Towards a more humanistic medicine

• The patient as a biopsychosocial being.

• Understanding the patient experience. Empathy.

• The importance of the social environment in every healing process.

• Caring for carers.

• Physician"s engagement, balancing between closeness and distance.

The first step towards a new medicine, a more humanistic one (and we could say in order to change any paradigm) consists in rethinking the concepts from where we start. That means not only a mental activity but mostly a creative, original, rejuvenated approach to those principles which we once learned, we accepted and we incorporated into our lives and our own way to see the world.

The most dangerous risk we can see often is the small-mindedness, transforming the knowledge into beliefs. Beliefs that determine our way to conceive the reality, the health, the sickness and the patient itself.

If we learned that the human being is a biological machine and we couldn"t be able to rethink the concept incorporating the new ideas about human condition, the contribution of psychology, neuroscience and even the spirituality, then we will develop a mechanistic conception and acting as physicians.

If we learned and believed that cancer means death sentence, what could we do for the patient?

These days we use too much statistics, everything is translated into statistics.

Unfortunately too many people see the life as numbers and they treat the patient this way.

It"s sad seeing people dying because of statistics. Everyone will die eventually but, please, don"t die because of a statistic.

The first thing we should reconsider in order to change the medicine"s paradigm is the patient itself. We must find an integrating vision, complete, complex and particular as the human being is.

So, what is this reality we call "patient"? A bio-machine? A feeble being? An organism liable to fail?

These days, it would be absurd referring to the human being as a biological machine. However, many times we come up against that vision, against that cold and technical approach.

How could we think that a person who is going through a disease shouldn"t be supported emotionally and mentally?

Our daily life is affected by thoughts, feelings and emotions the same way that everything we experience causes an emotional and mental state.

The neuroscience talks about emotional molecules revealing that our feelings and thoughts are translated biologically producing a specific chemical state. That chemical state could accelerate a disease process or collaborate in the healing process.

Anyone who goes sick to the doctor feels fear, anguish, uncertainty and often desperation and has no hope. Listening to the patient is fundamental. We must try to understand his feelings beyond the physiology and include him in a global healing strategy.

And giving them hope is also fundamental.

I have heard more than one doctor saying "we cannot give fake hope" to the patients, and I absolutely agree. But be careful, because we cannot either give "fake hopelessness".

We should give as much hope as possible.

Recently a neurological patient told me he felt horrible because the multiple doctors he had gone to didn"t integrate the diagnostics, they simply talked about their specialty without a holistic vision. How is it possible?

I could feel the anguish and confusion of this guy "fragmented" by medical specialties.

Understanding and treating the patient as a whole implies team working and a good communication between all physicians and therapists.

A patient attended not only physically, but psychologically and even spiritually, if it"s required, who can feel and express the emotions, has too many more resources to heal for sure. The emotional support, the affection and the closeness are healer and stimulating themselves. And, if we ever have doubts about it, think of the terrible experimentations done during de II world war about marasmus.

That introduces a third key aspect of the new conception of the human being and the patient: the social environment.

People come to us as a biological reality conflicted by mental and emotional processes and as a part of a social environment.

From macro to micro level we must understand the patient"s culture, his social situation, and his closest social context.

Many times someone is suffering because of a pain, a disease with the uncertainty, anguish and fear which that disease causes and is not able to express his feelings to his closest people. That is really common when people receive an extreme diagnostic.

The patient is walking a tightrope and he cannot say what he is feeling because he "must" protect the others. This is terrible.

And as a biopsychosocial being his health is affected by the environment too, by the people who share life with. We can see often a phenomenon called "the conspiracy of silence", when people talk about everything but the important things. That is a fake resource which makes us think that "everything is ok" when we know that is not ok. People try to forget the painful situation but it is already there full of fear, anguish and hidden pain. The only way to win this battle is expressing without restrictions what we are feeling. And that is not only for the patient but also his closest environment.

A person who is going through a sickness process and can only communicate superficially with his family and friends without talking about his fear, pain and feelings in the end will become isolated with more fear and pain.

But, what can we do with this conspiracy of silence? First of all, we must understand that fear, suffering and often repressed angry lie under this poor communication. Above all we have to listen, understand and be clear with the patient and his family.

However, this work would be unfinished if we don"t take care of the caregivers, I mean the people who everyday take care of the patient. Teaching how to accompany a sick person, to overcome the fear and denial is fundamental to contribute to a healthy process.

