CONCEPT OF HOLISTIC AND CONTINUOUS CARE IN FAMILY PRACTICE - JAN 2016 1.pdf

1. THE CONCEPT OF HOLISTIC AND
CONTINUOUS CARE IN FAMILY
PRACTICE
By
DR. ITA B. OKOKON
MB,BS[Ibadan];FMCGP;FWACP[Fam Med]
January 11th , 2016

2. OUTLINE OF THE LECTURE
 Objectives of the lecture
 Introduction/Definitions
 Principles of Holistic Medical Practice
 Traditional and Alternative Medicine as part of the
whole
 Issues for Consideration Regarding the Intrinsic Aspects
of Holistic Care in Family Practice
 The Extrinsic Aspects/Components of the Holism in
Family Practice
 Factors that undermine Holistic Care in Family Practice
 The Way Forward
 Conclusion
2

3. 1. Objectives of this Lecture
At the end of this lecture, undergraduate trainees in
Family Medicine would have been able to:
1. recognize the expansiveness of their grounds of
anticipated practice, and
2. possibly wake up with a greater commitment to
address those uncovered territories by
arming themselves with requisite knowledge
for deeper person-oriented approaches to
more family-friendly service delivery in the
days ahead.
3

4. 2. Introduction/Definition of Terms
“If you want to go fast, go alone; but if you want to
go far, go with others” – Mother Teresa
The Term “Holistic Care” brings together many
different theories and practices all over the world; but
all Family Physicians appreciate through their
training, that health is a positive state of functioning
and not just the absence of symptoms of disease.
The increasing universal awareness of issues of
health-care along the lines of healthy living is posing a
serious threat to the indolent doctor for tomorrow’s
patronage.
4

5. 2. Introduction/Definition of Terms
contd.
Many are aware of the place of:
- exercise
- sporting activities
- Rest
- good and healthy eating
- need to check self-indulgences with
restraint from alcohol, tobacco &
tobacco products
- Restraint on sexual matters and the like.
5

6. 2. Introduction/Definitions contd.
 Holistic Health Care has been defined as a System
of comprehensive or total patient care that considers
the physical, emotional, social, economic and
Spiritual needs of the person; his or her response to
health and the effect of the illness on the ability to
meet self-care needs.
 Holistic Medicine, on the other hand, has been
described as the art and science that addresses the
whole person and integrates conventional and
complementary therapies to prevent and treat
disease, but most importantly to promote optimal
health.
6

7. 2. Introduction/Definitions contd.
• Holistic Physicians work together to transform
health care and integrate all aspects of well-being,
including physical, environmental, mental,
emotional, spiritual and social health, thereby
contributing to the healing of ourselves and the
earth.
• What is Holistic Care Assessment?
The gathering of information and the formulation of
judgments regarding a person’s health, situation,
needs and wishes, which should guide further action.
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8. 2. Introduction/Definitions contd.
• Family Practice is the implementation of the
principles of Family Medicine by the Family
Physician.
• We recall that Family Medicine itself is the Medical
Specialty that provides Continuing and
Comprehensive health care for the individual, in a
holistic manner within the context of his/her family
and environment without prejudice to gender, age,
organ systems or disease.
• Holistic Care in Family Practice could therefore be
taken as the matching and merging together of the
philosophies of Care marshalled out above.
8

9. 3. Principles of Holistic Medical Practice
• The Practice is person/patient-centred, comprehensive,
co-ordinated and has ample elements of continuity of
care in its administration.
• Unconditional love is life’s most powerful healer.
Holistic physicians try to adopt an attitude of
unconditional love for the patients, themselves and
other practitioners.
• Optimal health is much more than the absence of
disease. It is the conscious pursuit of the highest
qualities of the spiritual, mental, emotional, physical,
environmental and social aspects of the human
experience, and the awareness of being fully alive.
9

10. 3. Principles of Holistic Medical Practice
contd.
• Illness is viewed as a manifestation of a dysfunction of
the whole person, not as an isolated event.
• Holistic physicians embrace a variety of safe, effective
options in diagnosis and treatment, including education
for lifestyle changes and self-care; complementary
modalities; and conventional drugs and surgery.
• Searching for the underlying causes of disease is
preferable to treating symptoms alone.
• Holistic physicians expend as much time in establishing
what kind of patient has a disease as in establishing
what kind of disease a patient has.
10

