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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Definitions of Healing
Response to Thomas Egnews: The Meaning of Healing: Transcending Suffering
Questions on the implications of the use and meaning of the word "healing"
Egnew: The meaning of healing:Transcending suffering
Research Agenda for Healing
Healing and the doctor patient relationship
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Wayne Jonas, MD, Alexandria, VA, USA Director, Samueli Institute
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I enjoyed the article by Dr. Egnew on the “The Meaning of Healing” (AFM May/June, 2005)and his approach of interviewing "7 allopathic physicians" doctors (one of whom is actually an acupuncturist and not allopathic) as to their meanings for the term "healing." Certainly healing involves “wholeness” including caring for what patients refer to as spirituality. However, in his review of the literature on healing, including definitions, he fails to mention one of the most extensive and ongoing efforts in defining and establishing standards for research on healing and that is the efforts by the Samueli Institute and its collaborators. This 3 year process involving now nearly 70 physicians, nurses, social workers, anthropologists, psychologists, alterative practitioners and others has produced the largest single body of peer-review publications on healing including three proceedings (one is press) and multiple articles. Please refer to the Samueli Institute website for these references. (www.siib.org). This effort, which is still ongoing, has resulted in a consensus definition and a description of hypothesized operational components of healing and healing environments. The definitions of healing and healing environments taken from one of these articles are as follows: “Healing is defined as the process of recovery, repair and return to wholeness. It is the foundation for a vision of medicine where the focus is the alleviation of suffering, the enhancement of well-being and the treatment of chronic illness. Healing is important for management of chronic illness and development of sustainable approaches in health care. It may serve to integrate diverse healing philosophies from around the world. We believe that developing inner and outer environments that optimize the inherent healing capacities of individuals, social systems and the physical environment in an important step in achieving that vision. We define an optimal healing environment [OHE] as one where the social, psychological, spiritual, physical and behavioral components of health care are oriented toward support and stimulation of healing and the achievement of wholeness. In our opinion, these components include at least five domains plus physical and organizational structures that support them The five core domains of an OHE are: 1) Conscious development of intention, awareness, expectation and belief in improvement and well-being; 2) Self-care practices that facilitate the experience of wholeness and well-being; and that foster greater compassion, love and awareness of inter-connectivity; 3) Development of listening and communication skills and service oriented, altruistic behaviors that cultivate social support and trust, including the “therapeutic alliance”, in the health care setting; 4) Instruction and practice in health promoting behaviors in lifestyle to support self-healing such as proper diet, exercise, leisure and work balance and addiction management; 5) Responsible use of integrative medicine via the collaborative application of conventional and complementary practices in a manner supportive of healing processes; These five domains need support from the physical space in which healing is practiced, including characteristics of light, music, architecture and color. They also need supportive organizational structures including leadership, mission focus, evaluation and reward policies that among other elements that can influence the impact on an OHE. Health care managers and leaders ideally should have the experiences contained in the OHE domains, and practice self-care, personal wellness and prevention approaches in their own lives.” I hope that Dr. Egnew and other readers of the Annals of Family Medicine will enjoy reading these articles and we invite all those involved in medicine and health care to join us in improving these definitions and their application. Wayne B. Jonas, MD Competing interests: None declared |
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Virginia A Aita, Omaha, NE Ethicist: University of Nebraska Medical Center
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Thomas Egnew’s manuscript, “The Meaning of Healing: Transcending Suffering” highlights the ideas of some of America’s foremost contemporary physician leaders concerning the art of healing. Egnew’s curiosity concerning the lack of a systematic definition of healing led to his search for an “operational definition” that would encourage the phenomenon in clinical medicine. He defines healing as “the personal experience of the transcendence of suffering.” Physicians can enhance healing, he says, by “recognizing, diagnosing, minimizing, and relieving” suffering. I agree that an awareness of suffering and thoughtful medical management of pain and physical discomfort can begin to assist with its relief. While I acknowledge the legitimacy of Egnew’s findings, I wonder whether or not the search for an operational definition of healing doesn’t miss the mark. To operationalize something entails the planning and performing of practical activities