A real and more humanistic medicine, focused on the patient will only be possible if he is attended in the biological, psycho-emotional and social aspect at the same time. And I can say without any doubt that patients emotionally supported with all those resources, who can express feelings without being judged increase considerably the healing possibilities.

Of course, the new paradigm, this new way to consider the human being and health will present serious challenges which we will talk about later. But above all, it requires doctors to be reeducated in their anthropological and medical vision as much as in a change of the doctor-patient relationship.

In that way, attending all the aspects of the person requires a closer approach of the professional.

In our country the system doesn"t work this way, especially the public system.

Too many people came to see me in the last years looking for a global treatment, disappointed by the fragmented and rushed assistance they received.

The hospitals are not able to cope with the patient flow because every day they are full of people, more than the doctors can handle. Because of that they see each patient for a few minutes even after they were waiting for weeks or months.

At this point we could talk for several hours about the need of a health system change. Of course there is a lot of work to do but if we wait for such a radical change to offer a more humanistic and authentic medicine we will get lost in a situation which will require several years or decades to improve.

However, we can change ourselves, we can give a good quality assistance treating each patient like more than a number. Changing our forma mentis means to approach the patient "kneeling down" as walking a sacred path. The medical work could be hard, demanding and tiring. The fact is that we didn"t choose to be business people, we chose to dedicate our lives to help people in their healing processes. Sure we can"t and mustn"t forget to take care of ourselves, which would be absurd. But if as health professionals we are not capable to assist in a human, dedicated and close way, so please quit this profession.

At this point we can think "how close to the patients must we be? What is the limit? How is possible to engage without being affected?"

Let me tell you something: don"t be afraid to being affected. Empathy"s pain, the pain of a lost life is real and unavoidable. But living that situation, feeling that pain shouldn"t be meaningless and fruitless suffering. The suffering has anything (nothing?) to do with pain, it"s an extra thing. Suffering is shutting you in that experience without the possibility to see beyond.

Living the pain without being negatively affected is not easy and it requires an internal stability and such an open-handedness that allow us to give everything without clung to the results.

At this point, the first thing we should eradicate as health professionals is the identification and our own frustration. If we live the sickness and death of our patient as a frustrated mission, then we will be always negatively affected. And that has nothing to do with empathy but with our ego.

Another key element is a new concept of healing. I shall return to that theme later but I would like to say a few words now regarding this matter. In Spanish we have to different words to describe a health process. One is "curación" and it"s referred to the body health, the other is "sanación" which means more than that. Those are two important words because a healing process does not always mean a body health recovery.

Taking care of someone who is sick, helping him to be in an empowerment role, giving him the chance to choose and helping him to use the time and the current conditions to grow as a person, heal relationships and live the present with intensity is the greatest victory we can reach as doctors and therapists. This is a global healing process.

"The patient as protagonist in his own healing process"

• The importance of the choice.

• Empowering the patient.

• Empowerment vs. vulnerability.

• The role of the doctor and the new paradigm.

• Effective communication.

• Challenges and obstacles.

Previously we have mentioned the importance of empowering the patients giving them power in front of the sickness and their own process. That new role makes an important difference in order to overcome any obstacle as the illness is.

The patient is the one who must have all the information that needs to feel safe, to plan with the doctor the healing strategy and to choose with consciousness, liberty and trust what is better for him.

Having the possibility of choosing is the foundation stone for the empowerment.

Too many times, people that are going through a disease cannot choose what kind of treatment they will receive. Many times oncological patients, for example, are subjected to chemotherapy without having ever issued any opinion.

That incapacity for choosing and expressing their doubts, fears and decisions use to be driven by an uncommunicative professional, with no empathy at all and distant from the people. Another usual factor is their own family and the closest social environment. We can frequently hear the relatives asking the patients to do some treatment "for them".

That situation is traumatic and anguishing for the sick person. Having a condemnatory diagnostic without express their feelings and forced to do any treatment even when they aren"t convinced can only generate more anguish and impotence.

I remember when, a few years ago, in a support group a woman said really sad than two days later she should receive her first chemotherapy session and she didn"t want it at all. She felt that they would inject venom in her veins. Beyond what would be the right choice for the treatment I can affirm without any concern of being wrong that in those conditions that woman couldn"t face the treatment.

Facing any therapy with no choice, unconvinced and apprehension could have more negative than positive effects not only in a psycho-emotional level. Today the neuroscience confirms that emotional states as anguish and fear can weaken the immunology. From that point of view is clear that the same therapy in a convinced, calm and trusted person with an appropriate support will have more chances to be successful.

