CHAPTER 4

The Whole Health Process

David Rakel, MD  •  J. Adam Rindfleisch, MPhil, MD  •  Tracy Gaudet, MD

We can’t solve problems by using the same kind of thinking we used when we created them.
ALBERT EINSTEIN

VALUE OVER VOLUME over time. Ideally, this approach recruits the self-healing
mechanisms possessed by all living beings. When the
As health care spending in the US surpasses three trillion self-healing potential is tapped, there will be less need
dollars a year, there is a push to shift the focus of health for costly and potentially harmful interventions, be they
care delivery away from volume and toward increased pharmaceuticals, surgery, or acupuncture needles. How
value by improving quality at less cost. This “Value over is this value most efficiently obtained? We start by asking
Volume” approach is quickly changing reimbursement each patient to explore what matters to them most and
models and encouraging health care systems to create then to define his or her own health goals.
new models of care.1 Organizing resources around patients’ self-defined
This evolution honors the advances achieved using health goals is the most efficient way to motivate sustain-
the biomedical model while at the same time enhanc- able behavior change. These goals are those most rele-
ing it with a much needed transition away from a reac- vant within the context of people’s lives, so they are much
tive, disease-centric approach toward one that prioritizes more likely to foster patient engagement and adherence
improving health outcomes. New approaches place to the plan of care. This approach shifts our focus from
greater importance on patient engagement, highlight asking, “what’s the matter with you” to “what matters to
health promotion, and place care within the context of you.”
each individual.
One of the most important ways to enhance value is
to strategically tailor health care resources according to INNOVATIVE HEALTH SYSTEMS
the context of each person’s life. Ongoing, relationship-
centered care allows the clinician to understand what sort After more than 50 years of treatment by the Indian
of person has a disease (to paraphrase Osler) instead of Health Services, more than 60,000 Alaska Native and
simply focusing on what disease the person has. This con- American Indians living in Southcentral Alaska became
text helps explain why there is a predicted 15-fold return the owners of their own health care system, the South-
on investment when health systems have a strong primary central Alaska Foundation. Known as the Nuka System
care foundation.2 of Care,6 the system focuses on establishing long-term,
trusting, accountable relationships built upon a shared-
decision model where the patient’s health goals are pri-
PATIENT-DEFINED GOALS mary.7,8 After implementation in 1999, urgent care and
emergency department use decreased by 40%, specialist
To improve health outcomes, goals that drive clinical use decreased by 50%, and hospitalization days decreased
care must arise from the individual or community that is by 30%.9 Blood sugar and blood pressure control
served. This structure requires that we work beyond the improved,10 and customer satisfaction data showed that
traditional biomedical model that has been directed by 91% of customer-owners rated their care as “favorable.”7
physician-dominated dialogue. In this model, patients and their families are the principal
Research on contextual errors has shown that even drivers of health, which has reduced dependence on the
when clinicians are told by a patient that “I can’t afford health system (Fig. 4.1).
my asthma medication,” 50% of physicians will prescribe The Nuka strategy resulted in significant improve-
it anyway.3,4 Often the clinician will “do the right thing” ments in the health of a population that was at high risk
according to the evidence protocol for a condition that is for disease. A similar high-risk population is American
concrete instead of working the evidence into the context Veterans. A conventional biomedical model that places
of someone’s real life, which is more complex than gen- the patient in a passive role as they receive treatments for
eral guidelines can accommodate (Table 4.1). symptoms and disease states does not serve Veterans (or
A better balance is needed to combine the scientific, other Americans) well. Such a model risks the potential
biomedical model by artfully adapting it to be as rele- harm of polypharmacy while not recruiting the person’s
vant and useful as possible to the person being treated.5 active participation in their health.11 In 2012, The Office
Doing so will ensure patient adherence to a plan of care of Patient-Centered Care and Cultural Transforma-
that emphasizes what is needed most to change behavior tion (OPCCCT) was created to bring needed change to
27
28 PART I  Integrative Medicine

