himself in the patient’s shoes and thus adopt the wounded healer role.4

The epistemologies in the curing and healing roles are also very different. In the curing mode the basis of knowledge is scientific and this is expressed in the current requirement of evidence-based practice. In the healing mode this approach is not helpful. Since the essence of the facilitation of healing is the relationship of one person to another, the physician’s role in healing has to depend on his particular gifts and characteristics as a person and on the particular gifts and characteristics of the patient. Art rather than science is required to enable the physician to make the best intuitive use of himself in the healing relationship with the patient. The dynamics of the interaction would be different with every physician–patient pair, a complete contrast to the standardized requirements of science.

Given the contrasts outlined it is not surprising that physicians and other health care workers have had a hard time encompassing both roles in their practice. The solution is often to restrict care to 1 of the 2 poles, curing or healing, but not both.

To be an effective curer and facilitate healing at the same time is a challenging task: this patient may be dying and I must remain emotionally present to that possibility and behave and communicate with the patient and family accordingly; at the same time, I must concentrate on inserting this femoral catheter so that we can perform the dialysis to treat his acute renal failure and possibly save his life, at least for now.

As may be apparent from this example, the enlargement of awareness required is significant, but can actually result in a decrease in the psychological tension that comes from identifying exclusively with curing or healing. However, our tendency is to restrict awareness when we are faced with stressful situations.5

Physicians and other health care workers need to relearn1 an important skill: how to retain a broad enough awareness to encompass simultaneously the needs of both curing and healing in stressful clinical situations. We might hope that this is the purpose of teaching hospitals and clinical clerkships where students can see this process in action in a clinical setting. This does undoubtedly occur, but because medicine itself is unclear about these 2 roles and has tended to opt for curing at the expense of healing3 we have found that students’ experiences in hospital can hinder, rather than foster their development as facilitators of healing.6 It is not only students, but faculty as well who need to learn how to encompass these 2 roles.

We believe that the key lies in bringing clarity and commitment to these 2 complementary aspects of medical care. We at McGill are exploring various approaches, including a focus on mindful medical practice7 and a new 4-year healing curriculum8 to foster the healer role. In this way, the gateway to what we term whole person care may be fully reopened in the context of sophisticated 21st century biomedicine.

* REFERENCES
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REFERENCES

1. Kearney M. A place of healing: working with suffering in living and dying. Oxford (UK): Oxford University Press; 2000.
2. Mount B, Kearney M. Healing and palliative care: charting our way forward. Palliat Med 2003;17: 657–8.[Free Full Text]
3. Cassell E. The healer’s art. Cambridge (MA): The MIT Press; 1976.
4. Guggenbühl-Craig A. Power in the helping professions. Dallas (TX): Spring Publications; 1971.
5. Driskell JE, Salas E, Johnston J. Does stress lead to a loss of team perspective?Group Dyn Theory Res Pract 1999;3:291–302.[CrossRef]
6. Allen D, Wainwright M, Mount BM, et al. The wounding path to becoming healers: medical students’ apprenticeship experiences. Med Teach 2008;30:260–4.[Medline]
7. Epstein RM. Mindful practice. JAMA 1999;282: 833–9.[Abstract/Free Full Text]
8. Boudreau JD, Cassell EJ, Fuks A. A healing curriculum. Med Educ 2007;41:1193–201.[Medline]

http://www.cmaj.ca/cgi/content/full/180/8/845