Canary Wharfnew

www.drmikesheldon.com

With links to my Sheldon Genealogy pages and Whole Person Medicine

 

  :

Return to YWAM MA Index

YWAM MA Resources 2

 

Applying whole person principles in health care

The whole person assessment leading to a whole person diagnosis

Dr Michael Sheldon

All the heart of all therapeutic interventions in health care stands the art and the science of making an accurate and complete diagnosis. No treatment can be effectively applied before a satisfactory diagnosis is made. Sometimes this has to be incomplete or provisional and then reviewed as time passes and interventions are made. A doctor will often use therapy as a trial of a diagnosis, although this is less preferable than making an accurate diagnosis in the first place. In order to make a satisfactory diagnosis a full assessment must be made of the patient’s health. This involves combining the physical, psychological and spiritual assessments which are necessary in order to make a whole person diagnosis leading to effective therapeutic interventions.

Undertaking this full assessment may take more than one therapist and more than one consultation to complete. In most general practices there are now counsellors who are more able to elicit a psychological history, although they rarely work as an integrated team with the other medical professionals. They receive patients by referral and then use confidentiality to resist any sharing of information with the referring doctor. An increasing number of Spiritual Care advisors are also being employed within practices to specifically elucidate and help with the spiritual aspects of health care. The issue of using different medical professionals to gather all of the assessment together will be covered later in this chapter. We will also discuss the three modes of whole person information gathering:
 
Full whole person assessment using three therapists, and therefore taking several sessions with the patient.

Brief assessment taken by a doctor or therapist within an extended consultation, so taking around 20 to 30 minutes.
 
The 10 minute “quickie” assessment which can be conducted within the busy every-day life of most doctors.

 

The Physical Assessment

Most doctors will probably assume that undertaking the physical part of a whole person assessment is the easiest of the three. We may be a bit hesitant about the psychological and spiritual assessments, but the physical is what we are trained to do. However, it is my belief that even experienced doctors don’t do it very well! Because our training is mainly in the scientific reductionist method of medical practice most doctors find it quite hard to take the physical history in a whole person way. We may have a communications skills course in the undergraduate programme, but most students still prefer to look at the investigations and imaging of the patient’s body rather than listen to their story.

It will take more time to conduct a full assessment, and time is the one thing which seems to have been stolen away from doctors (of course I can only speak from my personal experience within the British NHS system).

Traditionally the purpose of the physical assessment is to enable the doctor to elicit all of the symptoms and signs from the patient, sort them out so that they fit into one of the disease patterns he or she has been taught and so make a “correct” diagnosis from which suitable treatment can be chosen. Within this diagnostic process there are several myths which have stood the test of time and still affect the process today.

 

Medical myths around diagnosis

The doctor starts each consultation with many assumptions and beliefs, most of which are subconscious. These assumptions drive and determine much of what goes on in the next 10 to 20  minutes during which such important conclusions will be drawn. Some of these beliefs include:

  • One pathology: most doctors have been taught about Ockham’s Razor which may be summarised as always seeking the simple answer. We are told to look for one diagnosis that will bring all of the symptoms together, rather than have two or three diagnoses. This results in the temptation to ignore those findings which don’t fit into a single pattern.
  • Cause and effect: there is a linear progression from underlying pathology to effects experienced by the patient and demonstrable on physical examination. For every physical symptom or sign there will be an underlying cause.
  • Physical causes: there exists a sort of dualism where physical pathology is alone assumed to be of importance, and the meta-physical area of feelings, emotions and attitudes can be separated off and so excluded from the diagnostic process. The holy grail for the doctor is not to discover the patient’s experience, but the physical causes that underpin the whole illness process.
  • Pattern recognition: when faced with an overwhelming amount of information the doctor slips into pattern recognition mode seeking to fit “facts” into known patterns of pathology. This means that the doctor can see what she expects to see rather than what is actually there.
  • Illness Categorisation: the illness experience of the patient is often categorised into one of the following groups, in order of importance –
    • Major, acute, life-threatening condition needing urgent attention. These are the vital pathologies that the doctor must not miss as the patient’s life and future well-being may depend on timely interventions. Most doctors have these conditions in the front of their minds, as the consequences of missing such diagnoses can be catastrophic.
    • Major chronic condition needing long term care. These will include conditions such as asthma and diabetes which can be life-threatening and need on-going medical interventions. Much of the medical professionals time is spent treating these conditions in order to limit mortality and morbidity.
    • Minor, self-limiting condition. These would include most of the minor infections which each person will acquire several times a year, and which will usually resolve if left alone. However these take up most of the time in general practice as fewer patients have the confidence to manage these conditions.
    • Minor chronic condition, often only needing adaptations by the patient. These will include the wear and tear we all experience as we go through life, and the minor long term illnesses such as hay fever and allergies which can be a nuisance but are not life-threatening.
    • Trivial, everyday symptoms often produced without underlying pathology. These would include the sort of symptoms most people get every day with indigestion, aches and pains, tiredness etc, all of which may be part of the human experience and not evidence of mal-functioning. Such symptoms are experienced but ignored by many people, but examined by the anxious patient and engendering fear in some patients.

