This raises a most critical issue. Who shall be the future primary care practitioner? From the perspective of an integrated healing model there is no clear reason why this role requires the training of a physician. In fact, in the current medical setting nurse practitioners and physician assistants have often undertaken this role. Although it may be appropriate for the primary care practitioner to undergo training in a specific healing approach, it may not be essential that this be biomedicine. The rigors and intensity of a training process allows for a certain intellectual vitality, personal discipline and maturity which are essential qualities of a healer. But, an expertise in a particular perspective should be expanded to include a knowledge and understanding of the capacities, assets, and liabilities of other healing systems allowing the practitioner, irrespective of his healing approach, to appropriately use and relate to other practitioners and practices.
|Biomedical Model||Expanded Model
|Health professional||Shared responsibility
Fig. 2. Implications of an expanded healing model
Primary Care Practice
Let's examine how the primary practitioner will actually handle his/her task. In the ideal and preferred circumstance the practitioner-client relationship develops over an extended period of time and emphasizes disease prevention and the attainment of full health. However, given our present cultural practices, practitioners and clients usually forge their relationship in the context of an illness setting. Beginning with the first encounter, an emphasis will be placed on1 eliciting an expanded biographical history, one that encompasses the orientation of the four healing systems and is therefore bio/psycho/social/spiritual in perspective (see figure 2), and2 developing an empathic, person-centered relationship. The nature and severity of the initial concern, the age and maturity of the client, and the details of the history will assist in sorting out the primary factors to be considered in each circumstance. For example, a transient upper respiratory infection may call for specific treatment and limited advice whereas the onset of atherosclerotic heart disease will certainty require that all of the healing systems be addressed within the context of a rapidly developing healing relationship.
As depicted in figure 3, the initial and ongoing efforts at establishing an historical database will expand from its previous and exclusive focus on disease to one that seeks a comprehensive understanding of the multidimensional factors that together compose an individual's life; personal history, attitudes, lifestyles, social and work relationships, environmental elements, and spiritual perspectives. Rather than converging towards a physiologic based diagnosis, the practitioner first diverges towards a holistic vision of the individual. This is an individualized approach mandated by the circumstances af a unique individual in contrast to an approach that is dictated by the presenting signs and symptoms and the need to converge, as soon as possible, towards a disease related diagnosis. As stated by the famed internist Sir William Osler, "It is better to know the patient that has the disease than the disease that has the patient".
Fig. 3. Multidimensional Healing: the clinical process
The objective of treatment modality, whether it be conventional or alternative is to repair the abnormality and restore, as best as possible, normal function. The objective of our new primary care practitioner is broader, a summation of the objectives of the individual healing systems which include: (1) the maintenance of an internal/external balance, (2) the repair of abnormalities and the restoration of normal function, (3) the development of personal autonomy and the expansion of self-awareness, personal capacities, and resources, and (4) the achievement of wholeness as signified by a spiritual perspective that conveys meaning and purpose to life.
Although the practitioner is frequently placed in the position of reacting to the presentation of the signs and symptoms of illness, it is essential that he/she learns to maintain and promote a proactive perspective. The practitioner must "hold", often initially for himself and his client, the vision that I believe was best stated by C.G.Jung, "... disease is the beginning of a natural healing process". Further, the practitioner must view health more as a verb than a noun, a life long orientation rather than a static condition, one that is expressed through attitudes, choices, and actions. This conceptual expansion and re-definition of our ideas about health and disease is the primary factor in the shift from a reactive approach to one that is proactive. It is understandable that the ill client is primarily focused on disease. It is the role of the new primary care practitioner to meet this need while at the same time placing it in a far larger context, "using" it as a vehicle through which to assist the individual in expanding his more limited view of health and healing.
