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Definition of whole person care in general practice in the English language literature: a systematic review

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      Abstract

      ObjectivesThe importance of ‘whole person’ or ‘holistic’ care is widely recognised, particularly with an increasing prevalence of chronic multimorbidity internationally. This approach to care is a defining feature of general practice. However, its precise meaning remains ambiguous. We aimed to determine how the term ‘whole person’ care is understood by general practitioners (GPs), and whether it is synonymous with ‘[w]holistic’ and ‘biopsychosocial’ care.DesignSystematic literature review.MethodsMEDLINE, PubMed, EMBASE, CINAHL, PsycINFO, Web of Science, Proquest Dissertations and Theses, Science.gov (Health and Medicine database), Google Scholar and included studies’ reference lists were searched with an unlimited date range. Systematic or literature reviews, original research, theoretical articles or books/book chapters; specific to general practice; relevant to the research question; and published in English were included. Included literature was critically appraised, and data were extracted and analysed using thematic synthesis.ResultsFifty publications were included from 4297 non-duplicate records retrieved. Six themes were identified: a multidimensional, integrated approach; the importance of the therapeutic relationship; acknowledging doctors’ humanity; recognising patients’ individual personhood; viewing health as more than absence of disease; and employing a range of treatment modalities. Whole person, biopsychosocial and holistic terminology were often used interchangeably, but were not synonymous.ConclusionsWhole person, holistic and biopsychosocial terminology are primarily characterised by a multidimensional approach to care and incorporate additional elements described above. Whole person care probably represents the closest representation of the basis for general practice. Health systems aiming to provide whole person care need to address the challenge of integrating the care of other health professionals, and maintaining the patient–doctor relationship central to the themes identified. Further research is required to clarify the representativeness of the findings, and the relative importance GPs’ assign to each theme.PROSPERO registration numberCRD42017058824.

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      Methods for the thematic synthesis of qualitative research in systematic reviews

      Background There is a growing recognition of the value of synthesising qualitative research in the evidence base in order to facilitate effective and appropriate health care. In response to this, methods for undertaking these syntheses are currently being developed. Thematic analysis is a method that is often used to analyse data in primary qualitative research. This paper reports on the use of this type of analysis in systematic reviews to bring together and integrate the findings of multiple qualitative studies. Methods We describe thematic synthesis, outline several steps for its conduct and illustrate the process and outcome of this approach using a completed review of health promotion research. Thematic synthesis has three stages: the coding of text 'line-by-line'; the development of 'descriptive themes'; and the generation of 'analytical themes'. While the development of descriptive themes remains 'close' to the primary studies, the analytical themes represent a stage of interpretation whereby the reviewers 'go beyond' the primary studies and generate new interpretive constructs, explanations or hypotheses. The use of computer software can facilitate this method of synthesis; detailed guidance is given on how this can be achieved. Results We used thematic synthesis to combine the studies of children's views and identified key themes to explore in the intervention studies. Most interventions were based in school and often combined learning about health benefits with 'hands-on' experience. The studies of children's views suggested that fruit and vegetables should be treated in different ways, and that messages should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective. Thematic synthesis enabled us to stay 'close' to the results of the primary studies, synthesising them in a transparent way, and facilitating the explicit production of new concepts and hypotheses. Conclusion We compare thematic synthesis to other methods for the synthesis of qualitative research, discussing issues of context and rigour. Thematic synthesis is presented as a tried and tested method that preserves an explicit and transparent link between conclusions and the text of primary studies; as such it preserves principles that have traditionally been important to systematic reviewing.
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        The biopsychosocial model 25 years later: principles, practice, and scientific inquiry.

        The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient's subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex--subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term "new paradigm" would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient.
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          An 'endless struggle': a qualitative study of general practitioners' and practice nurses' experiences of managing multimorbidity in socio-economically deprived areas of Scotland.

          To understand general practitioners' (GPs) and practice nurses' (PNs) experiences of managing multimorbidity in deprived areas and elicit views on what might help. Qualitative interviews with 19 GPs and PNs in four practices with a high percentage of patients living in the top 15% most deprived areas of Scotland. Data were analysed using constant comparison. Professionals' discussions of how they managed multimorbidity captured: (1) definitions of multimorbidity that included multiple social, psychological, and health problems associated with deprivation; (2) descriptions of the 'endless struggle' of patients trying to manage illnesses in the midst of chaotic lives with limited personal, social, and material resources; (3) accounts of the ongoing struggle of professionals trying to manage, with personal consequences for some; and (4) ideas on what might help, including 'whole person' approaches. Professionals' discussions of the difficulties that they face personally and attempt to help those most in need reflect both the continuing existence of the 'inverse care law' and the need for whole system changes to enhance the effectiveness of primary care for patients with multimorbidity in deprived areas.
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            Author and article information

            Affiliations
            [1 ] departmentPrimary Care Clinical Unit, Faculty of Medicine , University of Queensland , Herston, Queensland, Australia
            [2 ] departmentPsycho-Oncology Co-operative Research Group, Sydney Health Ethics, Faculty of Medicine , University of Sydney , Sydney, New South Wales, Australia
            Author notes
            [Correspondence to ] Dr Hayley Thomas; h.thomas@ 123456uq.edu.au
            Journal
            BMJ Open
            BMJ Open
            bmjopen
            bmjopen
            BMJ Open
            BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
            2044-6055
            2018
            14 December 2018
            : 8
            : 12
            30552268
            6303638
            bmjopen-2018-023758
            10.1136/bmjopen-2018-023758
            © Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

            This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

            Product
            Funding
            Funded by: Australian Government;
            Categories
            General practice / Family practice
            Research
            1506
            1696
            Custom metadata
            unlocked

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