It's a whole thing

The term “holistic” has become ubiquitous in health care, used frequently but often without precise definition. To some extent, that may be because the term seems self-explanatory; it refers to the “whole”—the sum rather than its parts. How this translates into practice is not always clear, however. Holistic practice—or “holism,” (from the Greek ὅλος, meaning entire, complete) as it is less commonly known—is not new. The name is thought to come from a 1926 book by Jan Christian Smuts called Holism and Evolution, but the concept has been around for millennia. Holism can be tricky to characterize since it is often defined by what it is not, i.e. specialized, reductionist. This leaves considerable room for interpretation. Indeed, texts on the subject acknowledge that holism can be assigned different meanings which can be variously applied to an individual, an environment, or a population. Yet, I think it is safe to say that, generally speaking, the holistic practice of medicine dictates that a patient not be reduced to a single body system or part, but rather viewed as a multi-dimensional human being existing in the rich context of their social, economic, cultural, and—the pathologists might be quick to remind us—microbial situation. A corollary to this is that the plan of care must then try and address these myriad factors. This philosophy has long underpinned nursing practice, and generations of nurses have been taught not only to administer treatments for physical ailments, but to address psychological and existential needs with “presence, intentionality, compassion, and authenticity throughout the caring process”.

According to the American Holistic Nurses Association handbook, Holistic Nursing: Scope and Standards of Practice, health is, “an individually defined state or process in which the individual (nurse, client, family, group, or community) experiences a sense of well-being, harmony, and unity such that subjective experiences about health, health beliefs, and values are honored; a process of becoming, expanding consciousness” (AHNA, 2012, p. 88); wellness is “[i]ntegrated, congruent functioning aimed toward reaching one’s highest potential” (AHNA, 2012, p. 92). Note that the language here is subjective and descriptive; health is not reduced to a series of measurable parameters (e.g., blood pressure, heart rate). While someone may lack disease, they have not necessarily achieved health. I think this distinction may be why patients sometimes feel frustrated when they are told that there is “nothing wrong,” in contradiction to their internal state. This dissonance renders people more vulnerable to misinformation and excessive claims. It is important to remember that while concentration on a particular gland, hormone or supplement is often billed as a “holistic” approach, a disproportionate focus on a single aspect or remedy is actually the opposite.

As a philosophy, holism underpins wound care, whose most basic tenant exhorts the practitioner to consider the patient in their entirety (an idea often pithily summarized as, “Treat the whole patient, not the hole in the patient!”). An emphasis on discovering and addressing underlying etiologies is stressed in most wound care curricula. For example, for a patient who develops a diabetic foot ulcer, it is important to know not just the location and duration of the wound, but to ascertain how well a patient’s diabetes is controlled (usually measured using a HbA1c blood test), the nutritional status of the patient, and their ability to afford potentially costly items like shoe inserts (of note, Medicare will cover 80% of the cost of one pair of therapeutic shoes per year for patients with diabetes).

What does holistic practice actually look like? Since health is defined by the patient, the first step is to elicit the patient’s story. This refers not only to collecting historical facts, but also patient perceptions and needs, and (if applicable) those of their caregivers/family members, in relation to the problem at hand. Once these data have been collected, goals can be identified by the patient and a plan to reach those goals can be developed. Of course, this is an ongoing process; revision of goals is not merely an option, but an expectation. The care team is there to facilitate in whatever way they can, be it through medication prescription, clinical monitoring, referrals, education, &c. Appropriate referrals and education are particularly important because it empowers the patient to understand and seek out more resources and avenues for action.

Another component of holistic practice is the inclusion of integrative therapies to help address patient needs, e.g. nutrition, relaxation/meditation, and aromatherapy. Proper nutrition is essential for wound healing, especially ingestion of adequate amounts of protein as well as key vitamins and minerals like vitamin C and zinc. I generally suggest obtaining as many nutrients as possible from whole foods and incorporating supplements only when barriers like lack of appetite make it difficult to meet nutritional needs. I also enjoy incorporating aromatherapy into my practice as an adjunct to topical anesthesia, in order to help soothe anxiety and reduce stress.

For clinicians, practicing holistically demands that we recognize the limits of our knowledge and influence. Health and wellness are unique to each patient and their circumstances, and subject to many external and internal forces. This can vex patients and practitioners alike in an era that valorizes instant gratification. For me, it helps to take a step back and consider that the complexity which can be so frustrating can also be a source of awe. This complex emotion is increasing the subject of psychological research, which suggests that the “perceived vastness” it entails is essential to human well-being. I will leave you with this quote about awe from psychologist Dacher Keltner’s book of the same name: “In moments of awe, we shift from the sense that we are solely in charge of our own fate and striving against others to feeling we are part of a community, sharing essential qualities, interdependent and collaborating….Awe awakens the better angels of our nature.”

Works cited:

Holistic Nursing: Scope and Standards of Practice (2nd ed.). (2013).

Keltner, D. (2023). Awe: The Transformative Power of Everyday Wonder. Random House.