TABLE 4.1 Patient-Defined Goals TABLE 4.2 

Models of Care
Volume Value Traditional Medical
(Biomedical Model) (Health Outcomes Model) ­Assessment Whole Health Process
Concrete Context Chief complaint Engage patient’s meaning
Reductionistic Holistic History of present illness Personalized health
assessment
Data and science Poetry and the arts
Family and social history Patient-defined goals
More things Less things
Physical exam Professional expertise and
Projection of science’s Internal motivation for
alignment
“truth” change
Requires compliance Self-sustaining Diagnostic tests and Interdisciplinary team support
imaging
Assessment with Personalized health plan
appropriate coding
Therapeutic plan Tracking outcomes and goal
Patient, family, community achievement
Health care system
Both these models are valuable, but the Whole Health Process will
add more value.
Control

therapy, and complementary approaches—all the aspects

of care that involve other people besides oneself. The
outermost circle, “Community,” encompasses the entire
circle, emphasizing that while self-care is fundamental, no
one has to seek health alone. The person at the center of
Low Acuity High the circle is the captain of a team of people who all value
that person’s well-being at many different levels.
FIG. 4.1  □  The Alaska Native Health Care model moved the
column to the left, reducing dependence on high-cost medi-
cal interventions by increasing the control of the patient, their
family, and community. This change resulted in better health Personalized, Proactive, Patient-Driven
and fewer acute health care needs. (From Rakel DP, Jonas WB:
The patient-centered medical home. In Rakel RE, Rakel DP, editors: Care
Textbook of family medicine, ed 9, Philadelphia, 2016, Elsevier,
pp 17-24.)24 A personalized process recognizes that every human
being has a unique story that puts any therapy into the
context of their lives. For example, 20 people with hyper-
the largest health care system in the US, The Veterans tension may have 20 different therapeutic plans to lower
Health Administration (VHA). Directed by one of the blood pressure. One person may need to change diet,
coauthors, Tracy Gaudet, the OPCCCT is leading the while another may need to address stress. A personalized
charge towards a shift in health care delivery. The VHA health plan is more likely to promote long-term health, as
has declared that its primary strategic priority is “to pro- each individual’s main health needs are explored.
vide personalized, proactive, patient-driven health care A proactive approach encourages recognition of health
to Veterans, and engages and inspires Veterans to their risks and seeks to proactively minimize them. It supports
highest possible level of health and well-being.”12 This each human being’s powerful, innate self-healing pro-
model moves beyond the traditional health assessment, as cess, attempting to mobilize it rather than just suppress
is highlighted in Table 4.2. symptoms.
Patient-driven care requires that the locus of control
be given to each individual. Clinicians assist patients with
THE CIRCLE OF HEALTH recruiting the most appropriate professionals needed for
their individual success. All healing is self-healing, and
The diagram “Components of Proactive Health and the Whole Health process empowers people to find their
Well-Being,” known more informally as the “Circle of particular paths to self healing. They are placed in charge
Health,” is featured in Fig. 4.2. This elegant framework of their own health destiny.
focuses attention on “Me,” the individual, who is placed
at the center. Moving outward from the center, “mindful
awareness”—paying attention to one’s thoughts and pat- THREE QUESTIONS
terns—is the next circle. Next is the light blue circle, which
encompasses eight smaller circles, the “Circles of Proactive The Whole Health process can be challenging to incor-
Self-Care.” Here, after we see that the central focus is on porate, as it suggests a shift in focus that is unfamiliar
the individual and on what a person can do for self-care, to both clinicians and patients. Several key questions can
does the diagram then draw in the navy blue “Professional be asked to initiate the Whole Health encounter, but the
Care” circle, which incorporates prevention, conventional first question below is perhaps the most important and
 4  The Whole Health Process 29

