00 Politics and Society Open Writings

Read this White Paper by Board Members Venodhar Rao Julapalli, M.D. and Vinay Rao Julapalli, M.D., F.A.C.C.

There is a dire need for the integration of the art, science, and morality of medicine. This paper explores the deep implications of the Unique Self in integrating medicine. Co-authors and physicians Venu and Vinay Julapalli call on their extensive understanding of the promises and pitfalls of modern health care to reconceive the practice of medicine. The paper provides the framework to evolve medicine through the emergent Unique Self insight. At stake is no less than the future of how we care for ourselves and each other.

Unique Self and the Future of Medicine

Abstract:

Medicine is at a critical crossroads in its evolution from antiquity to our modern age. This article aims to reconceive the future of medicine. Key to this conception is an understanding of the evolution of individual development. To this end, the discussion will first outline the stations of the selves, on the path to what has been termed the Unique Self by spiritual thinker Marc Gafni. Next, the discussion will distinguish between two poles of development and outlook, in order to understand how the insight of Unique Self integrates these dualities. It will then view the Unique Self from three perspectives, or four quadrants, of reality and also illustrate how Unique Self appreciates the balance between part and whole. The discussion will subsequently correlate the stations of the selves with the history of medicine and further examine dualities in medicine that parallel those of the self . It will then elucidate how an understanding of Unique Self fundamentally shifts our envisioning of the practice of medicine. This shift renews the unique calling that is the art and science of healing.

Introduction

Universal to the human experience is care of our health. Medicine is defined as “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease.” The topic of medicine is therefore relevant to all of humanity.In the United States, the practice of medicine has reached a critical crossroads. National spending on health care has been estimated to total $2.8 trillion in 2012, which is 18% of the gross domestic product (GDP). It is projected to increase to about 25% of GDP and 40% of total federal spending by 2037. Few dispute that this trajectory is unsustainable.

The dispute begins in how to alter this trajectory. The debate has raged on from multiple perspectives. Some have focused on the structures of payment for health care, while others have investigated the sources of health care pricing. Some have proposed the standardization of health care delivery with an emphasis on maximizing value through evidence-based medicine, while others have highlighted the role of the social determinants of health in influencing the rising costs of medical care. The Affordable Care Act, signed into law in March 2010, expanded health insurance coverage for Americans and introduced programs designed to slow spending on health care. However, there is no clear consensus on its ultimate effect in bending the health care cost curve down.

Most of the recent discussions on the practice of medicine have preferentially approached health care as an object. Evidence-based guidelines, quality measures, value-based metrics, and pay-for-performance programs presuppose an objective perspective on medicine. The increasingly acknowledged urgency of controlling spiraling health care costs has certainly advantaged this perspective, along with desires to improve patient safety and even out regional variations in health care delivery.

Somewhat drowned out in the recent movements in medicine is the voice of medical humanism. This voice presents medicine from a subjective perspective, as it highlights the individual values, goals, and preferences of a patient with respect to clinical decision making. From this perspective, paramount are factors such as honoring the dignity of patients and their families, acknowledging their cultural and ethical sensitivities, sharing clinical decision making between the patient and the physician, and upholding the autonomy of the patient in making medical decisions. Physicians voicing humanism in medicine feel that the subjective aspect is crucial in maintaining medical professionalism, demonstrating good clinical judgment, and caring for patients near the end of life. They question the effectiveness of health care based merely on utilitarian medical decision analyses, rather than nuanced conversations between the patient and physician on the patient’s perception of his/her illness and its treatment.

The two perspectives, medicine as an objective science and medicine as a subjective art, are often diametrically opposed to each other. Health care objectivists regret that “Our current health care system is essentially a cottage industry of noninteg rated, dedicated artisans who eschew standardization.” They criticize the current system as one that “overvalues local autonomy and undervalues disciplined science.” In subjective medicine, “‘Good doctors’ are celebrated for their unwavering dedication to doing whatever it takes to care for their individual patients.” In their view, this leads to excessive tests and procedures, a fragmentation of care, limited oversight of such care, and ultimately wasteful and unreliable medicine.

Health care subjectivists, on the other hand, lament that “Reducing medicine to economics makes a mockery of the bond between the healer and the sick.” They eschew the replacement of terms such as “doctors” and “nurses” with “providers,” and “patients” with “customers” or “consumers.” They feel these terms are “reductionist; they ignore the essential psychological, spiritual, and humanistic dimens ions of the relationship – the aspects that traditionally made medicine a ‘calling,’ in which altruism overshadowed personal gain.” In objective medicine, the “discourse shifts the focus from the good of the individual to the exigencies of the system and its costs.” In their view, this results in diminished independent and creative decision making, dehumanization of the patient and professional, destruction of the trust so crucial to the patient-doctor relationship, and ultimately a demeaning of medicine.

How best can we reconcile these two positions in a way that includes and transcends them both? Is there another perspective that honors medicine both as a science and as an art, without congealing the two sides into a muddled compromise that satisfies neither?

Acknowledging the instability of the current system, can we evolve medicine to a practice of greater value, efficiency, meaning, and purpose?

In the rest of this discussion, we aim to reconceive the future of medicine. Key to this conception is an understanding of the evolution of individual development. To this end, we will first outline the stations of the selves, on the path to what has been termed the Unique Self by spiritual thinker Marc Gafni. Next, we will distinguish between two poles of development and outlook, in order to understand how the insight of Unique Self integrates these dualities. We will then discuss the Unique Self from three perspectives, or four quadrants, of reality and also see how Unique Self appreciates the balance between part and whole. We will subsequently correlate the stations of the selves with the history of medicine and further examine dualities in medicine that parallel those of the self. We will finally outline how an understanding of Unique Self fundamentally shifts our envisioning of the practice of medicine. Our discussion will highlight the physician as the exemplar of the medical professional but can apply to any professional involved in caring for patients. All are included in the future of medicine.