 

In any health care system there are also constraints which put pressure upon the doctor as this diagnostic process is undertaken:-

  • Time is nearly always limited in clinical practice. Taking a fuller history and including other elements such as the patient’s beliefs and fears adds to the time needed for any assessment. As the science of medicine has progressed, so the importance of the history has diminished and the time spent talking to the patient has been eroded. This trend will need to be reversed in a whole person approach, as the issues surrounding the individual patient make up a greater proportion of the concerns which the doctor has to deal with.
  • Greater medical knowledge has produced a myriad of specialised doctors who concentrate on smaller and smaller parts of the whole. In order to manage my heart condition I have to visit three specialists – one to control my anti-coagulants, one to deal with my arrhythmias and a third consultant to deal with the underlying ischaemia. The danger with this approach is that the patient as a person falls through the middle and no one professional puts the whole person together. Traditionally, of course, this would have been the General Practitioner, but further erosions within our health care system means that having a full-time regular doctor practising continuity of care is an increasing rarity.
  • “A picture is worth a thousand words”. The advances in imaging have led to the situation where the doctor places more reliance of pictures and investigations rather than on the patient’s story. A patient with a headache is less likely to have a full history taken and more likely to have a scan to arrive at a diagnosis. There are two dangers in this approach. Imaging and investigations have their cost, both economically and to the health of the patient, and second the value of the story is diminished and the physical nature of illness is enhanced.
  • Expertise of the patient. We have encouraged expert patients, especially in managing chronic conditions. However most health education seems to concentrate on encouraging patients to undergo screening tests to detect illness early, rather than a sensible understanding of how to deal with self-limiting conditions, and when to seek further help from the medical professionals.

 

There are five main aspects to conducting a satisfactory physical assessment –

Taking the history from the patient.
Hearing carefully the patient’s story about their health and illnesses is at the heart of a complete assessment of the patient. The art of history taking may have suffered as the importance of investigations has risen, but I still believe in the importance of what one of the old physicians who taught me medicine half a century ago said “If you let the patient talk they will usually tell you what the diagnosis is”

Looking first at the traditional way of taking a history we are taught to divide up the history into following categories which enable the doctor to obtain information in the way best suited to the medical model.

 

The Traditional method of history taking
Most doctors are taught that the basic model of history taking should follow this pattern, which may be adapted in special circumstances (such as when the patient is unconscious and the history has to be taken from another person).

CO     Complains Of:                   these are the symptoms the patient now complains about
HPC   History of present complaint         the history of these symptoms, when they started, the severity and nature, associated symptoms etc.
PH      Past History                      a complete past history of relevant diseases, operations and medical events
DQ      Direct Questioning            a series of direct questions from the doctor checking to see if other symptoms are present and not already mentioned
SH       Social History                             details of work, family and social background

 

  • Patient complains of – an attempt to allow the patient to express in his own words what are the symptoms he is experiencing. This hopefully open-ended start to the consultation should allow the patient to describe the symptoms which are important to them.
  • History of present complaint – now the doctor goes into a more doctor centred enquiry to gather details of these symptoms, how long they have been there, what is associated with the symptoms etc.
  • A past history – usually fairly brief and majoring on previous medical encounters and the conclusions reached by other doctors. The compliant patient has remembered the diagnoses given in the past and is able to recite these back.
  • Some direct questioning by the doctor seeks to elicit and “hidden” symptoms which may be relevant but which the patient hasn’t mentioned. Most doctors have a personal check list and they fire questions at the patient, most of them having no relevance to the patient’s complaint.
  • Finally a brief social history is taken to elicit the patient’s context and level of social support.