Community

Working
your body

es
Power of Energy and Surroundings

ch
the mind flexibility

roa
Physical and

ap p
Relaxing and
emotional
ention and treatment
healing

d complementary
Mindful
Personal
Spirit and soul
development
Growing and Me
Personal life and
connecting
work life
Aw
areness

a l an
Prev

Family, friends, Food and drink

ti o n
and coworkers
Nourishing and

n
nve
Relationship Recharge fueling

Co
Sleep and
refresh

Me + Self
care + Professional
care + Community = Whole
health

FIG. 4.2  □  Circle of Health.

the most challenging. If framed correctly, it can connect and death is much less likely to change their behavior
people to their personal meaning, getting to the heart of than the person who wants to stop smoking because
a personalized, proactive, and patient-driven approach. the daughter they love recently developed asthma. The
The first question is at the center of the Fig. 4.2, the hemoglobin (Hgb) A1c test may just be an abstract idea,
mindful awareness of ME. while the fear of losing one’s eyesight or requiring dialy-
sis may be much more real. Eliciting emotional reasons
for change is much more effective than recruiting cogni-
Question #1, What? tive reasoning.
Experience in asking this question has provided valu-
What Gives Your Life Meaning?
able lessons. Many people initially may not understand
This question can be asked in a number of different ways, the question or may say, “I don’t know, you’re the doctor,
but the goal of the question is to connect the individual you tell me.” Providing context before asking the ques-
to what is most important. Without this connection, even tion can help with comprehension. Consider the follow-
a health goal that is defined by the individual will most ing script:
likely be unsustainable. This deeper exploration helps
to discover the underlying motivational driver that can In our clinic we are shifting focus from what is wrong with
allow for sustainable healthy behaviors.13,14 For example, you to a process that helps us understand what you want
a smoker whose clinician informs them of the evidence your health for. This way we can use the resources of the
linking smoking to increased risk of cancer, heart disease, health system to help you live your fullest life. Achieving
30 PART I  Integrative Medicine

What matters to you? such an event is a great opportunity but also a signifi-
cant shift. This exploration can be further supported
by self-reflection tools or group approaches outside of

s
me
e y the clinical encounter.
ng ilit

tco
nt ha nab

ou
e n c
at ters erm ati
o
vio
r ai
st

hy
at m pow tiv
Mo ha Su Other Versions of Question 1 Include

alt
Wh Em B e

He
What really matters to you?
vs. For what do you want your health?
Why do you want to be healthy or improve your health?
What is a health goal that will help you connect to what
is most meaningful in your life?  

Question #2, Where?

