Healing in Primary Care: A Vision Shared by Patients, Physicians, Nurses, and Clinical Staff

INTRODUCTION

Healing is a central concern of medicine, yet the role it plays in our modern health care system is poorly defined.^1–3 Biomedical research on healing is usually limited to the level of tissue repair. Broader study of healing appears in literature from other fields. Nursing discusses healing with a focus on the process of caring and the nurse as healer.^4–6 Anthropological research on healing tends to focus on documenting non-biomedical practices and eliciting deep symbolic and structural meanings from healing practices.^7,8 Complementary and alternative medicine often examines systems of healing outside the scientific biomedical model.^9–11 Healing plays a central role in psychology¹²; however, with the exception of a few Jungian psychotherapists, the meaning of healing goes unexplored.¹³ Other researchers have explored the meaning of healing in patients with chronic illness,^14,15 disability,¹⁶ pain,^17,18 and at the end of life.^19,20

There has been little empirical research on healing in modern health care, and we have little evidence on how physicians and other members of primary care clinical teams see their roles in healing.²¹ No published research has systematically asked patients in primary care what they define as healing or how it might be improved.

Egnew²² sought the definition of healing from selected medical experts and expressed concern about physicians’ lack of capacity for the empathy, communication, and relationships essential to healing. Leaders in medical education are calling for renewed attention to the importance of healing in patient care.^2,23 Some “believe an emphasis on healing is key to the future of medical management of chronic illness and the establishment of sustainable approaches to health care.”²⁴

Meaningful discussion about healing requires an understanding of what healing means to the key participants in the healing process: patients, physicians, nurses, and other members of the primary care team.^25–27 We used qualitative research methods to explore what they believe are definitions, fundamental dimensions, barriers, and opportunities for improvement of healing.

METHODS

This research was part of a larger effort to improve patient outcomes in primary care by enhancing the healing experience for patients, clinicians, and the primary health care team. We conducted the study in a large, integrated, consumer-governed, health care system in Washington State in 2005. We conducted 19 individual interviews to develop a discussion guide for the focus groups we report here. The Institutional Review Board of Group Health Cooperative approved all components of this study.

Our interdisciplinary team began with several assumptions based on discussions with a broad variety of professionals interested in enhancing healing environments. We expected healing would be a difficult concept to define and discuss, particularly across patient and professional groups. We also expected that many patients would consider healing to be the domain of alternative and/or spiritual practices, rather than an integral part of conventional medical practice.

We recruited both patients and clinicians for focus groups from the Seattle and Tacoma, Wash, metropolitan areas, using a multistage process that is detailed in the Supplemental Appendix 1 (available online-only at http://www.annfammed.org/cgi/content/full/6/4/307/DC1). We started with a random sample of established patients, stratified by sex, age, and medical condition. Letters were mailed to patients inviting them to participate in a study “to better understand how a patient’s personal experiences with their health care team may affect his or her ability to heal,” and to participate “in a discussion group…to share their thoughts about how the patient-provider relationship can help or hinder healing.” We recruited physicians and clinical team members through e-mail invitations to all such personnel in the primary care clinics in the study regions. For all those who responded, we explained the study procedures and obtained informed consent by telephone. We paid cash incentives to focus group participants (patients $75, nursing staff $100, physicians $150).

We conducted a series of 9 focus groups during July and August 2005 (Table 1⇓). Seven groups were homogeneous: 2 groups each of only patients, primary care physicians, and registered nurses (RNs), and 1 group comprising licensed practical nurses (LPNs) and medical assistants (MAs). Considering the debate about homogenous vs heterogeneous focus groups, we conducted 2 additional groups that included a mix of participants of all 4 types. The size and format of the focus groups followed recommendations in the literature.^28–31 We contracted with 2 independent, professional facilitators from a local marketing and consulting firm to lead the focus groups. They used a discussion guide designed to elicit (1) concepts and definitions of healing, (2) facilitators to the healing process, and (3) potential barriers to healing (Supplemental Appendix 2, available online-only at http://www.annfammed.org/cgi/content/full/6/4/307/DC1). In each group, after all participants offered their own thoughts on healing, the group constructed a consensus definition of healing. We made audio recordings of all discussions that were transcribed verbatim, either from the audio-tapes (3) or in real time by a stenographer present in the room (6). Members of the research team were present at all the focus groups.

We examined the content of the focus group discussions at biweekly meetings of the research team. Inclusion of clinicians and clinic trainers in these discussions helped validate interpretation of comments and themes. We judged that we reached saturation in eliciting new salient comments on healing well before we completed the groups we planned.

The analysis team identified the key themes, using an immersion/crystallization approach.³² Four team members (C.H., K.S., R.H., W.P.) read all transcripts in detail. Three team members (C.H., K.S., R.H.) independently coded 2 transcripts and generated a list of codes for the major themes and concepts, using Atlas. ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). They discussed all codes and developed consensus regarding the content and definitions of a coding scheme. All 3 coders then coded 2 complete transcripts, again reconciled the codes, and agreed on a final code list. Agreement among coders during this first phase was approximately 70%. Finally, at least 2 team members coded each transcript, compared results, and resolved any differences though discussion. Agreement in the final phase was approximately 90%. This process allowed the analysis team to closely reflect on the data, identify emerging patterns, and learn from each other’s perspectives. The process followed the constant comparative method of grounded theory, comparing and refining codes throughout the data analysis process.³³ Once all transcripts were coded and compared, 2 members of the team (C.H., W.P.) focused on references to healing. They reread and further analyzed the data under relevant codes to identify the findings described in this article.

