Toward Person-Centered Medicine: from Disease to Patient to Person Juan Mezzich, MD, Phd,1 Jon Snaedal, MD,2 Chris Van Weel, MD, Phd,3 and Iona Heath, MB, Bchir4
Total Page：16
File Type：pdf, Size：1020Kb
MOUNT SINAI JOURNAL OF MEDICINE 77:304–306, 2010 304 SPECIAL FEATURE Toward Person-Centered Medicine: From Disease to Patient to Person Juan Mezzich, MD, PhD,1 Jon Snaedal, MD,2 Chris van Weel, MD, PhD,3 and Iona Heath, MB, BChir4 1World Psychiatric Association President, 2005-2008 2World Medical Association President, 2007-2008 3World Organization of Family Doctors, 2007-2010 4Royal College of General Practitioners President, 2009-2012 Throughout its history, medicine has struggled with However, despite this definition, the attitudes the ambiguity between that which human beings and practice of much of modern medicine have hold in common and that which is unique to each become profoundly disease focused and organ spe- particular individual; between that which is shared cific with ever-increasing specialization. The benefits by all those with a named disease and that which of scientific progress on disease and innovative treat- is unique about each person’s illness experience. ment technologies may be squandered and hindered Early traces of the contemporary debate about the if they are not accompanied by understanding of the human face and soul of medicine can be found in patient’s concerns and needs.3 Subspecialization has the Sanskrit term for health, hal, meaning wholeness, often led to fragmentation and compartmentalization as well as in the Ayurvedic and Chinese medical of care. Ever more pervasive commercialization4 has traditions, ancient but still practiced. These traditions tended to render medicine a privilege and a commod- focus on the patient’s total health rather than simply ity rather than a human right, and has emphasized on disease, and attempt to articulate a comprehen- what can be packaged at the expense of what is sive and harmonious understanding of health while subtle or intricate in health care or human develop- promoting a highly personalized approach to the ment. Impaired and weak communication between treatment of specific diseases and to the enhancement clinicians and patients has constrained understand- of well-being.1 Similarly, the roots of the Western ing and collaboration and undermined the effective medical tradition–Platonic, Aristotelian, and Hippo- coordination of health care. A narrow and rigid cratic–involve a holistic perspective, according to focus on evidence-based practice has marginalized which if the whole is not well, it is impossible for the the values and aspirations of patients seeking help.5 part to be well.2 Remarkably, the modern definition Effective attention to comorbidity demands care of health enshrined in the World Health Organiza- that is person centered6 and relationship based.7 tion’s (WHO) 1946 constitution remains congruent The limitations of disease-specific approaches in with traditional aspirations and refers to a dynamic the context of the growing prevalence of comor- state of complete physical, emotional, and social bidity are becoming more obvious.8 In response well-being, and not only the absence of disease. to these problems and limitations, several clinical developments have started to emerge, including the engagement of biopsychosocial concepts and the integration of health and social services as well Address Correspondence to: as initiatives on fully personalized medicine, on Juan Mezzich the ‘‘recovery’’ of the whole person, and on the Professor of Psychiatry ‘‘healing relation’’ between clinician and patient.7 Mount Sinai School of Medicine As a result, the biographical and social contexts of New York, NY the patient’s condition with attention to personal, Email: [email protected] family, and carer resources are receiving increasing attention. Published online in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/msj.20187 2010 Mount Sinai School of Medicine MOUNT SINAI JOURNAL OF MEDICINE 305 Personalized and contextualized care is becom- disease management), by the person (with clinicians ing a major demand, in line with the dictum of the extending themselves as total human beings with philosopher Jose´ Ortega y Gasset: ‘‘I am I and my high ethical aspirations), and with the person (in circumstance.’’ Critically, contextualization encom- respectful collaboration and in an empowering man- passes cultural diversity as well as spirituality. Respect ner) summarizes a valuable response from the World for the patient’s autonomy, values, and dignity repre- Psychiatric Association through an initiative on Psy- sents a fundamental recognition of his or her person- chiatry for the Person,14 recently endorsed by the hood and an ethical imperative.7 To illustrate, respect World Federation for Mental Health with its profes- for the person behind a dementing illness is being sional, patient, family, and advocate constituents. considered essential to an unprecedented extent, To bolster this process, the above-mentioned persuasively prompting person-centered care.10 Also organizations started collaboration with the World crucial for clinical care is engaging patients thought- Federation of Neurology, the World Federation for fully, individually and in groups, including those Medical Education, the Council for International critical of doctors, so as to reaffirm the dialogic Organizations of Medical Sciences, the International basis of the medical profession.11 In parallel, there Council of Nurses, and the International Alliance of is renewed attention to the person of physicians and Patients’ Organizations, among other bodies. This other health professionals, involving promotion of resulted in the first Geneva Conference on Person- their wellness and their cultivation as whole persons Centered Medicine, in May 2008,19 followed by well grounded on science and ethically committed to the Second Geneva Conference in May 200920 and careandtohelp. the Third Geneva Conference scheduled for May Slowly, these concepts are finding their way into 2010 with an even larger number of cooperating evidence.12 And it is important to explore this further international bodies. Among these, of particular note, to strengthen the perspective’s scientific base, and in has been the WHO, which, on the basis of the particular to build on the importance of empathy and latest World Health Assembly’s21 strong endorsement 13 the physician-patient relationship and of treating of people-centered care, has become a major co- 3 patients as worthy ends rather than as means. All organizer of the Geneva conferences. Emerging from these trends seem to argue that a more comprehen- this process and now coordinating it and undertaking sive, holistic, and person-centered perspective, com- new initiatives is the International Network for bining science and humanism, is needed to enhance Person-Centered Medicine.22 14,15 and reinforce the foundations of medical care. We call upon other scientific societies, academic Global health and medical organizations are institutions, and public organizations in the medical beginning to respond to this agenda. The World Med- and health care field for support and collaboration in ical Association has an enduring concern for the pro- building a person-centered medicine dedicated to the motion of medical ethics reflected in the development promotion of health as a state of physical, mental, and periodic review of its well-recognized Declara- social, and spiritual well-being as well as to the tion of Helsinki. It recently published the exemplary reduction of disease, and founded on mutual respect 16 book of profiles Caring Physicians of the World, for the dignity and responsibility of each individual and its leaders are often speaking on the obligation person. We are keen to extend the focus of medicine 17 to respect human values. The World Organization from disease to patient to person by articulating of Family Doctors (Wonca) and its national coun- science and humanism and gaining better insight into terparts have a well-established commitment to the how the different dimensions of the person-centered holistic care of patients in the context of family and approach affect the process and outcome of care, and 7 community. Family physicians have been recently working respectfully with our patients toward every expanding their professional approach from patient person’s greater health and life’s fulfillment. centered to person centered, perceiving the latter as more effective and relevant to clinical responsibilities that include prevention and health promotion.18 Nowhere has the tension between a reduction- DISCLOSURES istic focus on disease and the consideration of the Potential conflict of interest: Nothing to report. whole person been more apparent than in the men- tal health field. The promotion of a psychiatry of the person (of the totality of the person’s health, REFERENCES including both ill and positive aspects), for the per- son (to assist in the fulfilment of each person’s 1. Patwardhan B, Warude D, Pushpangadan P, Bhatt N. health aspirations and life project, and not merely Ayurveda and traditional Chinese medicine: a DOI:10.1002/MSJ 306 J. MEZZICH et al.: TOWARD PERSON-CENTERED MEDICINE comparative overview. Evid Based Complement Alter- 12. Di Blasi Z, Harkness E, Ernst E, et al. Influence of con- nat Med 2005; 2: 465–473. text effects on health outcomes: a systematic review. 2. Christodoulou GN, ed. Psychosomatic Medicine.New Lancet 2001; 357: 757–762. York, NY: Plenum Press; 1987. 13. Van Os TW, van den Brink RH, Tiemens BG, et al. 3. Heath I. Promotion of disease and corrosion of Communicative skills of general practitioners augment medicine. Can Fam Physician 2005;