Diabetes mgmt.
Where Do You Need to Start to Achieve Your
FIG. 4.3  □  Aligning our work with what matters to the individ- Health Goal?
ual empowers them to be a proactive participant in care. Such
patient involvement is the most important factor in sustaining This question allows the patient to self-reflect and to pri-
healthy outcomes. Treating one disease at a time (e.g., diabetes oritize which area of self-care depicted by the light blue
management) is disconnected from the larger whole. T.S. Eliot
describes the bottom graphic well in his introduction to Dante’s circles in Fig. 4.2 are of highest priority. Each of the eight
Inferno: “The definition of hell is a place where nothing con- circles incorporate the foundational ingredients that
nects with nothing.” facilitate the proactive, self-healing mechanisms within
each individual.
A script that one may use to ask question #2 could go
health is much more about what you do than what you something like this:
take. I want to know what matters most to you, because
this will help us both know where to invest our time and These eight circles include key ingredients that are
energy to help you get where you want to go. important in the health of any human being. What they
all have in common is that they are linked to self-care.
If the response is, “I want to be healthy,” explore fur- That is, they are things that you can work on yourself,
ther, as in the following sample dialog: though we will be sure to talk about who can support
you with them along the way. Point to one or two areas
“If you were healthy, what would your life look like?” that you feel you need to work on most to achieve your
“I would be able to travel and spend time with my wife health goal.
and kids.”
“What will you need to be able to travel and connect to Ideally, the savvy information technology (IT)
your wife and kids?” team of the health system would populate each of the
“I need to get this arthritis pain under better control.” circles with available community resources relevant to
“That’s a great health goal! I am going to put down in the patient’s health goal. For example, the “Food and
your chart that your health goal is that you want to travel Drink” circle would include resources on how to access
and spend time with your wife and kids.” a nutrition consultant, healthy cooking classes, or mind-
ful eating classes.
The process of asking this question is as important To continue the previous scenario:
as the answer. The focus of the office visit changes from
a superficial conversation to a place of deeper meaning The patient whose health goal is to travel and spend time
that is rewarding and energizing for both the clinician with his wife and kids points to “Working Your Body” and
and the patient. Such interaction enhances the thera- “Personal Development” as the two areas that he feels need
peutic relationship while directing care towards value the most attention. He wants to move his body more since
because the action that follows the question will have he feels his arthritis is leading to a sedentary lifestyle. He
significant downstream health effects. This first ques- also wants to make sure he can afford the travel that he is
tion invites the patient to begin exploring what is most looking forward to with his loved ones, so he wants to add
meaningful to them and is a powerful first domino money to his retirement plan at work. For that reason, he
that drives positive health outcomes (Fig. 4.3). Sur- wants to get a promotion.
prisingly, the data show that such interaction does not
require more time and, more importantly, changes the
type of conversation we are having with our patients.4 Question #3, Who?
It is important to recognize that this question is deep, Who Do You Need to Support You in Achieving
and to truly explore it will take time and iterations. Your Health Goal?
Typically, people begin to reflect on such matters
when they are in health crisis, facing cancer or recov- This question recruits the most appropriate profession-
ering from a heart attack. To explore this issue before als, family members, friends, or community resources
 4  The Whole Health Process 31

