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October 4, 2000

No One an Island: The Geography of the Whole Patient

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JAMA. 2000;284(13):1704. doi:10.1001/jama.284.13.1704-JMS1004-2-1

It has become commonplace to bemoan the passing of the old-fashioned good family doctor. There is widespread concern about the lack of attention paid to the art of medicine for, despite the evolution of scientific medicine, the human heart remains the same. Thus, there is a heightened awareness of the need for physicians to address not only the biological but also the psychological, social, and cultural factors that contribute to the development and continuation of disease.

Is the growing attention paid to psychosocial issues a worthwhile endeavor, or is it, as some have argued, too much for one physician to undertake in these days of 15-minute office visits? In this issue, David Sobel gives us an answer, describing how attention to the whole patient not only yields better outcomes, but is also cost-effective.

Most medical students are well-versed in pathology, but their familiarity with life on the other side of the stethoscope often lags behind their scientific knowledge. Beyond cell counts and viral loads, what does it mean to be the person with the illness? Jane van Dis, whose stark photographs of South Dakota grace the cover of this issue, introduces us to a woman who is living with the human immunodeficiency virus in this remote locale.

More than two thirds of US citizens belong to a church or synagogue,1 and even more incorporate some spiritual practice into their lives. Yet the medical literature has only recently begun to include spiritual practices in its assessment of psychosocial issues. What is a physician's role in this arena? Harold G. Koenig offers some practical suggestions for how physicians might integrate what they know about their patients' religious beliefs into the effective practice of medicine.

Managing patients with chronic disease is the single largest source of cost for the health care system,2 but despite its prevalence chronic disease often receives little attention in the medical classroom.3 How can tomorrow's physicians learn to share in the partnership that such patients will need? The answer, according to Martha Funnell and Robert Anderson, involves a change of perspective. Their work suggests an example of how addressing the psychosocial issues of patient care makes for better, more effective medicine.

Reflecting on his own experience as a patient, essayist Anatole Broyard observed, "Not every patient can be saved, but his illness may be eased by the way the doctor responds to him—and in responding to him, the doctor may save himself."4 As they continue their training, medical students would be well advised to remember that treating a disease and caring for a patient are not necessarily the same activity.

US Census Bureau, Statistical Abstract of the United States: 1998.  Washington, DC US Bureau of the Census1998;
Fisher  LWeihs  KLfor the National Working Group on Family-Based Interventions in Chronic Disease, Can addressing family relationships improve outcomes in chronic disease?  J Fam Pract. 2000;49561- 566Google Scholar
Cohen  AJ Caring for the chronically ill: a vital subject for medical education.  Acad Med. 1998;731261- 1266Google ScholarCrossref
Broyard  A Doctor talk to me.  New York Times Magazine. August26 1990;17Google Scholar