That topic was going to be a quick read.
Having started writing two different articles about clinical aspects of treatment unique to naturopathic practice, I began to have doubts. Doubts similar to those raised by the former editor of the New England Journal of Medicine:
It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the New England Journal of Medicine.1
There are potential paradigm shifts in the wind. November 8th was an eye-opener, so what better time to examine the tenets upon which we base our practice. There is always another protocol, another botanical that has shown real promise in certain cases. We have more weighty issues at hand, I believe.
Recall the words of Dr. Bastyr: "The truth of our medicine will always win out, the truth of what we are doing will always survive."2 The Vis Medicatrix Naturae really is the basis of everything which makes naturopathic practice unique. The healing power is something ineffable, mysterious, yet supported by observations we have gleaned over the centuries, how the body works and what can go wrong with it. Case in point is the study highlighting the benefits of outdoor 'green' activities on childhood ADHD: "...ratings indicated that green outdoor activities reduced symptoms significantly more than did either built outdoor activities or indoor activities. The findings for specific subsamples echoed these results with remarkable consistency; in each of 56 analyses, green outdoor activities received more positive ratings than did activities taking place in other settings…"3 When we engage patients with Nature and acknowledge this with our therapies, we do indeed engage another healing influence beyond our various nostrums. The fluidity with which we are able to achieve this is dependent upon a trusting interaction with people. As the late Dr. Barbara Starfield stated, "…person-focused care is based on accumulated knowledge of people, which provides the basis for better recognition of health problems and needs over time and facilitates appropriate care for these needs in the context of other needs. That is, it specifically focuses on the whole person."4 Starfield wrote extensively on this person-based approach and highlighted its humane attributes repeatedly and convincingly, and as shown above, paraphrased another of our tenets: "Treat the whole person."
The appreciation of another human being embroiled in life and health changes is the point of person-based healthcare, contrasting with the diagnostic and procedural basis that spawned the electronic health record (EHR) systems. Yet we find ourselves, practicing physicians and healing/helping professions of all types, held under the auspices of a blinking cursor, accumulating patient-based evidence for healthcare corporations, obeying distant masters whose motivation is less about our patients' individual health than fiscal considerations. These entities have very, very little to do with the person in front of us recovering from an illness, bouncing back from a surgery, or notably exceeding their prognostic expectations. We are subject to propaganda, against our own experience and observation, that somehow these data-gathering systems make us better practitioners. They do not. We can acknowledge their usefulness as a tool and use them as such, yet they often interfere and isolate us from the very connection that is the heart and soul of our professions. One study concluded: "Higher clinician gaze time at the patient predicted greater patient satisfaction. This suggests that clinicians would be well served to refine their multitasking skills so that they communicate in a patient-centered manner while performing necessary computer-related tasks."5 The tail is wagging the dog it would seem. The circumstance where EHR has become part of the "Healer" equation is a pitiful thing indeed, and one that should not be in the forefront when human beings present themselves for assistance.
How do we retain our humanity midst the growing presence of this Borg? My suggestion is to embrace Starfield's person-based healthcare as a primary directive. In my 30 years of practice I've spoken about my recommendations with surgeons who don't have an issue with "unproven" treatments as long as their surgical patients show excellent recovery. I've had specialty care teams consult me for treatment ideas for patients having MRSA infection after brain surgery. I certainly have sent my puzzling cases to other practitioners for their input and expertise. Working cooperatively toward a common ground of person-based care sometimes takes jockeying and discussion to find consensus. I note a few of the principles that serve as guides, in intentional order of their gravity and importance to our work. Each statement is followed by the challenges we face in these times of paradigm shift.
Each Practitioner does intend the best for the people coming to see them. Occasionally professional status, 'turf,' ego, habit or education can get in the way of this shared goal; but when we communicate and move through those impediments, we realize our deep care for the well-being of the patient. This is a great affirmation of our humanity and serves as a solid stance from which we can begin our conversations and therapies.
A true person-based healthcare may be challenged by treatment prejudice, 'standard of care' ideals, financial or insurance challenges that prevent the best treatment of an individual person. This is a growing issue, one that is largely due to the corporatization of practices and the belief that data determines the best approach for the individual person. The person in the office is not asking for their position on the bell-curve of expected treatment response; they are seeking a needful connection with their healthy self. They want a knowledgeable, caring individual whose expertise is in how to regain their well-being. People are seeking hope, realistic but compassionate assessments, and proposal(s) for relief that do not categorize them but recognizes them as a human being.
