Abstract

Holistic medicine means consideration of the complete person, physically, psychologically, socially, and spiritually, in the management and prevention of disease. These different states can be equally important. All healthcare practitioners should aspire towards a holistic approach to patients and attempt to practice it. Recognizing the ‘whole’ person in the prevention and treatment of a disease may hold the key to some diagnoses for doctors. It may also allow valuable and important help and guidance to be given to the patient. Patients tend to be more satisfied if a doctor takes a holistic approach, feeling that their doctor has time for them and their problems. In addition to a holistic approach, a team approach to a patient is also extremely important. There are three types of teams: a multidisciplinary, interdisciplinary and transdisciplinary team. Which team will be used depends on the possibility, knowledge and the patients’ needs. In a team approach the patient is the main focus and is thus the responsibility of every member of the team. The team has a responsibility towards one another to have open communication channels and mutual respect for different professions. Each member of the team should know his or her own abilities and limitations. In many articles the outcomes of treatment with a team approach have been reported positively, with no reports of negative consequences of team intervention. Furthermore, the use of a team approach has been demonstrated in all healthcare settings across the continuum. Forming a multidisciplinary team is only one aspect of providing a multidisciplinary health care service. Developing systems and resources that ensure the team can function effectively is also essential.

Key words: holistic approach, team work, multidisciplinary, interdisciplinary, transdisciplinary

Holistic approach

Knowledge that a man is more than a combination of body and soul has existed since time immemorial, but only in the last century has there been systematic discussion about this. The term “holistic” comes from the term holism, which was coined by Jan Smuts (1870-1950), a politician and Prime Minister of the South African Republic, and a military leader and philosopher. The term is used in his book “Holism and Evolution,” which was published in London in 1926. (1) Jan Smuts defined the term holism as a theory that the whole (holos in Greek – whole, complete) is more than the sum of its systemic parts. His thesis is proved in the case of Einstein’s theory of relativity and Darwin’s theory of evolution. He believed that physical reality and nature have a tendency to more complex entirety. From his study, the key sentence on this is: “Creating a whole, holistic tendency or holism, which is manifested in units composed of parts, can be seen at all stages of all that exists.” Considering that this idea of his was based more on philosophy than on science, it was ignored for decades. (2) Only after the activities on quantum mechanics from physicist Bohm did the term “holism” take on a scientific note. (3, 4)

Although the term “holism” was coined by Jan Smuts in 1926, the concept of holism probably has its roots in ancient Indian Vedic culture (“veda” in Sanskrit means knowledge), which existed thousands of years ago. In Sanskrit, the word “sarvah” (meaning the whole, intact, uninjured) was used in the description of the nature of human existence as an integral part of the universe. (2) How the culture changed, so too did the meaning of the concept. In the Roman culture there are two words in Latin – salvus and salus that are considered to originate from the Sanskrit word sarvah. The meaning of salvus is safe, uninjured, good health, while the word salus means health, safety, well-being, salvation. In the Christian era the word save (from the Latin word salvus) means rescue from danger. (5)

The contemporary philosophical definition of holistic health incorporates a lot of these definitions. The human being consists of body, mind and spirit, integrated into a whole, whose parts are inseparable. All this represents a dynamic interaction within the human in self, among others people, and the whole universe. When all the parts are balanced and harmonious, there is a maximum of well-being. Although health can be defined in several ways, such as physical, social, emotional, cognitive and spiritual health, if that someone would be truly healthy, they must experience a sense of well-being. An imbalance and disharmony within a human being, human to human, and human being to the universe, disturbs the benefit of persons or their health. (2) Considering the above, it is very easy to make relation to the famous definition of health by Dr. Andrija Štampar (1888 – 1958), which he gave in 1926, that health is a state of complete physical, mental and social well-being and not merely the absence of disease.

Just as the concept of holism is not new, neither are holistic approaches to treatment. Its roots are found in the writings older than 5000 years describing the Ayurvedic holistic approach to treatment. (2) Ayurveda (a Sanskrit word meaning “science of life”, and consists of the words ayur = life and veda = knowledge) includes not only the aspect of treatment, but also includes other aspects that are associated with the word life. At its foundation it has three main goals: 1) mental emotional improvement, 2) prevention and 3) therapy, or curative. (7) This is a model recognized by the National Institute of Health, based on the belief that health problems arise when relations between people, the environment and the universe are disturbed. (2-8)

In the 4th century B.C., Socrates warned that treating only one part of the body would not have good results. Hippocrates also spoke about holistic medicine and (9), and a holistic approach is also advocated by Percival in his book – the first textbook of medical ethics, published just in 1803. Percival noted: “The feeling and emotions of the patients require to be known and to be attended to, no less than the symptoms of their diseases.” (10) John Macleod in his book “Clinical Examination”, first published in 1964, also commented that “we should aim to be holistic in our care.” (11)

