In its customary use the term primary care refers to the ongoing basic health services provided by a primary care practitioner to a client. These services may include the care of acute and chronic medical problems, the organizing and orchestrating of complex multi-practitioner interventions, prevention and health promotion services, education, advise, and psychological counseling and support. It is the intent and hope that the primary care practitioner-client relationship will extend over many years, progressively developing both the trust and intimacy that characterizes a caring and healing relationship.
Today, primary care health services are predominantly provided by physicians within a contextual framework that emphasizes the authority and expertise of the practitioner, focuses on disease and disease categories, encourages episodic care, and promotes the underlying assumptions of the biomedical model: objectivism, determinism, and positivism. These assumptions, although unknown to most practitioners, exert a compelling influence on the practice of primary care.
In brief, objectivism asserts the unqualified and exclusive validity of sensory based observations that are considered to be untainted by subjectivity. The observer is believed to be independent of his observation and science is seen to be non-relativistic and extra-cultural. Determinism is the belief in a direct linear upward chain of causality linking a singular cause to its specific effect, the process of reductionism. This view underlies the "gold" standard in scientific research, the clinical controlled experiment in which a single variable is manipulated while all others are kept constant. Positivism is the view that the ongoing accumulation of data from sensory based experiments will provide us with a progressively more accurate and life enhancing understanding of nature.
It is the premise of this paper that the meaningful integration into our health care system of holistic principles and complementary healing practices will require a fundamental re-orientation of our current approach to primary care. To do otherwise would more than likely result in a distortion and corrosion of holistic principles, a reduction of complementary practices into disease oriented treatment modalities, and a corrupting influence on the alternative practitioner whose practice style would invariably fall under the hegemony of the reimbursement system and the biomedical world view. Complementary approaches will invariably be re-shaped to conform to the contextual framework of biomedicine rather than extending and expanding this framework. Stated in another way, the existing system will change the alternatives rather than the alternatives changing the system.
There are ample examples of this for us to draw upon. In the 1970s John Travis1 initiated the wellness movement. His conceptual model was educational in orientation and based on the principles of psycho/social/spiritual development. Immersed in the context of our scientific world view it was quickly reframed in a manner that exclusively emphasized its most physical and material aspects: smoking cessation, exercise, and nutritional changes. The core and soul of this model was lost through its integration into our contemporary context. Much the same can be said regarding the concept of holism. Holism, a concept which is based on an expansive view of the human experience, emphasizes the essential and irrevocable interaction of mind, body, and spirit.2 In the context of our cultural paradigm, the concept of holism has been distorted and mistaken for alternative treatment practices. Although a practice may derive from a conceptual framework that is more or less holistic, the actual practice, as integrated into our culture, is most often used as a reductive treatment practice oriented towards repair and restoration of function. Holism is not a practice. It is a perspective.
These concerns are hardly hypothetical. They are occurring now as alternative and complementary practitioners are progressively incorporated into managed care reimbursement plans. In general, conventional reimbursement systems do not reimburse for a specific approach, for example, chiropractic or acupuncture, but rather, for the treatment of a particular disease category: lower back pain in the case of chiropractic and chronic pain and addictive problems in the case of acupuncture. The existing biomedical context reduces these approaches to disease oriented treatments and jettisons their holistic context. Unknowingly, practitioners, appreciative of having accomplished their long sought after goal of acknowledgement and reimbursement through the health care insurance system, have failed to see the subtle and insidious distortion that lies in wait for them and their practices as they are "mainstreamed" by the insurance system, a fate only too well known to conventional medical practitioners.
No effort to transform and expand the current health care model can succeed without a shift in the underlying world view that drives our current medical model.3 The primary care practitioner who, as a result of managed care initiatives, is emerging as the initial contact point for clients, the "gatekeeper" for external medical resources, and, in participation with the client, the orchestrator of an individualized health and healing process, is the central figure in the changing medical paradigm. The perspectives and attitudes of this individual will largely determine the content and character of health care.
