Tenet 4: Health 3.0 balances part and whole.
All things are parts of a whole. We find this understanding everywhere from the perennial philosophy of the world’s religious traditions, and the secular Stoicism of Marcus Aurelius, to the transpersonal teachings of Ken Wilber.
In the world of biology, for example, atoms are parts of molecules…molecules are parts of organelles…organelles are parts of cells…cells are parts of organs…and organs are parts of organisms.
The part gives the whole its capacity, while the whole gives the part its purpose.
Pathology occurs when part and whole usurp the roles of each other. When a part claims to be a whole, you’ve got cancer. When a whole dominates its parts, you’ve got tyranny.
Remember the Borg, from Star Trek? Like a part commandeering the whole, the Borg was a cybernetic alien race that went around the universe assimilating other species. Like a whole domineering its parts, the Borg also functioned as drones in a hive mind called the Collective.
So said the Borg:
We are the Borg. Your biological and technological distinctiveness will be added to our own. Resistance is futile.
But uniqueness is not futile. And what’s fascinating is that uniqueness is the key to harmony between part and whole.
Here’s how Marc Gafni in his book Your Unique Self explains right relationship between part and whole:
The mystery is that the more the part emphasizes its part nature, the more highly particularized the part is in its authenticity, the more freely the whole can express itself in the part.
The more unique each of us is, the better we fit into the whole. And the better the whole embodies itself through each of us.
Nature thrives in this balance between part and whole.
Look at a tree. No leaf of a tree looks exactly like another. Each leaf is unique. And yet a set of leaves with their branch mimics the whole tree.
Take the human body. Your specialized cells help make you the miraculous whole being that you are. But a cell becomes malignant when it mutates away from specialization and acts like your whole body. Conversely, if your body wanted all your cells to act the same, you wouldn’t be a human being — you’d be a collection of amoebae.
Medicine can thrive in the same way as nature.
Health 1.0 emphasizes parts. Health 2.0 emphasizes the whole. Health 3.0 balances part and whole.
We can observe this from a “micro” point of view, or from a “macro” one.
From the micro perspective, Health 1.0 reduces the patient into a collection of distinct organ systems. Isolate pathology in one organ system. Fix it. And you’re good.
If you’ve got a stomach problem, come see me. If you want to talk about your crazy wife, stop talking to me — and go see your shrink.
Specialists rule in Health 1.0.
Health 2.0 sees the patient as a whole being. You’re not just a collection of organ parts — you’re a whole biological system that’s greater than the sum of those parts.
I now want to know more about how the relationship with your wife is contributing to your upset stomach. Because there’s no boundary between your stress and your gut.
Primary care leads in Health 2.0.
From a macro sense, in a Health 1.0 practice I focus exclusively on my own self-interest and/or the interests of my own patients. I don’t care about the larger health care system that my individual decisions can influence and bankrupt.
For my individual practice, fee-for-service is my gravy train. I’ll order whatever you want. How that affects the whole health care system doesn’t matter to me. And so metrics to measure my patients as a population are irrelevant.
In Health 2.0 I see my individual practice in the context of a much larger health care delivery system. And I minimize variations in my practice so I can fit it into that larger context.
Capitation is now king. Whatever you want is subordinate to the needs of the whole population. Otherwise I will consume the health care system of which I am but a part. And metrics to measure the population are critical.
Health 3.0 balances the perspectives of both Health 1.0 and 2.0. In Health 3.0 I recognize that practicing medicine without regard to the whole health care system creates an unsustainable cancer on the system. But I don’t seek to destroy Health 1.0 — I just evolve beyond exclusive identification with it. I embrace the Health 2.0 tenets of cost-control, accountability, transparency, and regard for the greater good. But when I see, in the name of the greater good, Health 2.0 stifling unique approaches to health and consolidating the practice of medicine into a dictatorship of group-think — I will resist.
I now see that the ideals of Health 2.0 are not possible without uniquely skilled professionals caring for you as a unique human being, with health concerns in context to your unique circumstances.
Yes, there’s more to your health than just fixing each of your organ parts. A primary care quarterback who knows you beyond your organs is invaluable in your care. But to get you beyond your dyspepsia, it may take a team of specialized collaborators — a nutritionist, a chef, a psychologist, and a spiritual guide. With each person practicing at the top of their particular skillset.
Yes, stewardship of our whole health care system is a good idea. I won’t just order whatever you want. But I won’t subordinate your unique needs to the needs of the population at large. Because the patient-doctor relationship is too sacred.
Yes, capitation is now on the table. But I get to choose whether fee-for-service or capitation works best for what I do, with my specific community. And if I choose capitation, then I set my rates — not some omnipotent overlord. And I succeed or fail based on my choices.
And yes, metrics in health care matter. But they matter at the population level. They will never capture the complex relationship of care and healing between me and you.
In this patient-doctor relationship…the relationship at the very heart of medicine…you and I are a part of something bigger than ourselves.
But we are not the Borg. Our biological and technological distinctiveness will not be subsumed. The practice of medicine with uniqueness is not futile.
And if we as parts of this health care system do not resist, the whole of medicine will no longer evolve to what it can become for us all.
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