A similar belief was articulated in Florence Nightingale in 1969 (12), when expressed the role of nurses to “… put the patient in the best condition for nature to act upon him.” She thought that touch, kindness and other measures of comfort, provided within the context of environment treatment, are of crucial importance for nursing. These premises are held today. Even today nurses are educated to manage the environment and use touch, massage, eye contact, voice, and other measures to make patients feel more comfortable. These nursing activities, known as ”the art of nursing”, represent the basis of professional nursing. (2)

Nowadays different disciplines, such as physics, mathematics, science, philosophy, sociology, medicine, nursing, etc., supports the view that the integrity of an entity is much more complex and greater than the sum of their individual parts. (2)

Definition and principles of holistic approach

Holistic medicine means consideration of the complete person, physically, psychologically, socially, and spiritually, in the management and prevention of disease. These different states can be equally important. They should be managed together so that a person is treated as a whole. A holistic approach means that the doctor is informed about a patient’s whole life situation. (13)

Principles of a holistic approach include the following:

  • All people have innate healing powers;
  • The patient is a person, not just a disease;
  • Appropriate healing treatment needs a team approach;
  • Patient and physician are partners in the healing process;
  • Treatment involves fixing the cause of the illness, not just reliving the symptoms.

Surgical nurse Carolyn Watts often tells nursing students: “Look at the whole patient, and not just the hole in the patient”. Perhaps it is only in that one short sentence imposed the whole holistic approach to the patient.

Teamwork

In addition to a holistic approach, a team approach to a patient is also extremely important.

A team is defined as “a number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they are mutually accountable”. (14, 15) On the other hand, a health care team is defined as: “Team based health-care is provision of health services to individuals, families and or their communities by at least two health providers who work collaboratively with patients and their caregivers – to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high quality care”. (15, 23)

Types of teams

There are three types of team-approaches to the patient, respectively three types of teams, namely: a multidisciplinary, interdisciplinary and transdisciplinary team. The terms multidisciplinary, interdisciplinary, and transdisciplinary are often used to describe the contribution of multiple disciplines, but actually describes a continuum of involvement of disciplines. (16)

A multidisciplinary team is a group of health care workers who are members of different disciplines each providing specific services to the patient. The team members independently treat various issues a patient may have, focusing on the issues in which they specialise. The activities of the team are brought together using a care plan. This co-ordinates their services and gets the team working together towards a specific set of goals. Sometimes the person has a key worker, who becomes the main point of contact for the person. (17) Multidisciplinarity represents the basic efforts of multiple disciplines working together to solve a problem without challenging disciplinary boundaries. (16)

An interdisciplinary clinical team is a consistent grouping of people from relevant clinical disciplines, ideally inclusive of the patient, whose interactions are guided by specific team functions and processes to achieve team-defined favourable patient outcomes. Nowadays teamwork can be supported by properly designed eHealth applications which could help create more effective systems of care for chronic disease. Given its synchronous and asynchronous communication capacity and information-gathering and -sharing capabilities. (18) Interdisciplinarity is defined as the coordinated and coherent linkages between disciplines resulting in reciprocal interactions that overlap disciplinary boundaries, generating new common methods, knowledge, or perspectives. (16)

Transdisciplinarity is the most advanced level, and includes scientist, non-scientist, and other stakeholders who go beyond or transcend the disciplinary boundaries through role release and expansion (16, 19).

The concept of multidisciplinarity therefore suggests the use of different disciplines to answer a particular clinical problem, but each discipline stays within their boundaries. (15, 16) Conversely, the concept of interdisciplinarity suggests that there is a link between the disciplines where each moves from their own position into one collective group. This group is then engaged in creating and applying new knowledge which exists outside of the disciplines involved. (15, 16) The fundamental difference between the concepts of transdisciplinary and interdisciplinary is the actual bringing of new knowledge into the group through a transdisciplinary approach, and as such, this is seen as the union of all interdisciplinary efforts. (15, 16)

A team approach is required not only in the management of individuals with chronic conditions but in addressing these public health challenges more broadly. In general, care for chronic diseases is best delivered with a collaborative effort involving public health specialists, policy and service planners, researchers, information technology designers, and support personnel. For example, the multidisciplinary team in mental health includes psychiatrists, psychologists, nurses, general practitioners, occupational therapists and community/social workers who can share their expertise and collaborate with each other. (20, 21)

Why work as a team?

Alan Williams, Professor of Health Economics, University of York, on Health Outcomes Conference, 1993 said: “In a system with limited resources, health professionals have a duty to establish not only that they are doing good, but that they are doing more good than anything else that could be done with the same resources.”