 

Most of this model is doctor centred and involves the patient answering the doctor’s questions. This model is therefore to a large extent doctor centred and doctor-led, with the patient supplying information in answer to the doctor’s agenda and thought patterns. Most patients get used to this model and fall in appropriately, but it is not ideal and can often cover up important information which is necessary for diagnosis and management. I still remember the old physician who taught us clinical methods who had the memorable phrase “Let the patient talk for long enough and they will always tell you what is wrong”.  Of course we laughed at him (behind his back naturally) because we knew that the real diagnosis could only be made after performing the correct investigations, and we didn’t want to waste our time talking to the patient. However there was much truth in his wisdom, and letting the patient talk is at the heart of a whole-person approach.

The following method of obtaining a whole person history provides a skeleton from which the doctor can base his or her own method of “hearing the patient’s health story”.  It is important to remember that this history is patient centred and patient led, but the doctor takes an active part and inter-acts with the patient to draw out important details.

Whilst in a new patient this is likely to take slightly longer than the traditional method of obtaining a history it is much richer in information which is of use when diagnosing and managing a particular patient.

I find that one hour is more than enough for a complicated history where the patient has consulted with many doctors previously, and it may be spread over more than one occasion if required. On many occasions I have undertaken a complete history and relevant examination in a whole person way in 15 to 20 minutes. I don’t think it can be done satisfactorily in less than this unless the problem is very simple.

The whole person “her-story” taking can be divided up as follows –

  • Introduction  - a brief scene setting interaction to ascertain what the main problems are, how many the patient wants to deal with, and why they have presented now, that is what was the deciding factor to “medicalise” their problems at this time. The doctor may need to negotiate at this stage as to what will be tackled and in what order.
  • Problem description – a patient-directed and open-ended period where the doctor enables and facilitates the patient to adequately describe the issues, problems and complaints they have. Encouragement can also be given to explore the meaning of these problems to the patient, and what the patient’s beliefs are about them. Especially try to find out what other people have said about the problem as this may have influenced the patient’s beliefs and behaviour.
  • Feedback to complete understanding – the doctor has been attentive during the patient’s dialogue and now explores the problem by sympathetic questioning. The doctor can be quite direct in the questions asked and the following dialogue may be considered typical –
    • Dr:  So Mr G you have had odd stomach pains for about 6 months and unexplained bouts of diarrhoea for 4 months. Why did you wait until now to come and see me?
    • Mr G: I was afraid it might be cancer, you see my father had the same symptoms.
  • Elaboration of complaints and health issues – this takes the place of direct questioning and consists of invitations for the patient to describe any other complaints or odd events out of the ordinary.
  • Clarification – this lead to a process of clarification where the doctor explores any aspect of the complaints which are not clear.
  • Summary – finally the doctor summarises the history in medical shorthand with any additional patient centred aspects which have been discovered.

 

 

Whole Person method of History Taking

Introduction             Open the relationship and invite the patient (with open-ended questions) to recount what has made them come at this time.
Problems                Patient is invited to tell the story of each of their health problems in their own words. They are then invited to prioritise them.
Feedback                The doctor feeds back to the patient what he or she has heard so that the patient can check and add anything else they have forgotten.
Elaboration             Invite the patient, in an interactive way, to complete the story of each of their problems.
Clarification             Final chance for the doctor to ask any clarification questions, and add any questions which may be relevant (in line with the old Direct Questioning).
Summary                Final summing up by the doctor at which the patient can add any corrections

 

Whilst listening to the patient’s story the doctor has made sure that –

  • They have facilitated the patient to tell the whole story
  • Demonstrated empathy to build up a trusting relationship
  • They haven’t over-medicalised the patient’s issues
  • Picked up both verbal and non-verbal clues
  • They don’t focus down too soon, but keep an open mind
  • List problems at this stage rather than trying to make diagnoses

 

Accurate Observation of the patient

One of the greatest gifts of a doctor is the ability to observe through actions, words and the whole range of non-verbal communication.