11. 3. Principles of Holistic Medical Practice
contd.
• Prevention is preferable to treatment and is usually
more cost-effective. The most cost-effective
approach evokes the patient’s own innate healing
capabilities.
• A major determinant of the healing outcomes is
the quality of the relationship established between
physician and patient, in which patient autonomy
is encouraged.
• The ideal physician-patient relationship considers
the needs, desires, awareness and insight of the
patient as well as those of the physician. 11

12. 3. Principles of Holistic Medical Practice
contd.
• Physicians significantly influence their patients by
their example.
• Illness, pain and the dying process can be learning
opportunities for patients as well as the physician.
• Holistic physicians encourage patients to evoke the
healing power of love, hope, humour and
enthusiasm and to release the toxic consequences
of hostility, shame, greed, depression and
prolonged fear, anger and grief.
12

13. 4. Traditional Medicine
• Traditional medicine (TM): is the sum total
of knowledge, skills and practices based on the
theories, beliefs and experiences indigenous to
different cultures that are used to maintain
health as well as to prevent, diagnose, improve
or treat physical and mental illnesses.
13

14. 4. Traditional and Complementary
Medicine
• Traditional medicine that has been adopted by
other populations (outside its indigenous
culture) is often termed: Alternative or
Complementary Medicine.
• ‘Complementary Medicine’ –involves the use
of a non-mainstream approach in patient care
together with conventional medicine.
14

15. 4. Alternative Medical Practice contd.
• Whereas ‘Alternative medicine’ – refers to
using a non-mainstream approach in place of
conventional medicine;
• Integrative medicine, on the other hand,
combines mainstream medical therapies with
Complementary and Alternative Medicine
(CAM) therapies for which there are some
high-quality scientific evidence of safety and
effectiveness.
15

16. 4. Why Complementary and
Alternative Medicine?
• Growing popularity of T/CAM.
• In some Asian and African countries, 80% of
the population depend on traditional medicine
for primary health care.
• In many developed countries, 70% to 80% of
the population have used some form of
alternative or complementary medicine (e.g.
acupuncture).
16

17. 4. Ethical Basis
• The role of traditional medicine and its providers
in Primary Health Care was recognized in Alma
Ata in 1978. The use of traditional medicine has
increased dramatically worldwide.
• There is an increasing number of countries with a
national research institute on traditional /herbal
medicines and who have also included traditional
medicines on their national essential medicines list
(Ghana is a case in point).
17

18. 4. Ethical Basis contd.
• By 2007, 48 countries had a national policy on
traditional medicine and over 110 countries had
mechanisms in place to regulate traditional
medicines.
• The World Health Organization encourages and
supports Member States to integrate T/CAM
into national health care systems and to ensure
their rational use.
18

19. 4. Ethical Basis contd.
• WHO also facilitates the exchange of
information between Member States through
regional meetings and publications.
• It assists countries in sharing and learning from
one another’s experiences to aid forming
national policies on T/CAM and developing
appropriate innovative approaches to integrated
health care.
19

20. 4. Ethical Basis contd.
Examples of publications on T/CAM include:
• Regulatory situation of Herbal Medicines: A
Worldwide Review (1998).
• Legal Status of Traditional Medicine and
Complementary/Alternative Medicine: A
Worldwide Review (2001).
20

21. 4. NIGERIA – Regulatory situation
• Informal interaction between the Government and
traditional medicine practitioners can be traced back
to the 19th century.
• However, formal legislation promoting traditional
medicine (TM) dates back to 1966 when the Ministry
of Health authorized the University of Ibadan to
conduct research into the medicinal properties of local
herbs.
• Efforts to promote TM continued throughout the
1970s in the form of conferences and training
programmes.
21

22. 4. NIGERIA – Regulatory situation
contd.
• In the 1980s, policies established to accredit
and register traditional medicine practitioners
and regulate the practice were strongly pursued.
• In 1984, the Federal Ministry of Health
established the National Investigative
Committee on Traditional and Alternative
Medicine.
22

