Patient Scenario
Dr. James is a head and neck oncologic surgeon hosting a two-week preceptorship for a third-year medical student in his practice. Ms. Perez is a very intelligent, engaged, and eager medical student, with excellent communication skills with patients and staff. She has demonstrated a keen capability for empathizing with patients, with the result that patients tend to share their illness narratives with her in detail. After interviewing the last patient of the morning, she comes to Dr. James to present the history and physical exam findings.
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January 2025The patient is Ms. Angela Wood, a 30-year-old female with a two-centimeter neck mass in the region of the right thyroid lobe. The endocrinologist who referred her to Dr. James had ordered a fine needle aspiration biopsy, which yielded the diagnosis of follicular carcinoma of the thyroid. Imaging studies identified several ipsilateral lymph nodes that are suggestive of metastatic disease. At the end of the presentation, Ms. Perez hesitates, then states, “But wait, there’s more if you want to hear it.” Ms. Perez relates that Ms. Wood is a single mother with two young children; she lives with her mother after the tragic death of her husband in an auto accident, and she works two jobs to provide for the basic needs of her family. She indicated to Ms. Perez that she feels constantly stressed, financially marginal, and always tired. Ms. Wood appreciates that her mother plays a significant role in looking after her children, but she is limited in her capabilities because of health issues. Ms. Wood expressed to Ms. Perez that she does not know how this cancer will affect her jobs and her ability to care for the children, and wonders whether she will live long enough to see the children into adulthood. Ms. Perez states that Ms. Wood burst into tears during their discussion. Finally, Ms. Perez asks if holistic medicine is a part of the practice of otolaryngology, as this patient might benefit from a broader approach to her disease, within the context of her quality of life.
Dr. James agrees that this would be a good topic for discussion over lunch. What could that discussion entail?
Discussion
While otolaryngology–head and neck surgery is conventionally considered a surgical specialty, it is, in fact, a hybrid specialty, with both general medical and surgical aspects. While the specialty of urology, for instance, has a medical counter-specialty in nephrology, otolaryngology–head and neck surgery does not have a similar model. Indeed, the counterpart could be considered to be all primary care specialties. The holistic medicine approach in primary care seems to fit well with the “patient-centered” model, which considers myriad aspects of the patient’s physical, psychosocial, socioeconomic, environmental, cultural, familial, occupational, and spiritual dimensions. The extent to which these elements contribute to health and well-being versus disease and ill-being in a given patient can be significant. The question posed to Dr. James by Ms. Perez pegs the issue of whether holistic patient care has a role in otolaryngology and, if so, what would be the optimal elements to consider.
Holistic patient care fundamentally approaches health and disease, recognizing that illness may not occur in isolation but rather may represent the state of the interaction among physical, mental–emotional, and social well-being. Thus, considering the interconnectedness of these factors, optimal care of the patient may well be impacted by understanding their interaction in the patient’s life. Given the importance of the voice, articulation, hearing, facial emotional expressions, taste and smell, and swallowing in communication and social interaction, the otolaryngologist may have a duty to consider their impact on disease and well-being. Addressing just the patient’s chief concern may not uncover pertinent information and quality-of-life factors that have contributed to or might contribute to an enhanced therapeutic outcome.
Some of the more common aspects of holistic care may impact barriers to care (financial, transportation), increased risk for surgery (smoking, alcoholism, substance disuse), family or spousal support (abuse in the home or absence of responsible caregivers), and stress (potential job loss, childcare, fear). Otolaryngologists are quite aware of the impact of these stressors. Therein lies the opportunity to consider the patient as the “whole,” within the understanding of how the factors might impact the course of treatment.
When physicians of any clinical specialty take the time to understand the patient’s life, the barriers to their health or healing, and their concerns, patients will feel more valued, and the patient-physician relationship will strengthen. Trust and understanding between a patient and their otolaryngologist are of immeasurable importance in shared decision making and effective communication.