involving cognitive and action modes of behavior. Egnew’s proposed operational definition of healing seems to suggest a vague recipe with cognitive and behavioral ingredients that may not be adequate to relieve suffering and promote healing. Although suffering may have cognitive and physical components, it is largely a psychological, emotional and spiritual experience. A response to suffering and the ordeal that it causes patients may most call for healers to “be present.” Being present is indeed the most challenging aspect of healing for the courage it requires. My hunch is that Egnew’s analysis of subjects’ insights can be expanded, especially in regard to the significance of the patients’ evolving narratives of illness and the importance of patients’ relationships with healers. Putting these ideas together implies that a physician healer would be willing to accompany a patient on a journey into vulnerability to confront the demons of loss, fear, grief, and isolation that cause suffering. This journey is neither cognitive nor procedural, but emotional and unpredictable. Such confrontation offers the patient the possibility of finding a new equilibrium, sense of integrity and wholeness invested with new meaning. Healing is personal work that happens in intimate, non-physical, psychological planes of existence. I would argue that healing might be best promoted, not by trying to give it an operational definition that fits within the scientific and technical formats of allopathic medicine, but by calling attention to the healer’s varied abilities and giving explicit permission and encouragement to physicians and others to be with patients in the unexplored, unpredictable, ominous territories of suffering and illness. Competing interests: None declared |
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Phyllis R. Silverman, Ph.D., Boston, MA Brandeis U. Women’s Studies Research Ctr & Dept of Psychiatry, Mass General Hosp, Harvard Medical
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Several questions need to be considered in considering the implications of Tom Egnew's excellent paper on the use and meaning of the word “healing” in the context of western or allopathic medicine. One question that needs to be asked is what “to heal” means to the consumer? I recently had surgery and I asked how long will it take for the wound to heal and what can I do to quicken this healing? In my role as consumer and as “patient” what preparation would I need to receive to change my use of the word to reflect Egnew’s findings?. Another question relates to how “ healing ” has been used as a goal when people deal with other life cycle experiences, for example after a death. This pain has been likened to a wound that closes over, that “heals”. The implications are that they can then go on as before. The use of this word is being challenged by the very experience of the bereaved when they do not recover. They find themselves living through the pain, with a changed way of living in the world. To suggest healing, given the definition of the word as understood by most people, often creates an expectation that is not possible to achieve. Engew’s work brings us to a fuller definition of what healing can be about. It relates to caring, bringing an entirely different perspective to medical practice. A third question this paper raises for me, is how to bring this definition into common usage and who should implement it? Should this be the work of a physician? Treatment/ caring in medicine today is seen as a commodity, with a measurable outcome that happens in a limited time and with a price tag on it. Can healing be a commodity? Implicit in Egnew’s inclusive definition of healing is an expansion of the physicians’ view of their work. This would involve changing the system in which this work is practiced. Should some of what we are talking about be provided by people in our social network, in our community. Should our view of care and connection be expanded to recognize the variety of people and the variety of roles required for a holistic view of healing to take place? Phyllis R. Silverman, Ph.D., Brandeis U. Women’s Studies Research Center; Department of Psychiatry, Mass General Hospital, Harvard Medical School; Co- Editor Living With Dying: A Handbook for End of Life Health Care Practitioners. Competing interests: None declared |
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G. Gayle Stephens, M.D., Birmingham, Al., USA -
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I wish I had remembered, when Tom Egnew interviewed me, to talk about the role of imagination in healing. (Do not substitute “imaginary” here.) The physician’s clinical imagination must be adequate to discover and respond to the sick patient’s altered self-consciousness. Illness induces predictable and identifiable fears and fantasies in medical settings, among which are fear of strangers and separation anxiety, fear of the loss of love and approval, of losing control of one’s body and mind, of injury and mutilation, along with guilt and shame and fear of retaliation.1 These threats undermine and subvert the patient’s sense of integrity and inhibit recovery. A physician who is unable or unwilling to deal with these demons is unlikely to rise above the requirements of mere technical competency. It is a formidable undertaking to wrestle with another’s injured self-consciousness but that is the place where healing happens. 1.Strain, James J., and Grossman, Stanley, Psychological Care of the Medically Ill: A Primer in Liaison Psychiatry; New York, Appleton-Century- Crofts 1975 p24 Competing interests: None declared |