23. 4. NIGERIA – Regulatory situation
contd.
• Similar Committees were also formed by the
Federal Ministry of Science and Technology in
1988.
• The Nigerian Medical and Dental Practitioners Act
Cap. M8 Laws of the Federation of Nigeria 1990
(“the Act”) forbids the practice of medicine or
dentistry by unregistered practitioners, specifically
the issuance of death certificates, performance of
post-mortems, or certification of leprosy or mental
disability.
23

24. 4. NIGERIA – Regulatory situation
contd.
• However, traditional medical activities are protected
by a provision in Section 17.6 and 17.7 of the Act,
which reads as follows:
– “Where any person is acknowledged by the members generally of
the community to which he belongs as having been trained in a
system of therapeutics traditionally in use in that community,
nothing in [the provisions of the Act dealing with offences] shall
be construed as making it an offence for that person to practise or
hold himself out to practise that system; but the exemption
conferred by this sub-section shall not extend to any activity
(other than circumcision) involving an incision in human tissue
or to administering, supplying, or recommending the use of any
dangerous drug within the meaning of Part V of the Dangerous
Drugs Act”.
24

25. 4. NIGERIA – Regulatory situation
contd.
• Registration requirements for chiropractors and
osteopaths are outlined in the Medical
Rehabilitation Therapists (Registration, etc.)
Decree of 1988.
• A 1992 decree created the National Primary
Health Care Development Agency with a broad
mandate concerning health matters, and
included the endorsement of traditional birth
attendants (TBAs).
25

26. 4. NIGERIA – Regulatory situation
contd.
• In 1994, all States health ministries were
mandated to set up boards of traditional
medicine in order to enhance the contribution
of traditional medicine to the nation’s official
health care delivery system.
• The National Traditional Medicine
Development Programme was established in
1997.
26

27. 4. NIGERIA – Regulatory situation
contd.
• Various measures to formally recognize and
enhance TM practice include:
 the inauguration of the National Technical
Working Group on Traditional Medicine;
 development of policy documents on TM,
including:
the National Policy on TM,
National Code of Ethics for the Practice of TM,
the Federal Traditional Medicine Board Decree, and
Minimum Standards for Traditional Medicine Practice in
Nigeria, etc.
27

28. 4. NIGERIA – Regulatory situation
contd.
• In 2000, the Traditional Medicine Council of
Nigeria Act was proposed.
• Functions of the Council include:
 facilitating the practice and development of
traditional medicine;
 establishing guidelines for the regulation to
protect the population from quackery, fraud,
and incompetence;
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29. 4. NIGERIA – Regulatory situation
contd.
 liaising with State Boards of TM to ensure
adherence to the policies and guidelines
outlined;
 establishing model traditional medicine clinics,
herbal farms, botanical gardens, and traditional
medicine manufacturing units in the
geopolitical zones of the country;
 and collaborating with organizations with
similar objectives within and outside Nigeria.
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30. 4. MDCN and CAM
• Alternative Practitioners’ Registration
• CAM practices currently approved by MDCN:
Herbal Medicine
Homeopathy
Naturopathy
Acupuncture
Osteopathy
Chiropractic
30

31. • In Nigeria, the regulatory body concerned with
herbal medicines is the National Agency for
Food and Drug Administration and
Control(NAFDAC).
• The Drugs and Related Products Act, Decree 15
in 1993 empowered NAFDAC to make
regulations concerning herbal medicines and
related products.
4. NAFDAC and CAM
31

32. • ADEQUATE AND CLEAR LABELLING
INFORMATION
• NAME AND ADDRESS OF MANUFACTURER,
PACKER OR DISTRIBUTOR
• DECLARATION OF INGREDIENTS
• TRADE MARK
• NAFDAC IDENTIFICATION NUMBER
• ADEQUATE INFORMATION ON INSERT
• WARNING STATEMENT CONCERNING USE
IN PREGNANCY AND WARNING FOR
CHILDREN
• EXPIRATION DATE
4. NAFDAC regulates these products
with regards to:
32