 

Her own observation of the patient’s mood and health status as the history is being taken. The good doctor develops a “pattern recognition” sense which is often sub-conscious but allows further questioning and investigation to arrive at a correct diagnosis.

 

 

Past knowledge of the patient

This is of great importance when the patient’s problems are a combination of physical (especially chronic conditions), psychological, social and spiritual. However be aware that “familiarity breeds contempt” which means that the doctor can be fooled into thinking that he knows the patient and so stops listening. Often the patient will develop new conditions which are masked by the old familiar ones.

 

Past knowledge of the patient. Many doctors have the benefit of being involved in a continuity of care situation where previous knowledge and understanding of the patient can increase the chances of arriving at the correct diagnosis. Of course too much familiarity may mean that vital information is ignored and so developing situations may be missed. One of the most embarrassing moments of my professional life came as I was leaving my single handed country practice to move on to “better things”. One of my regular patients had been very ill and was almost bed-bound. I had spent many hours trying to make her better, with limited success. As I made my farewells she sighed “How can I manage without you doctor, you have looked after me so well”. A few months later I bumped into her in the town, walking along quite sprightly. I stopped in astonishment and commented on how well she looked. She replied “Oh, yes doctor, I am completely well now. As soon as the new doctor arrived he sorted me out, put me on some treatment, and now I am completely cured”.

 

The physical examination

This is an important time for gathering more information from the patient. It can enhance the level of trust as the doctor asks permission to examine and explains findings to the patient as they go along.

The method of conducting the examination would be the same as in the traditional medical model.
Results of a physical examination skilfully carried out, followed by relevant investigations.

Context of the encounter

Awareness of the current context of health in the community

The doctor conducts all of the above assessment taking into account the following –

  • Age and sex of the patient which makes some conditions more or less likely
  • Genetic background of the patient which may pre-dispose to some conditions
  • Life-style, wealth, habits such as smoking in the family which may affect health
  • Community conditions and infections to which the patient may be exposed.

 

So that completes the physical assessment of the patient, although in reality the other aspects of assessment (psychological and spiritual) have been going alongside this process. For example when conducting the physical examination, a doctor may discover much about the feelings, fears and experience of the patient.

This is the everyday experience of all doctors and health care professionals – the detailed psychological and spiritual assessments which follow will be outside the experience of most doctors, however we will include a brief assessment process which can be added to the above physical assessment to complete a “whole person health assessment”, and so enabling a suitable set of diagnoses to be made.

 

 

The Psycho-social Assessment

Taking a psychological and social history is best conducted by a counsellor or other therapist who has basic counselling skills. Medical professionals can undertake this task but they will need to set aside enough time to allow the patient to talk and perform the basic skills of listening and reflective questioning.

The main purpose of this assessment is to look at life events and inter-personal relationships to understand their bearing on the causation and continuation of health problems.

It is often useful to prepare the patient before this session by giving them some homework to complete and bring with them. Telling them in advance that the sessions will concentrate on two activities – the life-line and the map of relationships, will help them to be prepared for the session.

This whole process is an ongoing one involving self-discovery and empowering of the patient in an atmosphere of valuing, care and encouragement. It is important to guard against focussing down too soon. It is easy to jump to conclusions too soon and in the end waste a lot of time and resource in the long run. Conclusions should be made after the session, and a feedback consultation arranged after a few days, which also gives the patient time to reflect on the process as they will then usually come up with further insights.

 

There are two basic tools which may be used to facilitate the patient’s story -

    • Life-lines
    • Significant people/support networks

Other additional questionnaires and counselling tools may also be used as appropriate.