An interesting paper by Hasler provides a historical overview of the development and integration of the concept of health care teams within primary care services in the UK. Hasler argues that development of teamwork arose for many reasons beyond the actual desire of individuals to start working together. (15, 22)

The focus should be on the patients’ needs and expectations. At its essence, the adoption of a team approach is argued as being fundamental to achieving these goals. The group needs to truly work as a team to ensure that all the available skills and expertise can be targeted in an appropriate fashion. (20) However, one of the major challenges in moving from promoted to lived adoption of team work lies in the use of confusing, often interchangeable terminology that is poorly understood, and even more poorly implemented in practice (14, 15).

In the US, the Institute of Medicine (23) has identified an urgent need for high-functioning teams to address the increasing complexity of information and interpersonal connections required in contemporary healthcare. The transition of practitioners from soloists to members of an orchestra has gained national momentum through healthcare reform with substantial interprofessional policy and practice development in recent years. (24) Best practice collaborations have identified the basic principles and values for team based care, and support for inter-professional learning strategies is increasing. (15, 23, 24)

The WHO argues that professionals who actively bring the skills of different individuals together, with the aim of clearly addressing the health care needs of patients and the community, strengthened health systems, leading to enhanced clinical and health related outcomes. (25)

Zena Moore and co-authors conducted medical research in which they performed a literature search about the results of a team approach to treatment of chronic wounds. (15) Their search produced 84 articles with additional sources identified in an index search from 1995 to 2013, with a notable increase in the frequency of articles relating to wound management as a team over the past six years. The studies originated from 23 different countries representing nearly every continent. Most of the studies described the highest quality of evidence and a positive effect from care delivered by a team approach. All outcomes have been reported positively, with no reports of negative consequences of team intervention. Furthermore, the use of a team approach has been demonstrated in all healthcare settings across the continuum. (15)

How teams work?

Within the team concept members are focused to working in such a way to achieve a mutually agreed goal. Furthermore, the work of the team is interdependent and team members share responsibility and are accountable for attaining the desired results. (15) Workers are not just individuals but are integral parts of functioning health teams in which each member contributes different skills and performs different functions. (20)

In a team approach the patient is the main focus and is thus the responsibility of every member of the team. The team has a responsibility towards one another to have open communication channels and mutual respect for different professions. Each member of the team should know his or her own abilities and limitations.

Dorahy and Hamilton (26) suggested a method for maintaining a professional identity whilst adopting a team identity. The model called ‘The Narcissistic Me’ suggests that multidisciplinary teams operate on two continuums. The first is a “me-to-team” continuum and the second is a “me-to-client” continuum. The two continuums are placed at right angles to form four quadrants of decision making. (Figure 1) The authors suggest that most decisions should come from the “Client-Team” quadrant, but on occasion, some decisions will be required from the “Me-Client” and the “Me Team” quadrants. In short, most decisions should be made by team and client collaborations, but at times, health professionals will be required to make decisions between themselves and the client alone, or between themselves and the team alone. This suggests that effective multidisciplinary teams incorporate dynamics that work towards a team approach to client problems but maintain the right of individual members of the team (professional or clients) to operate independent of “groupthink” when required. (26,15)

Figure 1. Narcissistic_Me Model (Modified from Dorahy & Hamilton 2009)

Forming the multidisciplinary team is only one aspect of providing a multidisciplinary health care service. Developing systems and resources that ensure the team functions effectively is also essential. (15) Health professionals, by definition, are autonomous. While the need to collaborate with other professionals is recognized, the work of each professionals is structured around an independent practice. A multidisciplinary health care service will require a team-based system that may at times conflict with above systems. The geographic location of team members, the manner in which they communicate, the time given to communication and the system or remuneration requires innovative approaches to meet the needs of the client and the multidisciplinary team. (15)

Utilising teams, such an approach has been encouraged to facilitate better care for the patients and also to support a cost-effective approach. Unfortunately, this is not always possible due to a number of influences such as: lack of resources, funding, patient compliance, treatment continuity, availability of multidisciplinary team members, professional jealousy, misconceptions and misunderstandings, no clear boundaries to the different disciplines involved, isolation especially in the rural areas etc.

Conclusion

All healthcare practitioners should aspire to a holistic approach to patients and attempt to practice it. Recognizing the ‘whole’ person in the prevention and treatment of disease may hold the key to some diagnoses for doctors. It may also allow valuable and important help and guidance to be given to the patient. Patients tend to be more satisfied if a doctor takes a holistic approach, feeling that their doctor has time for them and their problems. However, in General Practice, with only 10 minutes allocated per consultation, time constraints may sometimes make this difficult to achieve.

