Caring for the Patient: A Shift to Holistic, Integrative Care Post-Pandemic

“Whenever I start an encounter with a patient and say, ‘how are you?,’ our conversation goes down a very different path these days than it did a year ago,” reflected Heather Gantzer, MD, Chair of the Board of Regents of the American College of Physicians, during a recent interview with HCPLive®.

She proceeded to explain that such a simple question is now loaded with implied considerations for patient mental and emotional health, social wellbeing, home life, daily routines, and physical activity.

As an internist, Gantzer noted that, at a fundamental level, her conversations with patients have had to adapt to more thoroughly focus on these issues—many or all of which have been largely impacted by the COVID-19 pandemic.

“These are things that may have been fifth, sixth, or tenth on the list a year ago, but now light has been shed to show that these are critically important to the whole rest of the conversation,” she continued.

These very words suggest a potential undercurrent in patient care across the healthcare industry, regardless of specialty.

Over the past 12 months of this pandemic, physicians have had to take note of the lifestyle changes and the ensuing crises (mental, emotional, etc.) faced by many of their patients.

And because of this, the internist, the cardiologist, the dermatologist, the rheumatologist (and so on) has likely had to step outside their comfort zone and approach care in a more holistic manner.

As seen with Gantzer, conversations across specialties have certainly had to evolve to account for the complex challenges imposed by the paradoxically fast-paced and still, isolating world of the pandemic.

In essence, the psychological, emotional, and physical impacts of the COVID-19 pandemic have further challenged and pushed the boundaries of the seemingly siloed structures of the healthcare industry.

The Pandemic

These months have only reinforced the idea that patient care must first start with the patient—and that the context in which they live their life truly matters.

In a recent perspective piece published in The New England Journal of Medicine, Megan Evans, MD, MPH, Tufts Medical Center, et al., argued that “this pandemic has reinforced important truths: inequities related to social determinants of health are magnified during a crisis, and sheltering in place does not inflict equivalent hardship on all people.”

Furthermore, they highlighted that the lockdowns have placed particular stresses on those with economic, job, and domestic instability.

The piece focused especially on issues of intimate partner and domestic violence, a reality for 1 in 4 women and 1 in 10 men.

It also noted that stay-at-home orders have exacerbated these issues—most notably in communities of color, and especially for those whose living situations have already proved tenuous.

Of course, such concerns are just one of many issues faced by a locked-down society. More broadly, the mental health crisis is a facet of the pandemic that has largely been discussed by health care professionals across media.

What has less come into focus, it seems, is the way these crises have impacted healthcare provider-patient relationships.

“Medical professionals have an opportunity to identify these patients in health care settings and to provide counseling and connect people with social services,” suggested Evans and colleagues.

The pandemic-related lockdowns have also caused a general shift in physical activity—forcing many to live a more relatively sedentary lifestyle, a reality that all physicians must acknowledge.

Data has shown that individuals, particularly young adults, have largely engaged in low physical activity, high sedentary behavior, and long sleep duration during the course of the pandemic.

An article published in Sports Medicine and Health Science underscored the importance of maintaining physical activity, particularly noting the risks imposed by the lockdowns as well as the virus itself.

“Conceivably, this dramatic change in lifestyle, resulting from immobilization (hospitalization and bed rest), quarantine, and physical inactivity can cause a second-wave attack on the health and wellbeing of the infected as well as general population,” the authors wrote.

Therefore, when one speaks of the healthcare impact of the COVID-19 pandemic, viral infection and ensuing disease is just one piece of a larger mosaic of patient risk and impact.

It is this sincere recognition of these various pandemics within this pandemic, and a desire to act on it, that may inspire a physician to approach care in a more calculated, holistic, and integrative manner.

Acting Holistically

Integrative care is not a new concept in the healthcare industry, and yet the physical and mental crises had led healthcare professionals to further appreciate its value in practice.

Defined as “practices [that] generally emphasize a holistic, patient-centered approach to health, healthcare, and well-being—often including psycho-emotional, functional, social, and even spiritual aspects,” integrative care may have just found a greater foothold over these 12 months.

“[These considerations in care] are really important aspects that have been there all along,” noted Gantzer. “But it’s been beneath the surface, and we often don’t realize it. Now, these are becoming more overt because of the setting change of the patient-encounter.”

Of course, the degree to which a physician incorporates an “integrative” approach to their practice is at their discretion, but the foundational ideas have nonetheless become an integral component of care during the pandemic.

For Gantzer, she noted her relationship with patients has become more informal, as her role as a healthcare provider has taken on a new meaning and emphasis.

Her conversations have accounted for her patient’s physical and social life, nutrition, stresses, barriers, and values, while nonetheless treating for their specific conditions and helping them achieve their care goals.

Pediatric dermatologist Lawrence Eichenfield, MD, told HCPLive that a shift to telemedicine has allowed him to better assess the patient’s “pulse of life” at home.

“The conversations that we’ve had to adapt are [patient] social history,” Eichenfield said. “For our pediatric patients up to young adults that are still in school, we’ve had to assess what that means. This is just to get a sense of what the flow of their life might be.”

And so, this thread stringing Eichenfield’s and Gantzer’s patient experiences has been the recalibrating of encounters in light of logistical and socio-emotional/mental landscapes.

The Promise of Integrative Care

These adaptations that the healthcare industry has had to make go beyond simply overcoming logistical challenges.

The more important story to tell, one that is much more subtle and nuanced, is the ongoing reassessments in physician-relationships and approaches to care.

Should the internists sole focus be on internal diseases? A dermatologist on the skin? How might a physician best serve their patients?

These reassessments have long preceded the pandemic—even as far back as the Hippocratic and Galen times—but it is perhaps though times of global crises that such introspection washes once more over the health practitioner. And the COVID-19 pandemic is no different.

Where will the healthcare industry go from here?

Perhaps these literal and metaphorical pandemics, which will see no abrupt end, will continue to inspire innovation in patient encounters and practice. Perhaps, out of necessity, integrative care—in moderate or extreme forms—will someday take firm hold across specialties.

Maybe the walls between an internist and a dermatologist, and a psychiatrist, for that matter, will no longer be built so rigid.

Integrative and holistic care, and the ability to understand patients in their true, unfiltered contexts, may offer physicians an opportunity to evolve their practice and treat patients more effectively and with greater purpose.

Perhaps the lesson learned from this past year is that optimizing care begins with that first reading of the patient’s “pulse of life.”

And the rest follows from there.