Medicine in future will need to move away from the narrowly Newtonian emphasis on disease towards a more inclusive approach that allows for other traditional healing systems and approaches.
South Africa is in the process of planning for the introduction of healthcare reform to deal with the challenges the country faces in delivering this critical service. The proposed National Health Insurance is largely about healthcare funding and improving infrastructure and human resources to improve access and quality of health care to the public. However, lessons from around the world show that this may not adequately deal with the problems of health.
In spite of the fact that the World Health Organisation has pointed out that health is not the absence of disease, South Africa’s answer to health issues remains disease management. A colleague constantly reminds every fellow doctor within earshot that national health departments are not ‘health’ departments but ‘disease’ departments. Modern medicine is predominantly about studying diseases and how to manage them.
Biomedicine, also known as Western medicine, evolved from its traditional roots of Hippocratic medicine, which emerged from an ancient Greek tradition of healing. At its core was the conviction that illnesses are caused by natural phenomena that can be studied scientifically and managed therapeutically.
The discipline of medicine has evolved in line with Newtonian view of the universe that there is an objective physical world out there, separate from the subjective world of mind and consciousness. Modern medicine is a science that treats the human body as a machine and doctors as mechanics, whose job it is to stick things into it to find out which bits are dysfunctional – using technology to fix them or take out what is beyond repair. The inner world is left to the theologians, philosophers, psychologists, and psychiatrists.
Our hospitals look more like airports
Our high tech hospitals look more like airports than places for healing, as Fritjof Capra points out. Medical students go to medical school to learn to heal the sick and graduate as doctors whose main agenda is to look for pathology. The human being is lost in the process. The discipline of family medicine makes an attempt to correct this by ‘bringing back the patient’, who got lost during the training period of doctors. Modern medicine needs to review its biomedical model in light of a paradigm shift in science brought about by quantum physics and new insights from systems, complexity, and evolutionary theories and an increasing awareness that the body is not separate from the mind.
Candace Pert, in her work on Molecules of Emotions, shows clearly the role of emotions on physiology and molecular function. There is a strong relationship between psychology, physiology, and pathology. Emotion and stress that biomedicine leaves to individual patients, psychologists, and psychiatrists to deal with, ought to take centre stage in biomedical research. The number of diseases impacted on by emotions has increased from a handful at the turn of the century, to almost all known clinical-pathological conditions today. The biomedical model is failing to accommodate this. Body-mind integration will take the medical profession back to ‘healing’ and beyond disease management.
Biomedicine’s reductionist and Cartesian pursuits have denied it of insights gained in other disciplines about the nature of life and living organisms. A human being is a living organism. as is the basic unit of life – the cell. To understand health and ill health, we need to understand the behaviour of living organisms. A human being is an open system and like all systems, it has self-organising properties. As well as emergent properties that are not present in its constituent parts. Self-healing is an inherent property of living organisms, including human beings.
Stress is an imbalance of the organism in response to environmental influences. The stress syndrome is consistent with the systems view of life and demonstrates the interplay between body and mind. According to Capra, the phenomenon of stress occurs when one or several variables of an organism are pushed to their extreme values, which induces increased rigidity throughout the system. In a healthy organism, the other variables will conspire to bring the whole system back into balance and restore its flexibility. The physiological response to stress being the fight or flight response, which in most cases is only temporary. Prolonged stress results from our failure to integrate the response of our bodies with our cultural habits and social rules of behaviour.
Unrealistic expectations cause stress
This may lead to suppression of the body’s immune system – a syndrome called psychoneuroimmunology (PNI). PNI demonstrates how psychology affects physiology and in turn, leads to pathology. The trigger of the syndrome is an activity in the mind, a perception of impending danger or, more appropriately, an experience of imbalance in our perceptions. The source of the imbalance is our expectation of how events should be in a given situation and our attachment to that situation. The more attached we are to our expectation, the more stress we experience.
John Demartini explains this in terms of values. Every human being has a set of priorities or a hierarchy of values. Whatever is highest in our values informs our perceptions and dictates what we see, how we interpret what we see, and how we feel and behave. Stress, according to this theory, occurs when we have unrealistic expectation of ourselves and others to live outside of our and their own values and universal laws. In other words, stress occurs when we have lopsided perceptions.
William Glasser’s choice theory explains this values hierarchy in relation to man’s five basic needs (survival, freedom, power, love, and fun) and his ‘quality world’. Every human being has a quality world – a perceived world in which balance is maintained. Man uses his hierarchy of values to scan the world for people, events, or situations that support whatever is high in his values and bring balance in his quality world. Anything that supports our values is labelled ‘good’ and we are attracted to it, and anything that challenges our values is labelled ‘bad’ and we are repelled by it.
This understanding of human behaviour and particularly the role played by our perceptions to create our reality is central to understanding and thereby reducing stress. It is an understanding all physicians should have and should be communicated to their patients in consultations.
The future of medicine
The medical practice of the future will be biomedicine plus, not biomedicine minus. It will be scientific plus, not minus. There will be a bigger role for generalist physicians, who will be specialists in the human condition. They will be ‘aware’ physicians, who understand the body’s self-healing ability; the contribution to ill health of psychological (emotional), cultural, social, and ecological factors. This physician will resume the role of supporter of the patient’s responsibility for their health – the doctor as teacher and coach. This doctor will be competently trained in bio-psycho-social medicine, but in addition will have sufficient knowledge of other traditional healing systems, such as the Chinese and Ayuverdic systems. In South Africa, this would include some knowledge of African traditional healing. Capra describes this future generalist as a ‘sage’ physician.
This generalist sage physician should be the future primary care physician. Our current disease management-based public healthcare system in South Africa does not have physicians as first point of contact – it is nurse practitioner-based, with medical officers where these are available. It has been argued that resources do not permit a system based on primary care physicians. It can be argued that if we cannot afford a good primary care delivery for health, maybe we should not be in the business of modern healthcare delivery. Shifting of resources to strengthen primary health care, coupled with massive public and medical students’ education, should enable governments to implement this type of care.
Ian McWhinney and other founding fathers of family medicine had a generalist primary care physician as the backbone of modern health care. Its patient-centred approach, coupled with the three-stage assessment (clinical, personal, and contextual) makes this ideal. When a decision was made to introduce postgraduate training before independent general practice in South Africa, it was felt that this was a step towards such a future primary care generalist physician.
Sadly, the current public primary care service in the country is not general practitioner-based and general practitioners only practice in private service. To introduce the sage physician suggested above, requires a major shift in consciousness of healthcare planners in South Africa. It makes sense that the family physician (with appropriate additional training) be the future primary care generalist sage physician in public and private service.
The biomedical model is also in need of a shift to a model that is consistent with mind-body integration. The resulting expanded bio-psycho-social medical framework will call for a system built on an appropriately trained primary care generalist physician. The family physician training seems the obvious starting point for the development of the future doctor (teacher) and sage physician.
IMAGE CREDITS: http://i4.walesonline.co.uk/