An Integrated Healing Model
A re-orientation of primary care must begin with a shift in the existing world view of objectivism, determinism, and positivism. A reading of history, past and contemporary, and an understanding of current cultural trends clearly indicates that we are moving towards a new world view, a paradigm shift, that can be characterized by the emergence of a set of assumptions that are better matched to the needs of our time.4 These assumptions are: dynamism, holism, and purposefulness. In brief, dynamism is characterized by the view that human life is a vital process of growth and development resulting from the ongoing interaction and adaption of man to his changing environment. This perspective asserts that the human condition cannot be exclusively understood through the accumulation of static data which deny the influence and validity of psycho/social/spiritual and environmental influences. Holism is the term we use to designate the viewpoint that life is a natural, organized, and unfolding process that consists of constituent elements bound together from the very beginning in a unitary whole. Life cannot be constructed by the mere summation of its individual elements. Purposefulness express the view that intentionality and meaning can be found at all levels of the human experience.
Based on this world view we can devise an integrated healing model which can serve as the theoretical basis for a re-invention of the primary care process.5 This model, figure 1, is based on systems theory.6,7 It asserts that the human healing system is composed of four distinctive interactive sub-systems each with their own mechanisms, capacities, and resources. Taken together, these four sub-systems become the basis of a complete and vital healing system, qualities that resides in the total system rather than in any one of its constituent parts.
Whole Healing Model
|Checks and Balances||Reductive||Developmental||Unifying
|Steady State||Restore Funtion||Autonomy||Wholeness|
Fig. 1. Columns (read vertically) represent four distinct healing systems. Read horizontally, they incorporate the holistic perspective embedded in the model.
The homeostatic healing system is our most basic healing system. It is built-in, auto-regulating, and natural. This system evolved over millennia to support the living conditions of our primitive ancestors. Invariably, it breaks down when exposed to the conditions of urbanized life. Treatment systems are a reactive response to the failure of these natural healing mechanisms, and in the best scenario, should support our natural homeostatic mechanisms. Treatment systems are oriented towards the repair and the restoration of normal function. The authority and expertise lies with a professional whose practices usually involve external agents of one sort or another. The mind/body healing system is proactive, self-initiated, and directed towards the expansion of consciousness and the achievement of autonomy, an event that is heals both our psychology and physiology. Finally, the spiritual healing system relies on the emergence of a transcendent perspective which in and of itself can heal by spontaneously re-organizing both our psychology and physiology.
This inclusive and integrated model assists the primary care practitioner and his client in understanding and using both conventional and complementary approaches within a contextual framework that embodies a new and more expansive world view. Vertical movement within each healing sub-system extends the resources of that system, for example, the expansion of the treatment system with the addition of complementary therapies. Horizontal movement across the four sub-systems emphasizes the holistic perspective that is embedded in this model. Any of the sub-systems taken alone are inconsistent with the living process, taken together they constitute the essence of natural living system: dynamism, holism, and purposefulness.
The Primary Care Practitioner
As we re-consider the role of the primary care practitioner within the contextual framework of an integrated healing model, it becomes evident that there must be a defining shift in the relationships, perspectives, and practices that constitute the elements of primary care. This includes: a renewed emphasis on the quality and character of the diverse relationships related to the healing process - the relationship of the practitioner to himself, his client, other practitioners, and the community-at-large, and a careful balance between reductive and holistic perspectives. Primary care becomes more integrative and person-centered in contrast to fragmented and disease centered.
The diagnostic process expands to include a concern with psychological, spiritual, community, and environmental issues.(FIG. 2) In this manner the diagnostic process becomes inseparable from the substance of the practitioner-client relationship. The "medical history" is more a sketch of the unique story line of an individual's life, than a standardized check list of symptoms. This reflects an acceptance of an concern with the subjectivity of each individual's unique circumstance. The expanded practitioner-client relationship becomes a larger context within which the traditional diagnostic results are interpreted and acted upon. For the primary care practitioner the art of healing which is embodied in the healing relationship re-emerges to balance and provide a context for the technological and reductive aspects of healing.