The Practitioner - Client Relationship
It is in this area that we seek to achieve one the most significant differences between the old style of practicing primary care and the re-designed role that I am suggesting.8 Professionalism is a recent development in human history. It is based on the proliferation of information and technology, the related need for specialization, and the cultural practice of restricting, through licensing, the practice of a particular social role. Professionalism is inseparable from the dominant - dependent relationship that is built into the idea of professionalism and expertise. The client is placed in a relative position of powerlessness and helplessness as he defers responsibility for recovery and health to the professional expert. The practitioner-client relationship is seen as merely a vehicle with which to carry forth the prescribed functions of the professional role.
The consequences of the rise of professionalism, a loss of personal autonomy and a diminshed capacity for self-care, are not restricted to the disease process. The medicalization of our lives now extends to include the most essential existential issues of life: pain and suffering, ageing, and death. These experiences, ones which are necessary for personal development and the expansion of consciousness, are expropriated from our personal domain.9 The unbridled exercise of professionalism and expertise (conventional and alternative practitioners included) destroys the potential for full health and diminishes the autonomy and dignity of the individual.
The new primary care practitioner must see himself engaged in a partnership with the client in which responsibility must at all times move towards the individual and away from the professional, and in which the relationship is seen as the primary and enduring context within which recovery, healing, and health initiatives take place. As we each become more fluent with the extensive resources that are now available through the Internet and other online services, access to information will cease to be an important distinction separating the practitioner from his client.10,11
Imagine a client accessing the data bank of the Cochrane Collaboration, an international effort to perform, update, and disseminate systematic reviews of clinical trials.12 Or, consider him entering information on his illness and reviewing the output of disease specific information, seeking information on particular alternative practices, or contacting other individuals with his precise problem to determine the results of their efforts while at the same time establishing a supportive and healing relationship. Perhaps our client can even speak online with one or more "experts".
Paradoxically, what will distinctively remain the domain of the practitioner will not be his fluency in information and technology, but his art as a healer and his capacity to develop and participate in healing relationships. In T.S. Eliot's words from the Four Quartets we will "... arrive where we started, And know the place for the first time." The art will return to medicine. And what exactly is this art of medicine? It is the creative capacity to enter into the experience of another human being, understand from the clients perspective the nature of his life and its forces, what can be called empathic listening, and participate with this individual in the composing of a healthy life, a composition that involves recovery, healing, and health - the fully lived life.
The Practitioner-Practitioner Relationship
The full capacity to use all of the potentially valuable healing modalities, whether they are conventional or alternative, is based on the understanding and relationship that develops among practitioners. This understanding must include an acceptance of the fact that there are many complementary approaches to healing each of which developed in a cultural context. No one approach or technique has sole ownership of a singular truth. There is more than one way to heal.
Similar to how we as individuals learn to move beyond our biased judgements of another person by listening to and getting to know that person, as practitioners we must we willing to study and understand cross cultural healing traditions. The more we understand about a healing tradition, the more capable we become of using, when appropriate, the resources of that approach, and relating to and understanding the perspective and practices of the practitioner. It then becomes possible to establish a working relationship with a community of professionals that share a multiplicity of approaches to healing each of which can contribute to our expanded approach to health and healing.
In the practitioner-client relationship we are called upon to be sufficiently self aware and knowledgeable that we can move beyond our own perspectives to encompass those of our client - from the perspective of our client. In the practitioner-practitioner relationship we are asked to do much the same. Underlying each of these tasks is a maturing of ourselves and our consciousness, a maturing that can appreciate and value the relativity and subjectivity of all perspectives, seeing within this diversity a larger unity. This is difficult for all practitioners, conventional and alternative.
The Education of the Primary Care Practitioner
Science is the development of a systematized knowledge which is derived from observation, study and experimentation, and is directed towards achieving a cohesive and durable understanding of the natural world. Biomedicine is only one expression of the scientific ethic, but it is the only one that is taught to today's primary car practitioners. Although biomedicine, as a reductive branch of science, has provided us with a very powerful understanding of basic physiology and a highly effective technology that can be applied to a specific set of circumstances, like all branches of science, it is limited. The primary care practitioner of the future must be taught a broader based science which incorporates the psycho/social/spiritual dimensions of life.