33. 4. Classes of CAM
• According to the National Centre for
Complementary and Alternative Medicine
(NCCAM) – a US-based agency, 5 broad classes
exist:
1) Whole medicine systems
2) Mind-body interventions
3) Biologically based therapies
4) Manipulative and body-based therapies
5) Energy Therapies
33

34. 5. Issues for Consideration Regarding the
Intrinsic Aspects of Holistic Care in
Family Practice
[A] Attitude - Professional Attitude
- Political/Administrative Attitude
[B] Knowledge – Factual Knowledge
- Tacit knowledge
[c] Circumstances – Motivating factor
- Organization
- Sphere of Activity
- Tools for Service [Gen. tools &
Specific Family Medicine
tools]
34

35. 5. Intrinsic Components of Holistic
Care in Family Practice contd.
• [A] Attitude – (i) Professional Attitude
(ii) Political/Administrative Attitude
(i) Professional Attitude – This is more significantly
ethical attitude. It is a credit to Family
Medicine that the notion is already part and
parcel of our knowledge base – the
awareness that taking the whole person is
greater than handling a sum of his parts.
- Biomedical attitude is not enough. A bio-
psychosocial attitude towards the patient is better. 35

36. 5. Intrinsic Components of Holistic Care
in Family Practice contd.
• [A] Attitude contd.
(ii) Political/Administrative Attitude – The
Family Physician in the West African sub-
Region must position himself/herself as an
advocate for the people, especially regarding
their health matters. This requires possibly the
art of making “oneself to serve as the spider in
the web” when it comes to defending the
common weal of the people on health matters
and related issues. 36

37. 5. Intrinsic Components of Holistic Care in
Family Practice contd.
• [B] Knowledge – (i) Factual Knowledge
(ii) Tacit Knowledge
(i) Factual Knowledge – In medical training, over
80% of the content derives from Biology and
natural science. Olsen et al (2000) suggested
that it is time for the academic agenda of
Family Medicine to be revised and
incorporate more influence from behavioral
sciences into both the undergraduate and
specialist curricula.
37

38. 5. Intrinsic Components of Holistic Care
in Family Practice contd.
• [B] Knowledge –
(ii) Tacit Knowledge – Tacit knowledge expresses
itself during the process of working. Successful
practice does not require factual knowledge
alone, it is also about reading patients’ feelings
and commanding social competence.
• [C] Circumstances – (i) Motivating factor –
Stranberg et al (2007) reported that functioning as an
expert generalist (Family Physician) was of itself a
motivating factor for the physician. This point
underscores the fact that commitment to one’s tasks as
a Family Physician could boost an individual’s morale
in service as well as the morale of other colleagues.
38

39. 5. Intrinsic Components of Holistic Care
in Family Practice contd.
• [C] Circumstances – (ii) Organization –
Teamwork is a factor of importance for
understanding the patient’s whole situation.
Working together, it is possible to elucidate
the patients’ situations from different angles and
this is easily seen in a flourishing Family
Practice setting where all function together for the
common good of the patient.
39

40. 5. Intrinsic Components of Holistic Care in
Family Practice contd.
• [C] Circumstances – (iii) Sphere of Activity –
There are certain aspects of Family Practice
that require having a holistic view if success in
delivery of the service is expected e.g. Child
health care, Palliative Care and in Preventive
work generally.
• (iv) Tools for the Service (Gen. Tools & Specific
Family Medicine Tools) – The Consultation and
Communication have been noted as important
general tools in forging out holistic Care. 40

41. 5. Intrinsic Components of Holistic
Care in Family Practice contd.
• [C] Circumstances- (iv) Tools for the Service (Gen
Tools &Specific Fam. Med Tools) contd. – Family
Medicine Tools have a prominent place in the
fostering of holistic Care since each tool has
direct application in the unraveling of the totality
of the patient’s problems. It is for completeness that
they are listed below:
1. The Genealogic chart 2. Eco-map 3. Timeline
4. Family Cycle 5. Family APGAR, 6. Family
Circle 7. Home visits 8. Medical Informatics
41

42. 6.The Extrinsic Components of Holistic
Care in Family Practice
• The Comprehensive nature of the Care
• The Continuity in form of the care
• Its Person-centred/Family-oriented delivery
• Family-/Environment-based care
• The Integrative outlook of the Care that is
rendered
42