In addition to a holistic approach, a team approach is also extremely important to the patient. There are three types of teams, namely: a multidisciplinary, interdisciplinary and transdisciplinary team. Which team will be used depends on possibility, knowledge and the patients’ needs. In a team approach the patient is the main focus and is thus the responsibility of every member of the team. The team has a responsibility towards one another to have open communication channels and mutual respect for different professions. Each member of the team should know his or her own abilities and limitations. In many articles, the outcomes of treatment with a team approach have been reported positively, with no reports of negative consequences of team intervention. Furthermore, the use of a team approach has been demonstrated in all healthcare settings across the continuum. Forming the multidisciplinary team is only one aspect of providing a multidisciplinary health care service. Developing systems and resources that ensure the team function effectively is also essential.

References

1. Smuts J. Holism and evolution. New York: MacMillian Company; 1926.

2. Erickson HL: Philosophy and Theory of Holism. Nurs Clin N Am 2007;42:139-163.

3. Bohm D. Wholeness and the implicate order. London: Routledge; 1980.

4. Bohm D, Hiley BJ. The undivided universe. New York: Routlage; 1993.

5. Entomology dictionary. Available at: http://www.etymonline.com. Accessed March, 12, 2016.

6. Wikipedija. Andrija Štampar. Available at: https://hr.wikipedia.org/wiki/Andrija_Štampar Accessed March, 12, 2016.

7. Ayurveda i integrativna medicina. Available at: http://www.ayurveda.hr/hr/ayurveda/sto-je-ayurveda-,1.html Accessed March, 12, 2016.

8. Chopra A, Doiphode V. Ayurveda medicine – core concept, therapeutic principles and curative relevance. Med Clin North Am 2002;86(1):75-88.

9. Vantegodt S, Kandel I, Merrick J. A short history of clinical holistic medicine. Scientific World Journal 2007;5(7):1622-1630.

10. Medical Ethics or, a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Thomas Percival, publish in 1803.

11. Douglas G, Nicole F. Macleod’s Clinical Examination. First edition 1964. Churchill Livingstone Elsevier

12. Nightingale F. Notes of nursing: what it is and what it is not. New York: Dover Publications, Inc.; 1969. p. 133, 117-125.

13. Von Bultzingslowen I, Eliasson G, Sarvimaki A, et al. Patients’ views on interpersonal continuity in primary care: a sense of security. Fam Pract 2006;23(2):210-219.

14. Katzenbach J, Smith D. The Wisdom of Teams: Creating the High-performance Organization. Harvard Business School Press, 1993.

15. Moore Z, Butcher G, Corbett LQ, Snyder RJ, van Acker K, et all. Managing Wounds as a Team. Journal of Wound Care 2014;23(5)/AAWC/AWMA/EWMA Document 2014.

16. Choi BC, Pak AW. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. definitions, objectives, and evidence of effectiveness. Clin Invest Med. 2006;29(6):351–364.

17. Health Service Executive, Multidisciplinary team Health Service Executive, Editor. 2013, Health Service Executive: Dublin Available at: http://www.hse.ie/eng/services/list/4/Mental_Health_Services/dsc/communityservices/Multidisciplinaryteam.html Accessed March, 12, 2016.

18. Wiecha, J. and T. Pollard, The Interdisciplinary eHealth Team: Chronic Care for the Future. J Med Internet Res, 2004;6(3):22.

19. Newhouse RP, Spring B. Interdisciplinary evidence-based practice: Moving from silos to synergy. Nurs Outlook 2010;58(6):309-317.

20. World Health Organisation, The World Health Report 2006 – working together for health. World Health Organisation.

21. Pulling toghether: the future roles and training of mental helath stuff. London, The Sainsbury Centre for Mental Health, 1997.

22. Hasler J. The primary health care team: historical and contractual farces. BMJ 1992;305:232-234.

23. Mitchel PH, Wynia MK, Golden R, et al. Core Principles and values of effective team-based health care. 2012, Institute of Medicine: Washington DC.

24. LE.C.E. Panel. Core Competencies for Interprofessional Collaborative Practice: Report o fan expert panel, 2011: Washington DC

25. World Health Organisation, Framework for action on interprofessional education & collaborative practice, Department of Human Resources for Health, Editor. 2010, World Health Organisation Geneva.

26. Dorahy M, Hamilton G. The “Narcisstic-Me” model: A conceptual framework for multidisciplinary team working, researching and decision-making with traumatized individuals. Consel Psychother Res 2009;9:57-64.

Dubravko Huljev, Tatjana Pandak
Education Institute of Emergency Medicine City of Zagreb, Zagreb, Croatia

Corresponding author:
Dubravko Huljev
Education Institute of Emergency Medicine City of Zagreb
Heinzelova 88, 1000 Zagreb, Croatia
E-mail: huljev@hitnazg.hr

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