Our highest duty is, indeed, to "Do No Harm" We all agree on this tenet, yet the topic embroils us into strident estimations of what exactly constitutes "harm." Does delaying treatment of less-than life threatening conditions or some forms of cancer constitute doing 'harm'? How do we engage the person such that their understanding and self-healing capacities (and even the placebo effect) can be initiated? Can we acknowledge the benefit a committed patient has to a course of treatment since this appears to be part of the therapeutic potential? When people understand the treatments, are provided reasonable scenario for outcome, and have a trusted healthcare person evaluate treatment options and advocate for them, then we can be assured of honest choice being offered.
We cannot deny death when it is death's time. A personal understanding of someone's quality of life and death perspective is critical to being in their corner when it comes to intense life/treatment /healthcare decisions. This example may be the purest of person-based healthcare. Only by truly knowing the individual do we earn the right to participate in these discussions. When a person can clearly choose to eschew practitioner-based treatment recommendations or say "NO" to fear-based strategies used to fit a patient to a treatment or research protocol, then they have healthcare sovereignty. Death is not the enemy; unresolved regret, fear and anger are the things we hope to reconcile within ourselves before we pass.
We all participate in the financial impact considerations of proposed treatments. Unless and until we have a tsunami of change in our healthcare systems, all practitioners have concerns with keeping lights on, paying staff, and continuing to offer our services. We each have multitude reasons and influences that bring about our individual stance on this topic. While it may be that a single payer/government-run/physician salary system evolves as the primary reality, I'm not holding my breath. In corporate-owned practices, outcome-based incentives often result in treatment choices being under great scrutiny and limitation, without primacy of the person-based healthcare model being involved. With this fact in mind, I would submit that we are ethically obligated to consider our protocols and recommendation. Is this treatment medically necessary? Does this treatment make sense for an individual considering their emotional/spiritual dimensions? Is this treatment one with reasonable and timely chance for success or improvement? Does the treatment create an unhealthy dependency on the part of the patient? These considerations are different metrics than the list of approved medication options for a diagnostic code. Perhaps all practitioners can aspire to the goals of making the patient
- less dependent on our therapies,
- more able to be medically and therapeutically independent, and
- better able to be in charge of their own life.
Avoiding extraneous procedures and repeated office visits performed to achieve a financial target would seem to be ethically obvious. We might strive to meet the intention of returning an individual to living their life with minimal intervention as possible
It is the practitioners that must take control in the evolution of caring professions, NOT EHR designers, insurance corporations, or big Pharma. Until we achieve some degree of Unity, we'll be fragmented according to professional turf and dogma. As we develop organizations that are independent, yet cooperative in our goals, and adopt self-governance practices such that we are not beholden to financial interests, we will have a framework better able to fully engage person-based healthcare. We have many revelations of the conflicts present in'regular ‘medicine and as naturopathic physicians, we are not immune from such quandaries. We must pay attention! To achieve a high level of integrity, we must analyze the framework set upon us. Our system in the US clearly is not achieving cost-effective results comparable to health statistics of other developed countries. We CAN and should promote life, embrace hope, and enhance the dignity of people. By engaging with people and not allowing systems to relegate them to commodity status and thus reduce their personhood, we are making a difference. People are not units to plug into a database; person-based healthcare is not the goal of the EHR. Practitioners are the critical denominator to keep human dignity in medicine. We can take the lead. Person-based healthcare is the model adding to the historical tenets of our practice: Doctor as Teacher.
1. Marcovitch H. Editors, Publishers, Impact Factors, and Reprint Income PLoS Med. 2010 Oct; 7(10): e1000355. (Quoting Marcia Angell from the New York Times Book Review, January 15, 2009)
2. http://m.bastyr.edu/?q=noindex/tabs/about-dr-john-bastyr. Accessed 11/16/16
3. Kuo FE, Taylor AF. A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence From a National Study. Am J Public Health. 2004 September; 94(9): 1580–1586.
4. Starfield B. Is Patient-Centered Care the Same As Person-Focused Care? The Permanente Journal. 2011;15(2):63-69.
5. Farber NJ, Liu L, et al. EHR use and patient satisfaction: What we learned. J Fam Pract. 2015 Nov;64(11):687-96.
Dr. Furlong, it is said, doggedly pursues generation of the Electronic Health Record while teaching and supervising at the University of Bridgeport College of Naturopathic Medicine. Continuing his years of work in private practice in the Last Green Valley area of Connecticut, the frequent and poignant reminders of the Vis Medicatrix Naturae tower above the bell curve. While he admits the utility of such data being applied to groups of people, somehow he doubts that the human gestalt in healing will be sufficiently supplied by furtive glances from the omniscient screen. He can be reached at firstname.lastname@example.org, but be patient, there are often interesting things going on outside!