10/28/15: CURA PERSONALIS, Care of the Whole Person, Not Just the Parts

Vitruvian man, by Leonardo Da Vinci. Public domain image.

Vitruvian man, by Leonardo Da Vinci. Public domain image.

I learned a term last week that I should have learned 40 years ago, but my education was deficient. Or, more accurately, it wasn’t a Jesuit education.

Cura personalis. The care of the whole person.

Cura personalis is a key Jesuit concept which, according to the Georgetown University School of Medicine website, “suggests individualized attention to the needs of others, distinct respect for unique circumstances and concerns, and an appropriate appreciation for singular gifts and insights.”

In the medical setting, cura personalis reminds physicians that their mission involves the health of the entire person, not just the health of the body. The whole, not just the parts. When physicians regard patients as “discrete parts,” writes University of Albany Public Health Professor Timothy Hoff, they administer to them “in an impersonal manner.” I quote Dr. Hoff in my new book, “Our Parents in Crisis: Confronting Medical Errors, Ageist Doctors, and Other Healthcare Failings.”

My father, who was a brilliant physician-scientist, but a lousy patient, used to refer to the “status of the patient,” meaning his or her well-being, the union of all of the human realms: physical, mental, emotional, spiritual. Your best doctors know, regardless of their specialty, that medicine is not simply the treatment of symptoms and diseases; medicine is the (attempted) healing of the whole person. Your best doctors attend to the patient’s over-all status, his health, even if their “ology” is about parts: the heart, the lungs, the kidneys, the prostate.

In visiting his “ologists,” Dad sometimes bemoaned the loss of status care, of “How are you?” and “How can I help you to feel better?” care. I’ll never forget what he said when we were driving away from Duke University Medical Center after a frustrating surgery-follow-up appointment in the Urology Clinic during which Dad asked for help with pain that the urological surgeon had caused, but would not acknowledge causing. My beleaguered father put it succinctly: “Basic care is beneath their dignity.”

It’s hard to find a “best doctor” these days.

**

Dr. Stephen Ray Mitchell, dean for medical education at Georgetown University, which is a Jesuit institution, used the term, cura personalis, in the context of a talk he gave last week about “The History and Future of Medicine: The New Physician.”

I have returned this fall to Georgetown’s fabulous Mini-Medical School, a community outreach program that features medical-school faculty teaching practical lessons from actual medical-school courses. Now in its 20th year, the Mini-Medical School presents eight lectures over eight weeks each fall and spring semester. The classes cover a mix of the basic sciences that a medical student typically studies (memorizes) in his/her first two years and clinical medicine, the focus of the third and fourth medical-school years. I was especially interested in this semester’s classes about radiology, otolaryngology (ear, nose, and throat), plastic surgery, and degenerative diseases.

Mitchell, who is responsible for the curriculum that develops the new physicians graduated by Georgetown, was the second-week instructor in a two-hour class that was neither basic nor clinical. I had hoped the professor would tell me who the “new physician” is, so I would better understand how to communicate with him or her. Instead, I discovered, the new physician is an ideal that Mitchell aspires to create through his curriculum. Georgetown’s new physician is a “knowledgeable, ethical, skillful, and compassionate physician” who is also a biomedical scientist “dedicated to the care of others and health needs of our society.”

To become such a physician-scientist, Mitchell believes all Georgetown medical graduates must demonstrate certain knowledge-related, skill-related, and values- and attitudes-related competencies. He knows the what and why of these 17 competencies, which he shared with us—one knowledge-related competency he cited, for example, is to “acquire, integrate, and apply knowledge of biomedical science to the care of patients”—he just hasn’t completely figured out the how-to of teaching and instilling these competencies. But he is trying new approaches and aiming high. So are other elite medical schools around the country that recognize the failings of the traditional curriculum.

Your best medical educators know all of the complaints that you and I have about today’s physicians. As I write in “Our Parents in Crisis” (p. 242) :

     If you’re old enough to remember TV’s Marcus Welby, M.D., then you know the physician ideal of the kind, wise, all-knowing, and unhurried general practitioner who listened to his patients and made house calls. That ideal, personified by Dr. Welby, has been missing in action since the 1970s.  

     An older family physician, Welby—played by actor Robert Young, the television father who knew best in the 1950s—approached general medicine with common sense and compassion, not technology and specialty knowledge. While we wouldn’t want to sacrifice technological advances and ologists’ expertise, and we no longer embrace the elite white-male archetypal physician, most of us would like our doctors to be more Welbyesque. We want professionals, not businesspeople. M.D.s with M.B.A.s in healthcare economics need not apply.  

     As Professor Timothy Hoff elaborates in his book, “Practice Under Pressure: Primary Care Physicians and Their Medicine in the Twenty-first Century”: “[Dr.] Welby sought to know and have relationships with his patients, understand the psychosocial backdrops for their illnesses, and through this connection he had the key to successful diagnosis and treatments.”

     In short, Welby cared about his patients. Besides treating their symptoms, he tried to understand who they were and how they lived.  

     R.I.P., Marcus Welby.

Mitchell essentially asked my class: How would you educate a best doctor? What qualities, traits, characteristics, competencies would you insist upon?