 

 

Life-line

  • Timeline starting from birth.
  • Key episodes in their lives are represented by peaks and troughs, symbols, words and numbers.
  • Tell their story as they go along.
  • Having talked through the basic approach with the patient - the patient is asked to draw a timeline starting from their birth.
  • Key episodes in their lives are represented by peaks and troughs, symbols, words and numbers.
  • A generous amount of time is designated for the patient to complete this. It is a flexible, organic, non-directive approach.
  • It certainly seems to help people open up and talk about themselves more than if they were responding to a list of predetermined questions.
  • I also think the process helps to build up the patient’s confidence and trust in the counsellor who enables the patient to express and explore the emotions attached to individual items on the life-line.

 

 

Two examples of life-lines

 

picture1

 

picture2

 

Listening and watching
To see how the story is told
-changes in body language
-shifts in mode (adult, parent, child)
Reflecting back and asking appropriate questions

 

 

Significant people/support networks

  • Patient draws a circle representing themselves.
  • Other circles are drawn at varying distances to  represent significant people
    (+ve and –ve)

 

 

picture3

 

The patient is asked to draw a circle representing themselves. They are then asked to draw other circles at varying distances from their own circle to represent significant people and their relationships to the patients whether positive or negative including friends, family, colleagues other carers.
The patient is asked to talk about these various relationships as they draw the network of significant people in their lives. As with the lifeline particular attention is paid to body language and how they talk about the various people who have had a significant influence in their lives.

  • Emotional, medical and spiritual
  • Sequences
  • Repeating patterns
  • Triggers
  • Significant events
  • Significant people

 

It will come as no surprise to you that there is considerable overlap between the information obtained by the doctor, chaplain and counsellor. But each will come with information obtained from their particular perspective. I find I pick up a lot of information about health and faith issues. For instance with regard to faith issues – get an idea of its emergence, development and relative importance to the individuals and whether it has been a help or whether it has been blocked in some way. It becomes obvious that certain religious beliefs or episodes have had a negative influence.

I pay particular attention to the sequence of particular events. Very often there will be repeating patterns and sometimes particular triggers can be identified for episodes of ill-health.  It is here that I pick up strong links between the emotional and physical health of an individual. I will be giving some examples of what I mean. Then there are the associated negative/ positive beliefs, thinking patterns, emotions and behaviours.

As well as ongoing dialogue with the patients there is the ongoing communication with the other team members. Together we begin to make connections, develop a shared understanding, and identify further areas for exploration. Gradually we start to build up a picture of the patient’s experience of life and dis-ease.

Personality questionnaires
-client is helped to identify their strengths and weaknesses
Specific questions
-a list of questions to fill any gaps in the information already gathered. These questions may be selected from a master list or designed with specific details in mind.
Counselling assessment ratings
-the counsellor may quite early on fill out a ratings questionnaire- circling numbers on a scale from 1-5. At the same time or later on in the process the patient may be asked to fill out their own questionnaire.
Looks at things like:
Self-esteem
General attitude to life
Openness and motivation to deal with issues and work towards change
etc.

 

Assessment of Spirituality

In our Whole-Person Clinic we have conducted a spiritual assessment as the third window in which to view the person’s health status (after the physical and psychological areas have been explored).  The content of this assessment is based loosely on a seven layered model of the human spirit, each of which needs to be explored, and of which only the seventh layer is directly concerned with the patient’s religious experiences.

Spiritual assessment – interview structure according to context

In undertaking a spiritual assessment we need to first understand the setting in which this assessment is taking place. In an acutely ill person only a few simple questions may be appropriate in this area (the “Quickie” assessment described below). In a routine GP or out-patient consultation it may be helpful to undertake a basic three minute assessment which can highlight problem areas which may need to be explored further, either by the doctor or by another health care professional such as a counsellor. In a patient with diffuse symptoms, a chronic or a multi-factorial disease presentation, it may be appropriate to undertake a full spiritual assessment which could take up to an hour or more. We will highlight these three approaches and indicate how such an assessment may be undertaken. In addition we could also use a self-administered questionnaire – with mainly open type questions for the person to consider before the first “spiritual window” interview.

