The Hole in “Holistic”
These days, there’s a lot of talk in healthcare about caring for “the whole patient.” But what does that mean? On one level, it’s about integrating different parts of healthcare: medical, behavioral, dental, etc. By grouping many services under one roof and coordinating their delivery, we hope to provide a more holistic brand of care. But there’s another level to whole patient care that we sometimes forget, and we do so to the detriment of our patients.
I did a med school rotation in the little town of Rincon, Puerto Rico. On a fairly regular basis, a patient (often a middle-aged woman) would walk in with a complaint of “nerbios.” I’m not sure there’s an exact translation, but it usually meant some kind of emotional upset or anxiety. The patient was often unable to communicate effectively, but their family member would plead for us to give her “suero.” After a cursory exam to make sure there was nothing strange amiss, we would place an IV and start a slow saline drip. Over the next hour or so, other members of the patient’s family would arrive and fuss over her while the magic “suero” flowed into her veins. Inevitably, she’d perk up and feel much better, and we’d send her and her grateful family home before the close of the business day.
As a young medical student, I observed all this with a mixture of amusement and suspicion. Had I gone to medical school to become a charlatan? A snake-oil and suero salesman? But now, after three decades of taking care of real patients, I have a different perspective. Someone came in with real distress, and we cured her in a couple of hours with no complications and no serious side-effects. How many of my other interventions have been so successful?
Placebos are a potent weapon in our arsenal. Even as we reject them as irrelevant, we are unconsciously using them. Everything from the whirring and clanking of the MRI machine to the ritual drawing of blood takes our patients out of their everyday lives and invites them to invest their faith in our unfathomable powers. And that’s not a bad thing. In many studies, the placebo effect dwarfs the difference between placebo and treatment. And the biggest placebo of them all is the provider,
A patient’s faith in their provider results in objectively better outcomes. This is true, not only across many disease processes, but in multiple ways. Patients who trust their provider are more likely to adhere to medication regimens, to follow through with diagnostic tests and screenings, to accept preventive treatments, to follow-up at appropriate intervals and to report improvement of symptoms and functional health. Given that broad, stable and robust response, why wouldn’t we nurture and optimize that relationship every chance we get?
Holistic healthcare is a great idea, but it needs to go beyond the integration of services. If we want to treat the whole patient, we have to treat their hope, their optimism and their determination. The best way to do that is to strengthen their relationship with their caregivers, and to earn their trust.
