A new model of care to return holism to family medicine
Family medicine’s leadership in primary care is slipping as it loses its vision of whole-person care. This model of care can help us better manage and combat chronic disease.
PRACTICE RECOMMENDATIONS
❯ Build care teams into your practice so that you integrate “what matters” into the center of the clinical encounter. C
❯ Add practice approaches that help patients engage in healthy lifestyles and that remove social and economic barriers for improving health and well-being. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Reductionism is relentless
But the forces of medicine were—and still are—driving relentlessly the other way. The science of the small and particular (reductionism), with dazzling technology and exploding subspecialty knowledge, and backed by powerful economic drivers, rewards health care for pulling the patient and the medical profession apart. We pay more to those who treat small parts of a person over a short period than to those who attend to the whole person over the lifetime.
Today, family medicine—for all of its common sense, scientific soundness, connectedness to patients, and demonstrated value—struggles to survive.2-6 The holistic vision of Engel is declining. The struggle in primary care is that its holistic vision gets co-opted by specialized medical science—and then it desperately attempts to apply those small and specialized tools to the care of patients in their wholeness. Holism is largely dead in health care, and everyone pays the consequences.7
Health care is losing its value
The damage from this decline in holism is not just to primary care but to the value of health care in general. Most medical care being delivered today—comprising diagnosis, treatment, and payment (the innermost circle of the FIGURE)—is not producing good health.8 Only 15% to 20% of the healing of an individual or a population comes from health care.9 The rest—nearly 80%—comes from other factors rarely addressed in the health care system: behavioral and lifestyle choices that people make in their daily life, including those related to food, movement, sleep, stress, and substance use.10 Increasingly, it is the economic and social determinants of health that influence this behavior and have a greater impact on health and lifespan than physiology or genes.11 The same social determinants of health also influence patients’ ability to obtain medical care and pursue a meaningful life.12
The result of this decline in holism and in the value of health care in general has been a relentless rise in the cost of medical care13-15 and the need for social services; declining life expectancy16,17 and quality of life18; growing patient dissatisfaction; and burnout in providers.19,20 Health care has become, as investor and business leader Warren Buffet remarked, the “tapeworm” of the economy and a major contributor to growing disparities in health and well-being between the haves and have-nots.21 Engel’s prediction that good medicine cannot afford to ignore holism has come to pass.
3-step solution:Return to whole-person care
Family medicine needs to return to whole-person care, but it can do so only if it attends to, and effectively delivers on, the prevention, treatment, and reversal of chronic disease and the enhancement of health and well-being. This can happen only if family medicine stops trying to be all things to all people at all times and, instead, focuses on what matters to the patient as a person.
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