 

In the full assessment each of the seven layers would be explored, preferably in the order presented below so as to leave religious issues to the end.  It would be important for the interview to be flexible and adapted to the patient’s needs and responses. There is of course a large overlap with the psychological and social areas of the person’s life so the first three spiritual levels may be well covered in other parts of the history, however all levels are discussed here for the sake of completeness. The long list of topics mentioned in the full assessment will act as a checklist for a semi-structured interview which will seek to explore the most important of the areas below.  The actual interview will be driven by the health needs of the person and their attitudes and responses. In real life only a fraction of the topics may be covered, some in greater depth than others.

 

The seven layers of the human spirit as they impact on health are –

  • Relationship with one-self
  • Relationships with others
  • Relating to society and the world around
  • Ethics and morality
  • Purpose and meaning in life
  • Belief systems and faith
  • Religious experience and practice
  

1   RELATIONSHIP with ONE- SELF

 

Each person is a unique individual – thus the development and expression of that identity and person-hood may be explored in three ways –

  • Understanding of self
  • Image of self
  • Process of maturity in self

 

  • Understanding of self
    • What are the person’s strengths and weaknesses?
    • How has the person developed gifts of creativity?
    • What is the personality, and how does this relate to character?
    • Look at levels of self awareness (One of the tools we need to have for patients)
  • Self-Image
    • Need to make a nice summary here of self-image work.
    • Ability to accept and use constructive criticism
    • Ability to appropriately use self- criticism

 

  • Process of maturity in self
    • Quality of ability to learn through experience
    • Attitude to failures
    • Approach to suffering
    • Locus of control and sense of coherence
    • Appropriate attitude to their stage in life
    • Ability to adapt to circumstances
    • Coping strategies in health

 

2   RELATIONSHIPS with OTHERS

The second layer of the human spirit is involved in relationships.  We are made to relate widely and the quality and usefulness of our relationships may be considered as a spirit led activity. Our relationships will include family, friends, people we interact with socially and strangers.

In each of these four areas we need to explore the –

  • Number of people in a good relationship with the person
  • Quality of relationships
  • Ability to deal with conflicts and disagreements

In the psychological assessment we usually get the patient to draw a simple map of the important relationships in their lives This can be built upon in this section particularly looking at the ability to give and receive love, the help and support given to the person by these relationships, and looking at any relationships which drain and weaken the person’s spirit and therefore health status

  • Family

Some people have large extended families and others are almost alone. It is useful to explore in ways in which the relationships they have with family members contribute positively or negatively with their health status in the widest sense.

  • Friends

Explore the number of close friends and ways in which the person can draw from them in positive ways. Look at the ability to discuss issues in an open way, to encourage comments and criticism from friends, and ways in which differing opinions are resolved.

  • Social contacts

Look at the social support network of the person through work or leisure activities. Are there unresolved and important conflicts with others?

  • Strangers

How does the person relate to important people in their life with whom they have no relationship, such as politicians and people with authority over them. Are they able to show compassion and mercy towards people in need, and how threatened are they by other people around them. When in conflict situations do they have the skills of peace-makers?

The questions and approaches we can use to explore these areas would be outlined as follows –

 

3   RELATING TO SOCIETY and THE WORLD AROUND

 

Human being may be considered as having a duty and responsibility to react responsibly in the society and culture in which they live, and also to exercise restraint within the wider world – to control ourselves and our actions in a constructive way. In short how does the person relate to the society in which they live and the world around them?

Cultural issues – upbringing, living in a foreign culture, ability to make changes and adaptations
Place of early and continuing education – a lifelong learner – or fixed in their ways?
Place of work and leisure, life/work balance
Stresses in life – what caused by and how they deal with them
Attitude to people in need, those less fortunate than themselves

 

4   ETHICS and MORALITY

Our conscience enables us to have a personal morality and a set of ethics to guide our actions and behaviour.

  a)     The conscience

  • Do they set too high standards for themselves?
  • Is the conscience weak?
  • Any problems?

  b)     Basis of personal ethics

  • What is  their world view?
  • What is their ethical stance on common issues?

  c)     Nature of moral decisions taken

  • How do they put their ethics into practice

 

 

5   PURPOSE and MEANING in LIFE

We each need to have a sense of purpose for our lives, and also the will-power to see us through the difficulties and challenges.