The analysis team represented a variety of backgrounds: a medical anthropologist with special interest in women’s health care and community health (C.H.); a family physician researcher with special interest in patient-doctor communication and preventive services (W.P.); an epidemiologist experienced in conducting clinical trials of complementary and alternative medicine (K.S.), and a public health research manager with a background in psychology (R.H.).

We initially expected to consider the patient discussions as 1 data set and the clinician discussions as 1 or more separate data sets. Early in the analysis, however, we found that all groups shared remarkably similar views on healing. We therefore combined the data from all groups.

RESULTS

We conducted 9 focus group discussions with 84 participants. Response rates are summarized in Supplemental Appendix 1. The composition of the groups is displayed in Table 1⇑. Twenty-eight patients ranged in age from 22 to 62 years, with 71% female and 29% male. The 23 physicians (21 family physicians, 1 general internist, and 1 general pediatrician) worked in 13 different primary care clinics, in both urban and suburban communities. Focus groups included other key members of the clinical teams: RNs (20), LPNs (11), and MAs (2), drawn from across 13 clinics. We refer to them all as clinicians.

DISCUSSION

This study provides empirical data on the meaning of healing in primary care from the perspective of patients and clinicians, one of only a few such studies.^22,34 We found a remarkable level of concurrence on the concept of healing among patients, physicians, nurses, and clinical assistants.

The definition of healing that emerged from patients and clinicians was generally consistent with definitions in the literature.^22,27,35 We observed key themes emphasized by many others: wholeness,^36,37 recovery, balance, communication,³⁸ and relationships.³⁹ These areas of agreement suggest a broad consensus on what healing is and how it is achieved.⁴⁰

Consistent with recent work on the ways a person constructs and uses stories to articulate personal experience and meaning in clinical practice (also referred to as narrative),^41–43 the stories our participants shared represent an archetypal narrative of healing as a personal journey. The starting point of the journey depends upon who the patient is and what trauma, illness, or other loss he or she has experienced. The destination depends upon the patient’s personal goals and whether they are realistic. Doctors and nurses bring special knowledge and skills that are sometimes important in guiding or advancing the journey. The fundamental work of the healer, however, is to listen, hear, understand, and help the patient progress along the road toward recovery of wholeness and function. This help requires communication and the building of trusting relationships. Both patients and clinicians feel that the current burdens of workload, stress, and time pressure limit opportunities for healing.

The healing journeys described by our participants are similar to the type that Frank classifies as restitution narratives,⁴¹ except that technology seldom plays a prominent role in these narratives from primary care. Although most medical literature is devoted to the scientific and technical aspects of diagnosis and treatment, we did not find this emphasis when patients and clinicians talked of healing.

Many authors emphasize suffering and its relief in healing.^3,44–46 Our participants focused less on the relief of suffering and more on the restoration of function. Some authors advocate careful attention to the design of the physical environment of the healing encounter,^47–49 but the patients and clinicians in our study rarely mentioned the clinic space. Counter to our expectations, patients only occasionally expressed interest in complementary and alternative medicine (CAM) in connection with healing.

Spirituality is central to healing in much of the literature.^50,51 It was important for our participants for its contribution to the wholeness of mind, body, and spirit. Participants believed faith was important in healing and that faith communities could provide important social support. Few participants, however, talked of faith healing, prayer, or divine intervention. In fact, there was little talk of being healed by any intervention. Throughout the discussions, the patient was the subject—not the object—of the healing process.

We designed this study to inform a new program to optimize healing in primary care. Limitations include a selective sample, biases generated by the context of the study, and limitations of responses that were due to the nature of the questions asked. Our study participants were drawn from patients in one large health care system with long traditions of patient advocacy, community involvement, emphasis on prevention, and clinical research. All patient participants had established relationships with primary care clinicians, mostly family physicians. In addition, our population is more educated, higher percentage white, and less religious than in many regions. The invitation letter stated our interest in healing and health care and might have attracted biased participants. Although our findings may not be generalizable to all people or settings, we feel that these voices likely represent many patients and professionals in primary care in the United States.

Conducting our study in a medical environment with patients in established relationships with medical doctors may have introduced bias against other models of care. Our community, however, has high rates of CAM use,⁵² including among patients who regularly see medical doctors. In addition, this system provides benefits for CAM treatments, as mandated in Washington State.

This study adds to current scholarship on healing by asking patients and clinicians what they think. This exploratory work found a surprising level of agreement among patients and clinicians in primary care settings. The patients and clinicians in our groups agree that medical care, though important, is only one contributor to healing. Likewise, healing is only one element of what goes on in modern medical care. Other expectations include symptom relief, prevention, control of chronic disease, and a range of administrative responsibilities.⁵³ The participants we listened to made it clear, however, that healing is what brings patients and clinicians together. They also agreed that they need more unhurried time together to make it work. Further work is needed to explore agreement and differences across other medical specialties, professional groups, geographic regions, racial and ethnic groups, and health care systems.⁵⁴ Finding better ways to heal might help us address some of the chronic problems facing health care today.^55–57 Our team is using these findings to help guide changes in our primary care system, to increase clinician mindfulness, reduce stress, improve doctor-patient communication, and enhance clinic team function.⁵⁸

This research raises fundamental questions about the goals of the US health care system and the place of primary care. Patients and clinicians in our study believed that healing is possible in our current system, but that much must be changed to foster healing relationships. Do we want a health care system focused on healing? What attitudes, priorities, and resources would we need to change? What expectations stand in the way? If we designed a system to heal, what would it look like?