How would you foster in a medical student the cura personalis principle of medicine?

Think about it.

I offer a few ideas for medical-school reform in my book, and I was pleased to hear Dr. Mitchell endorse two of them: expose medical students to a variety of patients in their first two years, when students are still idealistic and eager and open to understanding people whose “stories” differ substantially from their own; and encourage college students with humanities backgrounds to apply to medical school or medical students to take humanities courses.

Medical educators are working especially hard to close the communication and empathy gap between physician and patient. Dr. Mitchell, who is a pediatrician with a subspecialty in rheumatology–studies show pediatricians and OB-GYNs tend to be more empathetic than other physicians–represented it well visually when he showed a cartoon of a doctor talking with a patient. The caption read:

     Can you please rephrase that in the form of a multiple-choice question?

**

Below is an excerpt from Chapter Ten, “2011: Concurrent Problems: Lung Nodules and Fatigue,” pp. 235-36, of my book, about specialization-induced healthcare fragmentation and the resultant destruction of cura personalis. The sentence immediately before this section is:

Whether an issue or a co-morbidity, the number of medical specialists in Dad’s life—ologists, I call them—would be expanding.

Ologists

The urologist, the cardiologist, the pulmonologist, the gastroenterologist, the neurologist, nephrologist, etcetera, and so forth, ad nauseum ologist.

The more co-morbidities your parent has, the more medical-specialty, -subspecialty, and -subsubspecialty ologists, he or she will see, and, therefore, the more likely it will become that breakdowns in healthcare will occur. Being a Mom-and-Pop advocate/watchdog becomes a matter of communicating and coordinating with “ologists.”

“Patients with several chronic conditions,” a description that fits most adults 65 and older, “may visit up to 16 physicians in a year,” writes Professor Thomas Bodenheimer of the University of California-San Francisco Center for Excellence in Primary Care, who describes coordinating healthcare as a “perilous journey.” (1)

“A patient with anything but the simplest needs is traversing a very complicated system across many handoffs and locations and players,” agrees Dr. Donald M. Berwick, then president of the Institute for Healthcare Improvement in Cambridge, Mass., in a 2006 Time magazine cover story titled:

“Q: What Scares Doctors?”

“A: Being the Patient.” (2)

Traversing is a good verb to describe patient movement within the Hydra-like U.S. healthcare system. There is a lot of crossing over and through. Multiple handoffs, multiple sites, multiple players. Medical specialization, sub- and sub-sub specialization. Such movement results in disconnection and dysfunction. Fumbles and mistakes that result in inconvenience, neglect, and disaster.

In contrast to primary-care physicians, your general internists, ologists typically focus on physiological systems, such as the cardiovascular or neurological system, not on the whole body or the general welfare of a person. In helping your Mom and Pop, you should be aware of ologists’ not-my-area-of-expertise boundaries and not count on them for more—not unless you push, and even then, they may ignore or dismiss you.

Generally speaking, medical specialization, which has enabled new and better therapies and breakthroughs in biological understanding, has spawned healthcare fragmentation: Each ologist attends to only one “fragment” of your Mom’s or Pop’s healthcare, and no systemic oversight exists to ensure care coordination and continuity among them. If you think that your Mom’s or Pop’s primary-care physician has the time, much less the incentive, to coordinate her/his care among multiple ologists, think again.

Modern U.S. healthcare is a multi-specialty-compartment locomotive that conspicuously lacks a dedicated conductor or even assistant conductors to keep the passengers informed and on track. The passenger-patient and his/her advocate must conduct the train.

Among the fundamental lapses that occur in our fragmented healthcare system: “Referrals from primary care physicians to specialists often include insufficient information,” writes Professor Bodenheimer, “and consultation reports from specialists back to primary care physicians are often late and inadequate.” You also can expect multiple errors in the consultants’ reports, some of them initiated by the PCP!

Your Mom’s and Pop’s visits to multiple healthcare providers, Bodenheimer warns, can result in “wasteful duplication of diagnostic testing [running up costs], perilous polypharmacy, and confusion about conflicting care plans.” (3) I can, and will, attest to all of these systemic failures.

A breakdown in care coordination can occur not only among multiple and diverse providers, including all physicians, diagnostic data sources, and emergency departments, but between physicians and their patients and their families. Bodenheimer cites studies showing that up to 50 percent of ALL patients, not just those with an impairment that affects their comprehension, such as deafness, leave an office visit with their doctor not understanding what they were told; and 75 percent of physicians do not routinely contact patients about normal diagnostic test results. (4)

Sound familiar?

1. Thomas Bodenheimer, “Coordinating Care—A Perilous Journey through the Health Care System,” New England Journal of Medicine 358 (2008): 1064.

2. Nancy Gibbs and Amanda Bower, “Q: What Scares Doctors? A: Being the Patient . . . What Insiders Know About Our Health-Care System That the Rest of Us Need to Learn,” Time, April 23, 2006, at http://content.time.com/time/magazine/article/0,9171,1186553m00.html.
3. Bodenheimer, “Coordinating Care—A Perilous Journey through the Health Care System,” p. 1064.
4. Ibid, 1065.

©2015, Ann G. Sjoerdsma

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