  a)     Hope for the future

  • What plans do they have for the future?
  • Do they have hope?
  • Have there been shattered hopes in the past?

  b)     Desires of the heart

  • What are the desires of their heart?
  • Dreams and aspirations
  • What plans to bring them to pass

  c)     Priorities in life

  • How do they place personal needs, family, work and ministry
  • How do they go about the decision making process?
  • Do they involve relevant others in decision making?

  d)     Fulfillments

  • What successes have there been in their lives?
  • Have they turned failures into successes
  • Do they have bitterness towards others
  • How do they view themselves – as a failure or a success
  • What areas of their lives have been successful?

  e)     Understanding of the purpose of life – their personal theology

 

6   BELIEF SYSTEMS and FAITH

 

We all have a well developed set of beliefs – many derived subconsciously from our upbringing and culture.  Faith may be considered as putting belief into action – we all have to have faith to enable us to put our trust in people and things with which we interact on a daily basis.

Areas to explore include –

  • Belief systems they inherited from their upbringing, and how these have changed over time.
  • Specifically their belief system regarding health and illness
  • When ill what do they put their faith in – self-help, doctors, medication etc.
  • Do they have a belief in God or a divine being who is supportive to them.

 

 

7   RELIGIOUS EXPERIENCE and PRACTICE

Finally we come to their personal understanding of the Divine and their relationship with God. Many patients will consider themselves religious in some way, and in most multi-cultural societies we will need to be comfortable talking about several quite different religious traditions. It will be important to allow the patient to express their religious feelings in the way they are comfortable, even if it is outside the experience or belief of the doctor. Clearly this can present difficulties and so we increasingly recommend the use of trained spiritual care advisors who are able to make a spiritual assessment suitable for all patients, including those with no religious affiliations.

Some of the important areas to cover will be -
 What has been the religious journey made by the patient?  Did they have good experiences as a child?  What battles and struggles with belief did they experience as they were growing up?  What have been the painful and harmful elements in their dealings with religion, and what have been the positive and helpful elements.

It is helpful to cover both the private and the public expressions of religion within the patient. The Church (or its equivalent) often provides a strong support network. Likewise many people obtain an inner strength through their beliefs and private devotions. All of these can be sensitively explored, with the underlying aim of hearing how the patient views the relationships between their health and their beliefs.

In some patients religion has had a negative effect upon them, and it is helpful to allow them to express their anger or disappointment as it enables them to understand the difficulties in continuing to harbor un-forgiveness and negative attitudes which themselves contribute to poor health in the patient.

 

Full assessment
In the full assessment all of the above topics outlined above are important, although this area is probably best covered by a qualified counsellor or psychologist.
         
Three minute assessment questions
                    In a short assessment interview with a doctor, nurse of other health-care professional, there are three important issues to begin to address, each with a simple open-ended question which can indicate if further exploration would be fruitful.

  • Is their view of themselves largely positive or negative?

Use an open-ended question such as –“Tell me about the strengths you see in yourself”.  People with a poor self image will struggle to answer.

  • Is their locus of control internal or external?

A question may be used along the lines of –“What resources within yourself can you call upon to help you when ill?” The answer should give an indication of how much internal control the person feels they have in combating ill-health.

          Do they have good skills of adaptation and coping?
An exploratory question would be along the lines of – “In what ways have you been able to positively adapt to and cope with the illness you have”

 

“Quickie” assessment
                    In a quick assessment the issue of locus of control or coherence is extremely helpful. Use the above question - –“What resources within yourself can you call upon to help you when ill?”

Self-administered questionnaire
                    Good questions to get people thinking about these areas are the three open-ended questions described above–

  • Describe the main strengths and weaknesses in your character as you have experienced problems with your health.
  • What resources within yourself are you able to mobilize when you become ill?
  • Describe the positive ways in which you have been able to make adaptations to your life and thus cope with your health problems.

 

Full assessment – Relationships with others
Again much of this area should have been covered in the psychological assessment, but the series of questions which might be used in this area are as follows.