Most otolaryngologists work effectively in a team environment, with consultations and opinions from colleagues in many areas of the specialty—otologist/audiologist/balance specialist, laryngologist/speech, language and swallowing clinicians, head and neck oncologists/radiation therapists/reconstructive surgeons/dental/medical oncologists, and so on. We are already a team-oriented, interdisciplinary-focused specialty, with broad collaborative approaches that can support a more holistic planning of patient care. While the appropriate medical and surgical care is expected—evidence-based and supported by experience and knowledge—patient outcomes may well be enhanced by attending to major deterrents to their optimal response to therapeutics.
In the April 2008 issue of ENTtoday, Angela Munasque wrote of the experiences of three otolaryngologists—Drs. Jennifer Judkins, Benjamin Asher, and Robert Sciacca—extended their patient care to include holistic approaches and integrative medicine options to enhance patient outcomes. Now, 16 years later, it is time to re-examine the opportunities for otolaryngologists to think beyond pharmaceutical and surgical measures to address patient disorders and diseases and consider what other patient needs might be important to address.
One key area for consideration is nutrition, which is germane to patient treatments for disorders ranging from sleep apnea to cancer of the upper aerodigestive system. As more evidence comes forth regarding the immune system inherent to the gastrointestinal tract, proper nutrition is beginning to be better understood as a factor in immune system integrity. Some mental disorders and extreme anxiety may need supportive care before, during, and after treatment. Financial issues are ubiquitous in today’s society, and most patients will be concerned (or very worried) about the impact of their disease and treatment on their financial status. Ensuring elder and childcare, paying the bills, keeping one’s employment, and quality of life are all understandable concerns for many patients, and cannot be ignored by the physician. While not all can be adequately addressed, physicians must recognize their negative impact and make an effort to seek support for their patients.
Stress is considered endemic in American life and may well be a negative factor in healing and response to surgery and pharmacotherapy. In this author’s experience, most otolaryngologists are aware of the potential for stress, anxiety, and anesthesia risk in certain patients, thus begging a pre-operative approach to diminishing anxiety in multiple ways. For some patients, a calm, reassuring demeanor in their surgeon can be very helpful; for others, it may be a reassuring touch to the hand or shoulder, along with a confident smile. Virtue ethics implies that trustworthiness, compassion, and empathy can have a salutary impact on patients, particularly in difficult situations where the patient must decide. Although shared decision making is the current concept for recognizing both patient autonomy and the duty of physician beneficence/nonmaleficence, it is not always a simple platform for decisions. Communication and active listening from both patient and physician need to be performed in the context of knowledge exchange, patient preferences and goals, and a discussion of the impact of various therapeutic options on the patient’s life.
Holistic medicine, often termed “integrative medicine,” includes a wide range of considerations, including acupuncture for persistent pain, massage and muscle therapy, meditation, music therapy, yoga, and spirituality. One can appreciate the low risk for these interventions (or therapeutic adjuncts), but not all would be appropriate or accepted by the patient. Spirituality is one option that really cannot be forced on the patient; however, if the otolaryngologist, as part of the broader narrative elicited from the patient, can identify the role of spirituality in a patient’s life, that knowledge could be helpful in the patient’s approach to surgery and the postoperative course. The main caveat is that many physicians, including otolaryngologists, are uncomfortable about how to proceed with incorporating the patient’s spirituality into the therapeutic plan, and that is understandable. When used as part of the therapeutic plan, and when it is acceptable to the patient to discuss, spirituality can often be a valuable strengthening element, though caution is advised.
There are some ethical considerations in using a holistic approach to otolaryngology care, including privacy issues, inappropriate lifestyle interventions for a given patient, autonomy and informed consent, and cultural sensitivities. While we cannot all be “culturally competent” for all our patients, working with the patient to identify those cultural issues that might positively or negatively affect their health could be quite informative. Trust and communication are integral to not overstepping boundaries, and not all patients want their physicians to step into their lives beyond medical or surgical diagnostic and therapeutic care.
Given Ms. Wood’s complex socioeconomic and family issues and her minimal support system, there could be an opportunity to discuss these concerns with her, understand the stresses, and consider (with her) what options might be available to assist her during the time of her surgery and recovery. And, equally important, Dr. James would do well to display appropriate empathy and professional support for her concerns as an ethical otolaryngologist. Ms. Perez would have another strong role model for her developing physician personhood.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.