Think about who you are. How do you define yourself? Is it just through your name? It's quite possible there are a lot of other people alive right now with the same name as you, especially if you were named after a character in a television series that was popular around the time of your conception. Are you your parents? Are you your career? Are you your family, your sports, your recreation or your education?
What makes up a person? Why is this important?
It's important to answer that question and those other ones because the factors that make up a person - their education, their career, their recreation and their future, all inform the practice of health in the clinic. In fact, those dimensions and others besides are all used outside of health as well. If you've ever applied for auto insurance, your under-writer will ask you about things like what suburb you live in, what you do for work, where you park your car, how much you drive and so on. Then they take all of this information and plug it into a series of equations, at the end of which is a number which becomes your premium. The practice of medicine and Allied Health does the same thing, albeit in a slightly less empirical and metric manner.
Consideration of the person and the dimensions of their lives informs all aspects of care - from the time you sit down in the interview to the discharge letter. Some of these factors are obvious - are you male or female, tall or short, young or old. Some things need a little bit of digging to be revealed - what kind of work do you do? Do you enjoy it? Is there a physical component to your job, due to strain or exertion? Do you drive? What do you drive? Is it a manual or automatic, hydraulic or electric pedals, adaptive mirrors or do you need to headcheck? Still other factors can only be revealed through time, and inference. What are your attitudes around health? How do you like to engage with medical and like services? Do you trust the information I'm giving you, and do you even want the information I'm giving you?
Thinking about these things - putting the patient in the center of the board and then illuminating the pushing and pulling factors that make up their character and their lives, is crucially important. It's called Holistic Health, Patient-Centered Care, Person-Embracing Care, and so many other names.
I just call it being thorough.
Over the past twenty years, Holistic and Person Centered Care have become prevalent concepts in the delivery of health and like services. Initially, it sprang up as a need to consider nonmedical factors that have an effect on patient outcomes - factors like someone's level of education, their risks as a result of their employment and socioeconomic status, or even their desire to seek care depending on their attitudes about health. It's important to engage with those factors proactively and respectively - they inform the unseen tidal forces that make someone who they are, and working with those invisble influences gives the patient power to make informed decisions. From that point, the concept of holistic health has grown to encompass other elements of the interaction and service delivery - things like rapport building, "activating" the patient as an agent in their own care, and motivational interviewing to find out what the patient wants but might not articulate. This practice recognises the patient as the core of the experience, and works to uplift them by embracing the seen and unseen factors that make up their gestalt, and leveraging them to get a good outcome. This is all well and good, but from this point on we start running into problems.
This is where salesmanship causes issues.
Thinks like rapport building, motivational interviewing, and activating agents are all strategies used in sales pitches and in targeted advertisement. It's essentially the practice of market assessing done on a much smaller scale. Instead of polling a constituency or a cohort, the practitioner becomes a microsampler with a test size of one, delivering a highly-targeted and individualised service while leveraging the rapport built through interpersonal friendliness, by guiding the activated patient through a care cycle designed to maximise their exposure to billable elements of care, and by motivational interviewing to inculcate an association between the practitioner and the patient so as to facilitate retention within the service by building dependence.
This is a theme that has been touched on in other articles of the blog - practitioners all compete for the billable hours of a finite population of sick people (physio vs chiro vs osteo), that the space between the question and the answer comprises the margin of business for a healthcare clinic (answers are not solutions), and that the healing process is a means by which individuals and structural ills can be addressed so as to empower the consumer to better deal with their problems down the line (New Normal). It's important enough that it warrants further stating.
But what's the problem? Surely if consideration of someone's extrapersonal factors can lead to better health outcomes, doesn't the practitioner reserve the right to charge for the time and effort needed to assess those factors and implement them in a recovery plan? Well, leaving out the morality and appropriateness of a clinician charging someone more money just to do the bare minimum of their job, as well as the broader discussion about the marriage of a private funding model with the implicit necessity of a thorough health assessment, the problem is that the tools used to discover pertinent elements of a patient's life can be used to disempower or empower them during the session or as individuals.
Every time someone doesn't know something, or is placed at risk because of factors in their lives or environment, there is an opportunity to empower the patient. Empowering the patient is as simple as offering a diagnosis - this is the first and most obvious step in orienting them to the topography of their illness as well as the direction in which their care can go. It's also an expected part of the initial patient assessment as well as necessary for full disclosure and informed care. From there, it's possible to ask a simple question - "How much do you know about the anatomy of the back?" "Has your Osteo told you anything about how your shoulder works?" "Did your Chiropractor tell you about why they've chosen the exercises they've done?" This addresses the diagnosis but grounds it in knowledge that the patient may not have. A physiotherapist is a professional who has completed at least four years of university study, part of which was spent studying anatomy. Why not pass some of this knowledge along in general terms for the benefit of the patient? This is analysis, consideration, synthesis, and delivery. Analyse the patient and find out where the gaps in their knowledge are, consider how best to address these gaps and what tools and resources need to be employed, create a solution, then deliver it. This can be taken even further - "What's your desk at work like?" "Do you need to lift boxes or can you use a machine for that job?" "Are you able to do headchecks while manually gearshifting or can we find a way around that?" "Is there a different way you could do this or do we need to hit this via some other angle?" Now the clinician is thinking about the context in which the person exists - the kinds of nuanced life demands that don't lend themselves to yes-no questions as part of an intake or screening interview.
Diagnosis, education, and consideration of extrapersonal and environmental factors are all elements by which the patient is considered as an individual, a participant in society, and an actor with autonomy. Diagnosis, education and consideration of those factors are all elements by which the patient is oriented to their condition, the way in which their lives or work may be contributing to it, and the means by which they can address these issues over the timecourse of their lives. Diagnosis, education, and consideration of patient factors are tools that can be used to build dependence or independence. They are the tools we as clinicians use to do our jobs thoroughly, but we can pass some of these tools and skills to the patient, so that they are better oriented to themselves, their bodies, and their lives.
An adequate clinician will provide you with a diagnosis and address your problem in immediate terms. A good clinician will give you the tools you need to do this yourself. A great clinician will set you up so that if this ever happens again, you'll be in a position to address your problems proactively. The heart of Holistic Care, Patient-Centered Practice, Person-Embracing Care and others, is a consideration of the individual that sees them not simply as a problem, a person, or an element of the care cycle, but which acknowledges and leverages the factors that make up that person. Who we are is the sum of our lives - the net result of a thousand thousand pulling and pushing forces that have subtly sculpted us as individuals and which gets us to this point in our lives where we have a problem, and come to a clinic to get it sorted out. Holistic care is the practice of taking the meeting of minds that happens then, and using that to uplift the person.
You're the one who has to live your life outside of the clinic.
We might as well help you do that as well as you can.