Empowering the patient doesn"t mean reducing the professional to a lower level but reaching a more engaged relationship between both of them in the pursuit of healthiness. It means to give back the word, the trust and the choice to the patient, moving him out from a vulnerable place.

Nobody would leave its own business in other hands, or the economy management or any other decision. Then, how is it possible when talking about health?

A doctor"s word could be really powerful. It could encourage the patient or destroy the hope and will to live.

If we don"t care what the patient thinks, feels and wishes then it will be impossible to empower him. This way he will become more vulnerable and resigned, feeling that the only thing he can do is taking the medication correctly and assist to the doctor"s appointment. That could be frustrating and unproductive.

The new paradigm requires listening the patients seriously, without underestimating them. It requires listening to them not only to understand what they are feeling but to give them as much resources as possible to fight the illness.

In that sense, we can say that the doctor passes from being an all-knowing person to making up a team with the patient. This team"s mission is to evaluate together the situation, the medical proposals with pros and cons and define which the best path is.

Picking up what we said previously this stance requires a greater closeness and engagement from the professional keeping at the same time a healthy distance without identifying with the patient.

The first step in this process is to have an effective communication which means developing the capacity of listening with attention. That implies being interested in the others and what they are going through and feeling. It means looking for understanding them to be able to clarify their doubts, overcome the fears and the confusion and propose an appropriate action plan.

One big challenge we will find consists in understanding that our role will be not destroyed by this change of perspective. You will be not less doctor by involving the patient and his social environment in the health process. Quite the opposite, taking this stance means becoming the doctor that the patient needs. There are several doctors in the world, but good doctors…? There are not too many. You can be a good doctor, making a difference.

"Palliative care, more than symptoms management"

• The palliative patient.

• Body healing vs. holistic healing.

• Palliative care and thanatology.

• Hospice movement.

The palliative patient use to be defined as "that one who has a critical, progressive and incurable illness having being optimized the treatment at maximum and who presents multiple problems or symptoms that doesn"t get better and whose life is limited"

That description is accurate and it seems to be complete.

However, considering the palliative patient that way is superficial and not very human. That is the academic definition, but we shouldn"t forget that a palliative patient is a biopsychosocial being who goes through an advanced-stage disease without any healing expectations further than symptoms management. We mustn"t forget that that person has been dealing with the disease maybe for years, suffering the most acute pain and having received pessimistic prognosis. And he also knows that the end is near. In that context, going beyond the academic definitions and attending more than symptoms and pain becomes an urgent matter.

Going in depth into the palliative care and its stages will make too long this lecture, however I would like to say a few things in that regard.

First of all, we have to be convinced that is not all lost for the palliative patient. I"m not saying that a person in these circumstances is going to recover the previous state of health, even though we can"t either deny that possibility.

Can a person who is in an end-stage disease recover the body health? We can neither confirm nor deny it.

Can a person who is in an end-stage disease heal in a global way? Sure.

So, what is the difference between body-healing and global healing?

Body healing pretends to move the patient to a previous state, when the disease wasn"t there. When we are looking for a body healing the past becomes our framework of reference. Our attention is focused in the symptoms which represents an obstacle between the unsatisfactory current state and the previous wellness. If we are able to remove those symptoms it would be like going back to the past and everything would be like before. So, standing in the present we would look at the future but longing for the past. We know that is not always possible, especially when we are talking about palliative care.

Instead, a global healing ("sanación" in Spanish) doesn"t try to return to any previous situation but recover and activate all the human capacities, the consciousness included. Keeping connected with the present time is more healthy that pretending to return to the past which doesn"t exist anymore.

The pain caused by a hard situation as the sickness is related to the objectivity of that situation itself. Instead, the suffering is not a part of the situation but the way we connect with it.

A global healing doesn"t move us away from the pain but it allows us to connect with it, instead of reject it. That supposes a different attitude facing life. Instead of giving up suffering waiting for pain to leave, life becomes an opportunity to take advantage of and to live it. Whatever the remaining time will be.

The global healing point of view makes us to stop saying "I don"t want to die" to start saying "what I want to live for?"And not wanting to die is very different from wanting to live.

However, discovering that, maybe doesn"t make the illness disappear. What is certain is that who is standing in that place could take advantage of the remaining time.

I think living a month with intensity is richer than survive many years feeling sorry by ourselves and wishing to return to a non-existent past.

Here timidly appears the Thanatology.

Thanatology is a holistic discipline which studies the death phenomenon in human beings.

