The amazing tale of holism

December 26, 2011

The incredibly odd tale of holism.

Or what it takes for holism to go mainstream

Or what it takes for holism to go mainstream

It’s quite the strange thing when day after day patients come into your office telling you: “you have such a holistic view on healthcare”. Very odd indeed. Particularly when you don’t think you do.

But then you realise that “being holistic” is a contradictio in terminis. A little like: “being perfect”. Both are in my view equally unattainable. The sheer fact of being immediately infers imperfection on the being. Holism, true holism that is, implies complete knowledge and understanding of all aspects of a person’s existence and being. Absolute knowledge is impossible and a delusion only few sane clinicians will entertain (and swiftly reject). Contradictio in terminis indeed.

That’s when you conclude that the patient must have meant you are “more holistic than some of the people they had met”. Not much of an accolade but at least it’s accurate. The other problem is that to some people it seems the term holism has some sort of anti-reductionist policy at its midst. That’s a problem to me because I am the polar opposite: a reductionist in absurdio, meaning that I believe that when you know everything about a system and its surrounding/influencing events, you will indeed find that one plus one is two. It is absurd because you can never know everything about a system and its influencing surroundings. That’s why there always is a risk ratio, there always is a failure rate, there always is a “shit-happenz-”factor.

So holism is a patient experience. An interpretation of your clinical motives and viewpoints. A subjective understanding of what you’re doing compared to their previous encounters.

It sure as hell is not a professional stance. I know physiotherapists that are more holistic than me, and homeopaths that are less so. Colleagues will recognise this I am sure. But this then leads me to ask: what does “holism” mean? And can one actually be holistic?

As I stated before: in my view holism is one of these things that one can only aspire to and never achieve. Aiming to fully comprehend all contributors to a person’s well-being or lack thereof is driven by sheer insanity. Not because it’s not a nice idea,… just because it doesn’t pay.

Yes, you read that right, the self-serving, money-laundering “tree-hugging CAM hippy” says it doesn’t pay to molly-coddle and get overtly over-zealous. The economics of it just don’t stack up. Most of the time. Maybe a little Faustian in some people’s eyes, but reality is that those who think so need a reality check: everything has a price and a value. What I mean by that is that say for example an investigative procedures like MRI scans cost a small fortune. Thing is though that often you can find out whether your clinical hypothesis was correct or not for a lesser cost than the investigative procedure. In CAM you can at least. In surgery we’re talking different ball-game altogether. Hospital, anaesthetist, surgeon, nurses, post op rehab etc make it very expensive indeed. Take for example 10 patients with what looks like a small disc hernia or an annular tear. To make sure that none of them have a big hernia would cost £3000 in MRIs. The one who does will then suitably be referred for micro-discectomy. The other 9 will cost £400 in treatment. Total cost: £6600. Or you could treat all 10 at a cost of £4000 find out the one who didn’t respond to treatment and refer for an MRI scan of £300 and refer for micro-discectomy. Total cost £4300. Net saving: £2300. Result.

But what of the time lost for number 10? I hear you protest… “£2300″ is my reply. Half the cost of the discectomy… worth it. Simpels. But then bear in mind that I tell my patients what I am doing. I tell them that they might have a substantial disc hernia but the signs and symptoms are indicative of soft neural symptoms and in consequence I think it’s worthwhile to find out by trial and error rather than cost them £300 to find out whether they are one in 10 or one of the 9. And I would work the same if I were working in the NHS. No point in wasting tax payers’ money.

In fact CAM-practitioners are not alone in this; most GP’s do it routinely pharmaceutically: prescribe something to see if the obvious and statistically significant will work and work your way up into the more expensive and less obvious stuff when failing. It’s quite normal really because if you think about it, the cost of evaluating all people can be prohibitive in the light of relatively cheap treatment. This is of course not always the case and has many caveats attached to it and I hope that clinicians reading this can see that sound clinical judgement underpins this cost-cutting approach.

But the point is salient nevertheless, as we were talking about holism. And holism is about understanding everything about everyone. Finding out certain things about most people is generally speaking cheap. Finding out certain other things about some people can be incredibly expensive. Ergo holism is incredibly expensive but rarely worth it. So we approximate it with some trial and error and we do our best to keep things affordable.

One of the most amazing examples of holism can be found at AC Milan, but the cost of this is 7 figures. And that is just for 20 or so footballers. That does make sense at AC Milan because the cost of not knowing the detail about the players can cost 8 figures. That’s because footballers are expensive people and their functionality is highly prized. Most of us aren’t worth that much in cold hard cash, and that’s why I will be hard-pressed to find someone else to pay for me as if I were. Let alone me. And that leads me to the last inconvenience to large-scale holism: self-apathy.