needed to support achievement of the health goal. The

Whole Health process identifies the interdisciplinary DEVELOPING THE PERSONAL HEALTH
team that will offer support and guidance with the next PLAN
steps of the process. This team is linked to the outer two
rings in the Circle of Health (see Fig. 4.2). The Whole Whole Health has been introduced to dozens of VA
Health approach stresses the importance of creating a facilities since 2013. Different facilities have experi-
team that will help the individual succeed in achieving mented with innovative approaches to making care
his or her goals. more personalized, proactive, and patient driven. One
A script for question #3 could go something like of the questions that frequently comes up is, “But how
this: do I apply this model to the real world of practice? I
have time constraints, I have to be sure I always ask
Now we need to recruit services or individuals to help you about things like tobacco use and safety at home. How
achieve your health goal. Who do you feel will be most can I possibly fit more in?” Many clinicians find it help-
important in helping you be successful? ful to keep a few key pointers in mind as they begin to
do Personal Health Planning under the Whole Health
To use the military metaphor, we ask the Veteran model.
what is their mission for health, where do they need the No clinician writes the health plan alone. We have
most support, and who do we need to recruit to ensure a been indoctrinated with the idea that care happens in a
successful outcome? one-to-one interaction, with the clinician—often a physi-
cian—taking responsibility for the plan. This approach
can be effective on its own but is enhanced by a team
In the case of the man whose health goal is to travel and
approach. There are clinics in which the entire team col-
spend time with his wife and kids, we recruit an acupunc-
laborates on health planning, from the receptionist who
turist to help improve the pain and function of his knees.
provides the intake forms (the VA has created a “Per-
We refer him to physical therapy to increase his strength
sonal Health Inventory,” see the following Key Web
and improve his mobility. Finally, we recommend that he
Resources) to the nurse who reviews the inventory with
connect to human resources at work to improve his chances
them and the psychologist and social workers who are
of getting a better-paying job that was posted recently.
integrated into the team to help with various aspects of
This Whole Health process is directed and organized by his
follow up and support. Health coaches can also be invalu-
primary health care team in the patient-centered medical
able to the process.
home, but he, the patient, has been consistently directing
Much of the foundation for the personalized health
the process.
plan can be done outside of the clinic, allowing more time
and support to reflect on one’s life. The VA has created a
9-week Whole Health program in which facilitators are
Case Scenario: Mt. Kilimanjaro trained to lead the group and guide Veterans through the
Circle of Health. Through this process, the Veteran cre-
A 48-year-old female veteran named Betty visited her ates the foundation of their overarching personal health
physician every 3 to 4 months to monitor her type II dia- plan, and interactions with their providers in the clinical
betes. She would often feel frustrated because she never setting can be much more streamlined.
felt good enough. She would hear that she needed to lose Health plans take many forms. A health plan may be
more weight and improve her nutrition to get her Hgb
as simple as a one-item recommendation. “Bob, it sounds
A1C and low-density lipoprotein (LDL) cholesterol un-
der better control. She soon became frustrated with how like you are up for switching over to sparkling water
many medicines she was asked to take. between now and our next visit, what do you think?”
After a period of self-reflection, she realized that she If this is all Bob is up for, it is best not to hit him with
wanted the resources of the VA medical system to help her more than he can handle. Another person may be just the
achieve what she wanted to work towards. She had a person- opposite. Some people love to have multiple items on a
al goal of climbing to the top of Mt. Kilimanjaro by her 50th to-do-list to follow. Remember, though, that they should
birthday. So the next time she visited her doctor, she told be coauthors of that list!
him of this goal. He was resistant initially, but was eventually Health plans are built on continuity and follow up. No
swayed to refocus attention not just on her Hgb A1C levels one expects you to cover every issue during a single visit.
but towards helping her achieve her health goal, that which
Everyone who interacts with the person can help with the
connected her to meaning.
Betty’s health care team now consisted of the profession- plan, tweaking it as appropriate. Focusing on question
als she needed to help her achieve her goal, including a nu- one helps to clear the clutter of the crowded problem list,
tritionist, physical therapist, and a health psychologist; her allowing the team to focus on what matters most. A useful
primary care physician organized her care. In her 50th year, question may be, if we focused on one thing that would help
she made it to the top of Mt. Kilimanjaro. Betty was happy to all your other problems get better as a side effect, what would
have reached her health goal, and Betty’s team shared in the that one thing be?
joy of her success. Everyone was energized, as the focus of Believe it or not, this approach saves time. People
work was on connecting to meaning, not only for the patient who adopt it find that not only does their work feel much
but for that of the whole medical team. Not surprisingly, more gratifying, but they are also more efficient. Time
Betty’s Hgb A1C and LDL cholesterol improved as a side
and energy are saved by asking someone what they think
effect.
is going to help them the most. The question “What are
32 PART I  Integrative Medicine