  • Describe those family members with whom they are in close contact. Then discuss the quality of these relationships especially referring to the support they give the patient or ways in which the relationship makes demands on the patient.
  • Discuss the influence of parents, siblings or other family members on their growth and development as a child.
  • What close family members have they lost, and how did the bereavement process affect them.
  • Are they able to give and receive love
  • Quality of close friendships
  • Do they have caring responsibilities for others
  • Can they confront in a positive way when indicated
  • In conflict situations doe they act aggressively and argumentatively, or become passive and withdraw
  • Can they accept criticism and deal with it appropriately

 

 

Making a whole person diagnosis

Diagnosis is at the heart of any medical model.

We evaluate the patient’s story, undertake an examination and perform indicated tests to come to an understanding of the disease or ill-health problem the patient has.

Only when we have an accurate diagnosis we can make accurate statements about the prognosis, and deliver the best evidence-based therapy.

There is a great importance to the patient of correctly naming the problem they have. When you know what the enemy is you are better able to join in the fight against it.

So making a diagnosis is the essential heart of any medical model. Get this wrong and all sorts of harm can follow.

Within the classical model the diagnosis may be made at several different levels. Examples –

1 Highest level – a patho-physiological diagnosis which clearly describes the unique collection of physical abnormalities in the patient. Such diagnoses are Diabetes Mellitis, Sarcoma of the femur, Basel Cell Carcinoma of the skin etc.  Each diagnosis here indicates a single pathological process which we are clear about and (usually) understand the causes, the likely course of the illness and the appropriate therapy.

2 Intermediate level – a well recognised set of symptoms and signs which may have several underlying causes, but produce a well-defined illness. Examples – Cushing’s syndrome, Hypertension,

3 Low level diagnoses are those where the patient has a set of symptoms and signs the cause of which are debated and unclear. Here a name may be given to the condition which can be provocative. Examples ME (or CFS or Fybromyalgia),  Tension Headaches, Munchausen’s syndrome. Here we begin to stray into the boundary area between purely physical diagnoses and those involving the mind and emotions of the person. Many psychiatric diagnoses occur here, although some may move up to the intermediate level when they have been shown to have clear physical underlying causes, such as anxiety and tension headaches found later to be due to a brain tumour.

Within the patient-centred model of care the above diagnoses may be made, but in addition statements may also be made about the patient’s experience of the illness which may add elements to the physically based diagnosis. These describe the functional limitations produced by the illness. Thus the arthritis of the knee following trauma may just be a nuisance, or may limit mobility such that special aids need to be used, such as a stair lift.

In a problem based diagnosis a diagnosis of headache may be made, but qualifications added about the circumstances which produce the headache (such as relationship difficulties, stress or food allergies) which may be helpful in treatment but which may not be proved in a patho-physiological way.

Social and economic factors can also be introduced which are helpful when looking at the appropriate treatment for the patient’s problems. Thus a child may be getting recurrent chest infections due to poor housing and an inadequate diet.

When looking at the Whole Person Diagnosis we can make diagnostic statements at seven levels and in three categories. These categories will respond to the three “windows” we have described in which we can look into the whole person to help untangle problems – Physical (the BODY), psychological (the MIND) and spiritual (the SPIRIT).

The levels or layers of the diagnosis help to describe the whole depth of the illness problem and will create a grid to help in making a whole-person diagnosis.

 

Level 1         Causation level, which will include both pathological (such as an inherited genetic tendency to a condition) and also the causes attributed by the patient. It is important to hear and validate these causes, and although they are often wrong they will give clues which will be useful in making diagnoses at other levels of the grid

Level 2         Symptoms complained of and the experience of the illness as narrated by the patient

Level 3         Physical, psychological and spiritual signs detected through an examination of the patient and conducting suitable tests and investigations.

Level 4         The Pathological and Physiological processes which can be identified in the physical sphere and which will be most amenable to the current western medical model using surgery and medications.

Level 5         Disorders of structure and functioning, again physically, psychologically and spiritually.

Level 6         Disabilities and effects on normal functioning including the area of work and social intercourse.

Level 7         Personal, Family and relational aspects

Each of these levels may operate in the physical structure of the person, but also within the mental and also we would argue within the spiritual dimensions of the person. A whole person diagnosis incorporates all three dimensions on this seven level scale.