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John G. Scott, New Brunswick, USA Assistant Professor of Family Medicine UMDNJ-Robert Wood Johnson Medical School
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Dr. Egnew provides a fascinating glimpse into the clinical experience and wisdom of some of the greatest physician healers of our era. It is especially gratifying to see the contribution of Dr. Elisabeth Kubler-Ross, for this was perhaps the last opportunity for her to share her insights about the process of healing. I believe that the “connexional relationships” that Dr. Egnew describes have as much to do with patients’ clinical outcomes as the medicines that we give them. If this impression from my clinical experience could be validated through thoughtful systematic research, it would have major implications for health policy makers and the structure of our health care system. The nature of doctor-patient relationships are not readily quantifiable, however, and as such have received little attention from medical researchers, as Dr. Egnew points out. We cannot begin serious research about the effects of healing relationships until we have an operational definition of what a healing relationship is and how it comes about. Dr. Egnew’s study provides one such definition. The idea that a healing relationship facilitates transcendence of suffering resonates strongly with my own clinical experience, and I suspect with that of other experienced clinicians as well. This study provides a good starting point to begin to understand healing and healing relationships, but there is much more work to be done. I suspect that patients have a great deal to teach us about how they experience healing, how relationships facilitate or inhibit that process, and what sorts of outcomes are important to them. My own preliminary work in this area suggests that the physician-patient relationship is important, but not necessarily central in the healing process. Family and community relationships may be even more important. Patients also form relationships with others in our practices in addition to physicians. Nurses, receptionists, lab technicians, billing clerks and other office staff can and should be enlisted in the healing process. The research agenda for the study of healing must include not only the doctor-patient relationship, but also the complex web of interactions in which suffering souls are imbedded and the narratives that are thus co-created that bring coherence and meaning to that suffering. This is an ambitious research trajectory and Dr. Agnew has taken the first step. Competing interests: None declared |
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Hamish J Wilson, Dunedin, New Zealand Senior lecturer in General Practice, University of Otago
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Invited commentary. The research report by Dr Tom Egnew is an invaluable addition to the medical literature on healing, the doctor patient relationship and the purpose of being a doctor. Perhaps the success of biomedical science has diverted our attention away from the original aim of medicine - that of healing the sick. The predominant medical focus is now more on organs, disease, investigations and treatment, than on the person who lives with that illness. One could argue that a focus on the ‘body as machine’ will offer considerable benefit to patients, including relief of pain and personal suffering through better treatment of disease. Yet somehow something is still missing; with this article Dr Egnew draws our attention back to the original intent of being a doctor, where technical knowledge and medical interventions need to be used in service of the person of the patient. His research method was to interview some leading clinicians of the 20th Century who had made significant clinical and theoretical contributions to the doctor patient relationship, suffering and healing. These people included Drs Eric Cassell, Elizabeth Kubler-Ross, and Cicely Saunders – writers who have shaped my own understanding of suffering and the role of the doctor, especially as a general practitioner in primary care. What emerges from this study is an ‘operational definition’ of healing, defined by Egnew as: “the personal experience of the transcendence of suffering.” Embedded in this definition are some important implications for clinical practice: that doctors are aware of and can identify suffering as part of their legitimate purpose; that they are not diverted by an unrealistic focus on cure; and that they are present intellectually and emotionally to acknowledge the patient’s illness experience over time. The implications then of Egnew’s definition of healing appear daunting. If they are to be taken seriously however, they pose a challenge to the biomedical focus in much of current medical education. If student doctors are to become healers as well as competent clinical scientists, they must also focus on, and work hard to improve, their interpersonal relationships with their patients. At present however, there is no well established method of doing so. Although other helping professionals use regular interpersonal supervision to learn about their healing relationships, medicine has yet to discover the importance of doctor patient relations or ongoing methods of enhancing and refining them. This may be the next logical outcome of Egnew’s seminal paper. Reference. Wilson HJ. Reflecting on the ‘difficult’ patient. New Zealand Medical Journal 2005;18:1212. Competing interests: None declared |
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