I recently travelled to McGill University in Montreal, Quebec, to undertake a two-week sabbatical. I was fortunate enough to be awarded a Fay Gale Scholarship by my university, UWA, that covered travel expenses and conference registration for myself and my family. I registered for the 3rd International Congress in Whole Person Care and elected to spend time before and after the Congress meeting with faculty members from the Programs in Whole Person Care, learning about the what, why and how of this progressive medical education program.
My mentor for the duration of my sabbatical was Dr Tom Hutchinson. Dr Tom initially trained as a nephrologist, during which time he become interested in the factors that contributed to the survival of patients with kidney disease. His concern for the lived experienced of patients living with chronic disease, including kidney disease, was the motivation to meet with therapist Virginia Satir and undertake further study in Family Therapy. He subsequently published a book on the stories of patients with kidney disease.
In 2002, Dr Tom decided to move into Palliative Medicine and together with Dr. Balfour Mount, began developing McGill Programs in Whole Person Care. The aim of these Programs is to “enlarge the Western Health Care mandate from cure and prolongation of life to an equal concern with patients’ quality of life”. The Programs seek to study, understand and promote the role of health care in relieving suffering and promoting healing in acute and chronic illness as a complement to the disease focus of medicine.
Since 2005, the Programs have taught healing in medicine to all medical students throughout all 4 years of the new Physicianship Curriculum at McGill. Dr Tom has consequently published a number of academic books, including “Whole Person Care: A New Paradigm for the 21st Century” and “Whole Person Care: Transforming Healthcare”. Further, he has now chaired three International Congresses on Whole Person Care, sponsored by McGill's Faculty of Medicine, in 2013, 2017 and 2019.
The What
Dr Tom shared with me that the overall purpose for the teaching of Whole Person Care is “mindful medical congruence”. This term refers to awareness of self, awareness of the other and the awareness of the context and is the three-pronged focus of the mindfulness that is the foundation of this teaching. This concept was developed by family therapist Virginia Satir, one of Dr Tom’s mentors.
The diagram at the top of this post demonstrates that to provide Whole Person Care, the health professional needs to stay in touch with the three elements of self, other and context to remain congruent. However, this can be much more difficult that it appears. Under stress, health professionals often drop one or more of the three elements, to the detriment of the health professional-patient-family interaction (1).
When the doctor drops themselves, they leave themselves out of the interaction and placate to the others’ needs. This is often the starting point for many medical students who wish to do the best for their patient. However, this can be a difficult stance to maintain over time and is often not what the patient wants (1).
When the doctor becomes sufficiently unhappy with the self-suppression, they move to the contrasting stance – blaming – when they want the other, for example the patient, to meet their expectations. This may manifest as the doctor developing an adversary relationship with the patient or family, perceiving their behaviour as “dysfunctional, difficult or non-compliant”. This may be true, but may also mean the doctor is taking on the blaming stance without considering the patient’s situation fully (1).
The super-reasonable stance, or “computer-head”, occurs when the doctor leaves out both themselves and the other person. This can happen when the doctor wants to avoid emotion and avoid being present to themselves and the patient as human beings. Although this stance appears to solve a problem, it can be extremely upsetting when a person is confronting a scary and emotionally powerful diagnosis or medical problem (1).
Finally, the distracting stance occurs when the doctor loses touch of all elements. This is not as uncommon as we might hope in clinical practice, manifesting as extreme multitasking (often with electronic media) and using humour inappropriately (1).
The Why
Interestingly, the reason why McGill University has incorporated the teaching of Whole Person Care into their medical curriculum is not about optimising medical student wellness. Although this is often a side effect of this education, it is not considered the primary aim. Instead, the objective of the Whole Person Care curriculum is to cultivate excellent Physicians.
As Dr William Osler, one of the founding professors of the McGill Medical Faculty, once said
“The good physician treats the disease; the great physician treats the patient with the disease.”
Whole person care is about being a doctor who will provide competent medical care and relate to the patient as a whole person, who has preferences and needs that need to be considered as part of their treatment. Sadly, many patients are becoming lost in health care systems that are focused on profit and KPIs rather that quality patient care (1).
Whole person care contrasts the reductionist view of medicine that sees doctors as technicians who repair broken bodies. Whole Person Care focuses on the fact that even though a patient may not be cured, they may still be healed. People are not machines, but rather spiritual beings that may experience wellbeing and healing regardless of how well the body is functioning (1).
In summary, whole person care requires that the doctor recognises their own whole personhood, including their valuable medical knowledge, skills and attitudes but also their own human limitations, ignorance, lack of skill and unhelpful attitudes (1).
The How
During the Congress, I attended a workshop led by three medical students, now in their final year of medical school, who chose to undertake some research into Whole Person Care when they were in first year. They presented the results of their qualitative research, which involved interviewing 34 physicians who practice Whole Person Care in Montreal, asking them the following questions:
1. What does Whole Person Care mean to you?
2. Can you tell me about a time you practiced Whole Person Care?
3. How did you know you were practising Whole Person Care?
Initially, they coded the data and came up with a number of categories into which they organised the physicians’ responses. They then created a thematic framework to demonstrate their findings. Essentially, they proposed that Whole Person Care consists of three elements: a way of being, the patient-physician dyad and the person beyond the disease. Further to this, they summarised the “how” of practising whole person care, which included the following
reflecting to patient in a human way
managing uncertainty
listening
giving patient space to be emotional
not judging
acknowledging emotions
addressing individuality and vulnerability
pausing and allowing silence
building a relationship/trust
I found this to be a really useful list that every medical student and doctor should be reflecting on daily as part of their professional development.
Summary
As a doctor who aims to provide Whole Person Care to every patient I encounter, I thoroughly enjoyed deepening my understanding of the what, why and how of Whole Person Care. It is my intention to continue reflecting on this practice and sharing it with my medical students and physician colleagues into the future.
Reference
1. Liben, S. & Hutchinson, T. (2019). MD Aware: A Mindful Medical Practice Course Guide. Montreal, Canada: Springer.