you willing to do today to make your health better?” can follow up with other members of the team? The quest
write the health plan itself. for health is lifelong, and you can show them possible
You, as the clinician, also have a place at the center. routes that they can follow along the way.
One of the most powerful ways to understand this process
is to apply it to your own life. Clinician self-care matters.
You may find that you learn a great deal by applying this
entire process to your own individualized care needs. For THE VALUE OF THE WHOLE HEALTH
what do you want your health? And you might just find PROCESS
that this process gives you a kick-start that reconnects
you to meaning in your work. The Whole Health process incorporates key ingredi-
ents that promote sustainable health outcomes, as shown
in Figs. 4.2 and 4.3. Patients sit in the driver’s seat and
clarify, with support, which areas are most important to
FOUR-STEP PROCESS FOR HEALTH them. This process is not only empowering but also acti-
PLANNING vates their innate capacity to heal, tapping into the wis-
dom within each of us.
Largely due to the efforts of the VA facilities in the Bos- The value of this approach has become increasingly
ton area, a pragmatic process for health planning has clear through recent research. For example, many people
been developed.15 This process involves four steps, which choose “Power of the Mind” as an area of focus on the
may not all happen at once: Circle of Health because of the high levels of perceived
1. Assessment. Gathering information—and doing it stress in their lives. Self-care in this area can result in
in a different way—is critical. Yes, if the patient is significant cost savings. In a 2015 study, 4452 subjects
being seen for a specific concern, you should have were taught mind–body skills to reduce stress and build
that in mind. Rarely, someone will not want you resiliency. After following this cohort for 4.2 years, those
to use this approach; fair enough—respecting their who completed the training had a 43% overall reduc-
choice is a way to personalize care. However, if they tion in the use of health-related care than did the 13,149
are willing, asking the three questions listed above controls. Clinical encounters decreased by 41.9%, lab
can be an excellent way of doing an assessment. encounters dropped by 43.5%, and procedures were
2. Shared goal setting. In health professions training, we decreased by 21.4%.16 In another study investigating the
learn about how to interview people. One of the is- incidence and cost of treatment for upper respiratory
sues that arises during such training is agenda setting. illness, those who were taught mindfulness had a 70%
Remember, you do not give up your own priorities for the lower cost ($65 per meditator vs $214 per control) than
visit. Rather, you weave them into the overall process. did untreated ­controls.17
For our example patient previously, the clinician may The Diabetes Prevention Trial confirmed the value
have the goal of bringing down the patient’s heart dis- of healthy lifestyle choices, noting they were not only
ease risk. The items noted in the health plan, such as more effective clinically in reducing the incidence of
a potential reduction in financial stress by attaining a progression to diabetes when compared to metformin18
better-paying job, are useful for this process. but were also more cost effective.19 Avoiding smoking,
3. Health planning. Health planning is the step in moving the body, improving nutrition, maintaining a
which the clinician and patient work together to healthy body weight, and limiting excessive alcohol use
talk about what they will do. Patients often have dramatically improved the cost effectiveness. Practic-
great ideas already—just ask. Clinicians should ing these lifestyle behaviors was shown to decrease the
bring up their own ideas as well. Remember, for a incidence of coronary events by 83% in 84,129 women
plan to be successful, you have to have their buy-in. followed in the Nurse’s Health Study20,21 and by 79% in
Now is the time for you to decide whether you do 20,721 Swedish men followed for 11 years.22 These key
have their buy-in and how to increase it. determinants of health were also associated with living
4. Skill-building and support. Health planning does not 14 years longer in 20,244 people followed in the EPIC–
end when the patient leaves the room. It is incumbent Norfolk Study.23 The Whole Health approach allows us
upon the health care team to provide guidance to the to link meaning to action so that those we serve are more
person seeking care. What skills do they need to have? likely to incorporate these powerful behaviors into their
Does someone teach them a mind–body approach? own lives.
Do they need help signing up to do volunteer work? What one does is much more effective than what one
Is there a meditation practice you would like them to takes. Value is added when we are able to encourage and
try? Providing the information and connections they support personalized, proactive, patient-driven care. The
need is important. As is the case with any clinical visit, Whole Health approach is a powerful and innovative way
you also need be very clear in stating what steps will to achieve value by valuing what matters to the people
follow. When will they see you again? When will they who seek our care.
 4  The Whole Health Process 33

Key Web Resources

The Veterans Administration Office of Patient-Centered Care Provides information on incorporating this Whole Health Con-
and Cultural Transformation cept within the VA Medical System
http://www.va.gov/PATIENTCENTEREDCARE/about.asp Includes resources and strategies on a personalized, proactive,
patient-centered approach

The Veterans Administration Videos from the VA’s patient-centered care that explores the
www.va.gov/patientcenteredcare/multimedia-and-resources.asp Whole Health process

Whole Health Video A VA-sponsored video that conveys the vision of the Whole
http://bcove.me/7si4hxcv Health Process of Care

Personal Health Planning Video A VA-sponsored video that summarizes the process of Per-
http://bcove.me/35dbfmed sonal Health Planning

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33.e1