43. 6.The Extrinsic Components of Holistic
Care in Family Practice contd.
• Comprehensive nature of the Care
- no specialty is exempt
- all organ systems are equally taken
- all diseases are covered
- all ages are taken – Generational Medicine
- Symptom complexes are addressed: viz -
ICPC [International Classification of
Primary Care – a classification method for
Primary Care encounter.
43

44. 6.The Extrinsic Components of Holistic
Care in Family Practice contd.
Continuity of the Care -
This specialty operates on the wheels of established
relationship between the patient and the doctor
much more than any other specialty.
- Poor adherence to chronic disease treatment, for
instance, hypertension and Diabetes, have been
noted as one result of lack of maintenance of
continuity of care.
44

45. 6.The Extrinsic Components of Holistic
Care in Family Practice contd.
• Person or patient-centred/Family oriented Care
- Care is offered to: the individual’s/patient’s
satisfaction
- family members participate in rendering the care
as well
- If the care must be in-depth then, Families not
healthcare providers must be guided to
become the primary care takers in chronic
illnesses management.
45

46. 6.The Extrinsic Components of Holistic
Care in Family Practice contd.
• Family-/Environment-based Care-
- Families are the basic-/micro- units of
Communities
-Chronic illnesses as well as mental challenges
tend to respond better when the patients
are managed in the midst of the community.
- Family Medicine attends to the above through
involvement of patients’ relations in the care
process while the physician serves as the
overseer.
46

47. 6.The Extrinsic Components of Holistic
Care in Family Practice contd.
• Incorporation of Integrative Approaches – It will be
recalled that Integrative Medicine focuses on the whole
person and makes use of all appropriate therapeutic
approaches, healthcare professionals and disciplines to
achieve optimal health and healing.
• It combines orthodox medical practice with other
therapies of proven effectiveness and safety, that is to
say, that, it combines mainstream medical therapies
with Complementary and Alternative Medical [CAM]
therapies that have evidence base of safety and
effectiveness.
47

48. 7. Factors that undermine Holistic Care
in Family Practice
 Disproportionate focus on Specialist and
Tertiary Care
 Fragmentation of Care with resultant
multiplicity of areas of attention
Unhealthy and pervasive Commercialization of
health
 Markedly increased general cost of health
48

49. 8. The Way Forward
Re-defining the Medical care calling or vocation.
Maintaining focus – Checking the temptation to
digress into areas that are not placing the patient at
an advantage in terms of the expected care.
Keeping track with Continuous Professional
Development in Family Medicine
49

50. 9. Conclusion
• Holistic Care is entrenched in Family Practice but
needs to be properly evaluated in the day-to-day
patient care or regular practice, as the days go by.
• Strandberg et al have suggested the incorporation of
the first letter: “w” to the word, for it to read:
‘wholistic’, in order to arrest the possible confusion
with Complementary and Alternative Medicine
[CAM].
• Although some authorities on CAM like Guttmacher
(2011) are already more comfortable using the word:
“Wholistic” interchangeably for their Specialty, it
remains true , however, that “holistic Care”
encompasses a wider array of territories than CAM.
50

51. Thank you.
Dr. I. B. Okokon
51

52. For further Reading
1. Stranberg EL, Ovhed I, Borgquist L. The perceived meaning of a
(w)holistic view among general practitioners and district
nurses in Swedish primary care: a qualitative study.
2. Olsen F, Dickinson J, Hjortdahl P. General Practice-time for a
new definition. BMJ 2000, 320:354 – 357.
3. Guttmacher S. Whole in Body, Mind & Spirit: Wholistic
Health and the limits of Medicine. Columbia University.
4. Guthrie B, Wyke S. Personal continuity and access
in UK general practice: a qualitative study of general
practitioners’ and patients of when and how they matter. BMC
Fam Pract 2006, 7:11
5. Udo IA, Okokon IB, Udoh SB and Akpan IV. Clinical and Socio
Demographic Profiles of Complementary and Alternative
Medicine Users among Outpatient Clinic Attendees in Uyo,
South-South Nigeria. Fam Med Med Sci Res 2014, 3:1
http://dx.doi.org/10.4172/2327-4972.1000117
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