Its mission consists in healing the death"s pain and hopelessness not only for the end-stage patient, but for his family as well, with prevention and intervention.

It"s not about giving neither advices nor consolation. It"s addressing to relieve those pains which are the greatest ones a human could suffer. It implies helping the patient in being conscious about his situation and being capable of communicate honestly with his family and whoever he needs. It"s helping him to live his last days plenty and accepting death as a part of a natural process. In that stage it"s usual to see exceptional situations when the patient is properly accompanied. They often heal relationships, they settle old scores and they can leave a legacy, a will.

Even with pain, of course, the people can accept the situation, say goodbye to their loved ones the same time they can do it.

Above all the patient can live his last days and his death in peace. Giving that opportunity to the end-stage patient is fundamental so, since he was empowered in his healing process making him owner of his life could now also be owner of his own death.

That we call "global healing", "sanación". And it"s 100% possible.

These days in our country, the palliative care services are more developed counting with a palliative department in some hospitals as "hospital de clínicas" and "hospital E. Tornú".

Until a few years ago that service only existed in private centers being the Hospice Movement a pioneer in this matter.In Argentina, the Hospice houses are an initiative of members of the Catholic Church opened to everyone who needs it. They are especially interested in people who don"t have any economic resources or a family which could support them.

Due to palliative care the Hospice Movement offers an especial treatment given by a team of volunteers and professionals who help to integrate the multiplicity of the human dimensions, especially the spiritual one, with the objective of reaching the human cares needed to that transcendental stage.

"Taking a holistic approach to health. New and emerging disciplines"

• Alternatives or complements?

• Naturopathy.

• Ethno medicines. Legislation in Argentina.

• Mind-body medicine. Psycho Neuro Immunology and Emotional Intelligence.

During the whole last century the world witnessed the birth of a bunch of new emerging disciplines with therapeutic orientation: the called alternative medicine, therapeutic medicine or complementary medicine.

Please note that this classification includes a lot of proposals, ones scientifically proven and recognized by World Health Organization and other ones unchecked.

Talking about that differentiation is not in the scope of this lecture. Instead, we are going to think what those therapies propose and why they are so popular in the current world.

Beyond the difference between all those disciplines is interesting how all of them introduce themselves as resources for a "holistic" healing.

But, what does it mean? Basically this stance postulates that all systems and their attributes must be considered as a whole and not just as parts.

If people are more sympathetic with this approach to the reality, the human being, health and sickness is simply because that point of view is covering for an unsatisfied need.

Whatever the proposal is, this sympathy is showing us the need of people of being considered as a whole. It highlights the common need of being understood and attended as a reality more complex than just biology, the need of being considered as persons.

In the past those disciplines were categorized as "alternative medicine" and we also hear that in our days. But… an alternative to what? To the Allopathy?

Under that concept we are in danger because of more than one reason. First, that would pretend to discredit the allopathy not seeing it as a healing path. Secondly, and this is a consequence of the first reason, we should choose one of two options.

Currently we prefer to consider these emerging therapies as a complement. This means recognizing the importance and a privileged role of the Allopathy in any healing process but including new contributions that could help in the treatment. It"s true that occasionally we could manage the healing process without synthetic drugs, for example, (and their adverse effects) and choose for a less invasive and natural treatment. But it"s also true that many times we have to work together with both methods, working each one in its field and helping mutually.

It"s clear that a man in an asthmatic crisis will need a symptomatic treatment to save his life, of course. But we also know that a long-term treatment with corticoids would bring other problems without solving anything. So, when life is not in danger, complementary medicine could contribute a lot.

In China, for example, hospitals work this way. They use to have an allopathic section and a traditional medicine section as well. And doctors from both areas evaluate what kind of treatment is required for every patient.

In the 20th century the term "Naturopathy" began to be used referring to the art of natural healing whose origin is almost as ancient as the humanity itself. At the beginning of the human race, primitive men used natural elements in order to heal, and in the next centuries those primitive techniques were improved and moved away from magic and superstition.

We can say that the modern Naturopathy was born between the 17th and 18th century. This therapy uses herbal medicine and a balanced diet as a way to maintaining a good health.

Currently, it"s a profession legislated in most of the countries and it offers many natural therapies as homeopathy, acupuncture, reiki, vitamin or mineral supplement, meditation, herbal medicine, etc.

All these practices, each one in its own field, contribute significantly to the health. We shouldn"t underestimate that fact.

As professionals it"s really important to be aware of all allopathic medical advances, as well as naturopathic. We must be updated and capable to suggest one of those natural therapies without forgetting that the ultimate goal as physicians is helping people to heal in every aspect of his life.