It’s only normal for an animal that only recently manufactured the tools to live a life-span of more than 50 years to not have evolved natural instincts in line with such longevity. Think about it. As an animal that has the decency of dying in accordance to its natural use (no double-glazing, no antibiotics, no strawberries in winter) homo sapiens sapiens died before he/she turned 40, just long enough to see your grandchildren. A “natural” death they call it. And it’s only in the last 250 years or so that we have had to actually be concerned with what happens with us when the nature we have so cleverly manipulated to feed us all year round and protect us from the elements and provide us with medicine which helps us fight illnesses we would normally (naturally) succumb to is no longer in synergy with our own nature. Our instincts for self-preservation are still largely rooted in the short-term survival and continuation of our genome (our children and grandchildren to you and me) but our life is not. I could get into things like racism and equality and so on because they too require us to go against a natural instinct of short-term self-preservation and survival and they are equally difficult to overcome in our humanity. So it is with the principle of looking after ourselves so as to enable a long and healthy life. Diet, smoking, drinking, all things we know we should be looking into, educate ourselves and empower ourselves fr a long and happy life. But still we do bugger all (statistically speaking) about even the glaringly obvious. It’s just not natural to us. Even if it is free (dental checks on the NHS are abysmally poorly implemented) let alone if it will cost, or more precisely if it means a reduction of ability to buy a flat-screen 3D television…

Some people are of course the exception. These become Sufragettes and sign the declaration of independence, kick up a stink over global heating or fight racism, and although I am missing out so many similar admirable examples: these are still in a minority. These super-natural people who over-come their natural primitive animal instincts and feed themselves well, don’t smoke, don’t drink (excessively) are generally considered “freaks”, Californian or “boring”. Point is that “holism” will only take hold when it is economically viable, which means cheaper technology. Cheaper technology needs many users. I for one am constantly looking at the computer gaming industry because they have so much stuff that could become interesting with a few tweaks. Motion analysis apps are starting to get off the ground and the idea of hacking into the Wii boards gets my juices going… anyway, I digress. Holism as a movement has a long road ahead. It will firstly need to identify willing investors (those “special” people identified above) willing to facilitate the reduction of cost per acquisition to those less proactive which will then eventually reduce the cost so significantly that the public will request that technology be made available to them. Now, we discussed technology before on this blog and it didn’t come out smelling of roses. I am not talking about Intergalactic Adjustinators. I am talking about force-platforms, motion analysis tools, predictive algorithms. Real stuff which at the moment would need you to raise treatment visit prices by £3 per visit in order to get return on investment within 5 years (a basic setup will cost your £50K and the average clinician sees 80 visits per week). Come to think of it, that’s not that much really. Maybe we need more Sufragettes in the professions….

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  • Liam

    I absolutely love this. On Le Carnardnoir twitter today he tweets this.
    “Professor David Peters. Osteopath and Doctor. A danger to the public understanding of medicine and science. “Its worth a look a GP and osteo wants comp therapies on the NHS and Dr (cough) Andy Lewis regards him as a danger to the public.He later retweets this from D colquohoun.”Very impressive letter from GPs and others to Cameron. Why won’t he listen to those who know? “Gotta laugh oh the irony.

  • Stefaan A.L.P. Vossen

    I think there is very little to argue on the point they make. The problem is just that we can see the (grossly speaking) two camps emerge in any similar (intra-professional) debate: the ones who are comfortable with the fact that not all is yet known in this universe, and those whose starting point is that some will never be fully known and are happier with the certainty of now contained in mystical paradigm.
    There similarly are camps which emerge when debating inter-professionally, something you have witnessed in many of the debates we have had here and on other blogs. 
    In my opinion the fundamental differentiator is that people have varying reward systems. Often we get distracted by what appears to be their “belief system” but on reflection I don’t think it is about beliefs but about reward-systems. I am probably explaining myself badly here, but we often end up debating “beliefs” sometimes going into quasi-religious discussion. I don’t think it is actually about that. I think it is about why we hold the beliefs we hold, and this fundamentally ties into our reward systems, ie we hold them because they make us feel a certain way. They give meaning to our thoughts, to our creations and our existence. I don’t know enough about reward-system psychology but I would venture a guess that there are those who on the surface need to be given reason and those who don’t. The thing is that to those who don’t: not being given a reason becomes reason in its own right. It has a tinge of calvinism and darwinism to it. I don’t know where I am going with this but my gut feeling is that there is a thought process which would eliminate this superficial differentiation, which when applied to say for example the chiropractic discussion we could end up with a slightly more constructive debate.

  • Colin Jenkins

    Interesting thread on Linked In about  subluxation.  Dave N (AECC) and John V make sense to me…  Happy New Year…


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