I think that step by step this is already happening and I"m proud of seeing in our country hospitals as "Hospital E. Tornú" where doctors prescribe reiki sessions or acupuncture for pain management.

Within this context of united efforts in the pursuit of health, ethno medicines reappear.

Ethno medicine or traditional medicine is a term referred to the medical tradition of ancient people as Traditional Chinese Medicine, Ayurveda, Unani Arabic Medicine or aboriginal healing practices. They use medication (as herbal medicine) or not (as acupuncture, manual therapy).

In countries where the predominant health system is Allopathy, Ethno medicines are classified as "complementary medicine".

Ethno Medicine considers the human being as a whole in an ecological context. It professes that people get sick not only due to a pathogen, but also because of the inability to adapt to the habitat. It restores the essential idea of balance between humanity and environment considering them as two interrelated and indivisible realities.

In legal terms, the local legislation must be in line with universal laws. In this sense the WHO perform the following functions:

• To make easier the integration of Traditional Medicine (TM) in national health systems helping the states in developing their own policies in this matter.

• To provide guidance for both medicines making international standards, technical rules and methods for therapies and products research.

• To defend the rational use of TM promoting an evidence-based practice of it.

• To manage the information about TM facilitating a knowledge exchange about it.

These days, Traditional Medicine represents an important option in order to meet the needs of health assistance in all countries of Latin America and the Caribbean, despite its subordinated status. That participation was recognized by World Health Organization and Pan America Health Organization which tried to support it and promote policies to integrate TM in official health system and focusing on primary health care.

The TM Project aims to boost the organizational processes of native communities to recover, preserve and promote the aboriginal practices integrating them with academic medicine, in order to offer a better assistance for native people.

Since 1999, Argentina counts with laws that standardize the use of herbal medicine. Those laws define what a phytotherapeutic drug is, how to register a product and the quality control required for labs in order to produce that kind of medication.

Through counsel, the laws are looking for promoting a greater development of the abilities and practices they have. And also a technical and economic support is provided to build a health assistance network creating local centers of TM development and helping to create mixed hospitals.

In Allopathy, we can also find many advances and paradigm changes driven in the last decades, especially by neuroscience.

By the hand of neuroscience the Psychoneuroimmunology appeared.

The PNI studies the interaction between mental processes, the nervous system, immune system and endocrine system. It works with an interdisciplinary perspective which brings together different specialties showing the influence of psychosocial factors on immunologic response.

Due to that academic medicine deepening, today we certainly know that an emotional state is translated in a biomechanical state and so it has an impact on immunity.

This doesn"t mean that one get sick necessarily because of his emotions but what it"s showing us is that negative feelings as frustration, stress, repressed anger, anguish and anxiety generate a chemical state and it could combine with a disease process accelerating it.

But the other thing it confirms is that a patient who can overcome that kind of emotions as the fear of imaginary catastrophes, expressing him without being judged and who can develop his own virtue is able to stimulate a hidden potential. And we don"t know what could happen when that potential is activated.

People use to call this phenomenon "miracle". The miracle is the activation of the human potential which helps to produce a resignification of present time, resilience development and in many cases a spontaneous remission of the disease.

To help this process, we have the contribution of Emotional Intelligence. Developing that kind of intelligence helps us being conscious about our feelings, understanding the others and becoming owners of ourselves due to understanding.

Being aware of our feelings and accept them is the first step to express them, to understand the others, to live in society, and to be complete.

That quality of wholeness will become our best allied to face any adversity, even the illness and death.

"Looking above and beyond"

• Challenges of a more humanistic medicine.

At this point, I am convinced that reaching a paradigm change towards a more humanistic medicine is absolutely possible and it"s already happening.

This revolution starts with oneself changing the way we do our work and the engagement with patient.

However, there are many challenges and obstacles to overcome.The first of them, I insist, is related to ourselves, to be capable of rethinking, of questioning, of seeing the patient, disease and health in a renewed and holistic way.That change implies to defeat fear of breaking structures and loosing authority. In conclusion it"s all about a fight with our own ego. If we can take that step we will have changed the life of many people, as much as we had looked after.It will be already pending an institutional revolution, of course. But even that huge change, will only be possible if we change as individuals.

Maybe the health system it"s not perfect yet and hospitals receive more patients than they can assist. But changing our point of view and having a more humanistic approach are the foundation stone for a new paradigm.

Autor:

Leonardo Fernández

St. Diego University – Abroad experience