The Principles of Inter-being, Medicine, Health and Awareness... The Apple Medical Model (The Collaborative Patient-Centred Care Model (CPCCM))

   My motivational and personal belief and structure around medical models theories evolve around an apple. Take the time, appreciate the apple and realize the facets and depths of dimension. Sadly in life, we don't appreciate neither depth nor breadth of the humble apple.

   How often have we eaten an apple? But what of the apple? Where does it come from and what went into the creation of the apple? How often do we stop in our busy lives to reflect, assess and reflect on the apple? That apple serves in so many ways both past reaching and future extending. It also can stand as a reflection of our day, our actions, our inspirations. When we stop, reflect and look at the dynamics behind what we are doing and seizing the moment, we are better suited and able to tackle the next steps.

   The simple apple is extra-ordinarily complex. Why dont we stop and appreciate? Think of the apple in its intricacies. That will help us deliver the day and deliver the moment and ultimately colour our thoughts, aspirations and interactions with others.  What if this was to be transposed into the concept of being a person, an individual? Let us interface the day to day and motivational concepts into medicine...

  This the the crux of the theory. There are basically 2 different accepted models in medicine. The first is the medical model that does a very good job of looking at the disease states in isolation. The next model that is in the literature is that of the bio-psycho-social mode.  This addresses a person from the medical perspective (biological) but not the psychological or sociological implications of a disease. Basically the bio-psycho-social model addresses the impact in a second and third dimension and gives some depth and breadth to the discussion and care of the person. No matter what disease, whether it be diabetes, mental health issues or infectious in nature, there is a ripple outward effect. However, I propose that there is a fourth dimension that needs to be effectively dealt with. It is the dis-ease of the disease and thus that fourth dimension is the one of the spirit. How can we best treat the individual to move ahead and recover beyond the pills, medications, treatments and nostrums? There in such lies my Apple Medical Model.

   So much goes into the physical treatment modalities of an individual. We too are very complex in nature. We bring our past, successes, challenges, accolades, problems, families, belief systems and genetics to the table. As such, treatment should be individualized and medications are but a piece of the puzzle. As such, treatment options should be bio-psycho-social-spiritual  in nature. They should address the patient from a biological, social and psychological component plus know how the patient FEELS and BELIEVES. The disease versus dis-ease (and in fact the inter-twine of the two) must be considered in therapeutic options. If one considers the complexity of a 2000 piece jigsaw puzzle, they will know only one iece fits exactly where it should. That the lines, shadows and colours all play into choosing that piece at that time in that puzzle. And not unlike a jigsaw puzzle, if you are missing 1 piece of the puzzle you can still see the picture, but the picture is not complete. So as the challenges and complexities of treatment in mental health. Many of these premises have come from masters such as Thich Nhat Hahn (primary), James Allen III and Norman Peale. Gyatso also serves as an excellent reference. 

   Back to the apple... when you look at the apple it it far deeper than it looks in complexity. Take the time and appreciate the apple. So too individuals. Take the time, appreciate the moment and love the small things. The apple is but a humble analogy but the facets are infinite. 

    Medical professionals and patients it doesn't matter... we need to be ourselves, often. Awareness, compassion, empathy and tolerance and acceptance all extend from being ourselves and aware of the intricacies that each of us possess. Take the time, appreciate what goes into an apple. That slowing down, building awareness transfers so well into life. Mindfulness and reflection are the keys to well-being.

    Here is the Introduction to the CPCCM Model by Lamoure J, Stovel J, Piamonte M et al being published in early March of 2011 (Copyrighted). Full text available through link, Contact pages or publications page link:

   "Patient care has traditionally been guided by the conventional paradigm known as the medical or biomedical model, whose roots can be traced back to the era of reductionism and mind-body dualism, which separates the mental from the somatic. (Engel, 1977)  In this model, disease is defined as a biophysical malfunction. (Engel, 1977)  In the biomedical model, the goal of treatment is to correct the malfunction in order to cure the disease. (Engel, 1977)  As such, this traditional medical model places the pathophysiology of the disease, objective tests, and therapeutic interventions at the centre of patient care. (McCollum, 2009)  Such a model offers a one-dimensional approach to patient care that excludes the patient experience of illness and how this might impact other facets of the patient’s life (e.g., work disability, finances, social networks, etc.) because they are believed to lie outside of medicine’s responsibility and authority. (McCollum, 2009; Engel, 1977)

By incorporating other psychological (e.g., thoughts, emotions, behaviors) and social dimensions of the patient into the care plan, one moves towards the bio-psycho-social (BPS) model of patient care. (Phelps, 2009)  The BPS model was first theorized by a psychiatrist, Dr. George L. Engel, in 1977. (Engel, 1977)  In the BPS model, patient care is based on the belief that psychological and social dimensions also contribute significantly to human functioning within the context of disease or illness and, as such, need to be considered when providing care to a patient. (Engel, 1977)  Specifically, the biological component examines the cause of the illness and how it affects the functioning of the body. (Engel, 1977)  The psychological component of the model explores any potential psychological causes for the illness (e.g., lack of self-control, emotional stressors, negative-thinking, etc.). (Engel, 1977)  Finally, the social component considers how different social factors (e.g., socioeconomic status, religion, culture, etc.) impact illness. (Engel, 1977)  In order to address all aspects of this three-dimensional model, an integrated team approach involving allied healthcare professionals such as physicians, nurses, psychologists, pharmacists, social workers, and rehabilitation specialists are critical for ensuring that more comprehensive patient care is provided. (Phelps, 2009)  Overall, the underlying premise of the BPS model is that the body and mind are intricately connected and what affects one will affect the other. (Halligan, 2006; Freudenreich, 2010)  However, while this model advances patient care and can address the dis-ease that exists within the disease, it still does not encompass the patient as a “whole” and consider all the multitude of facets that make up the individual.

An alternative model to the biomedical and BPS model of care is the recovery model.  In the recovery model, the patient is involved in a lifelong recovery process that involves a number of incremental steps across various facets of his or her life. (Turton, 2010)  Moreover, the primary illness is seen as only one dimension in the patient’s recovery process. (Turton, 2010)    Other key aspects of this model include negotiating treatment approaches between patients and practitioners such that the patient feels empowered. (Turton, 2010)    Moreover, this model enables patients to regain their dignity and identity beyond the illness. (Turton, 2010)   As such, this model takes the BPS model and advances it forward to include other patient dimensions in the provision of their care.  Thus, the underlying ethos of this model for the patient is one of hope and optimism. (Turton, 2010)

A recent study conducted in ten European countries aimed to examine the recovery model of patient care in order to identify aspects of care that key stakeholders believed to be most important in the promoting recovery, specifically in patients with mental illness. (Turton, 2010)    Eleven important domains of care identified by stakeholders in this study included: (1) social policy and human rights, (2) social inclusion, (3) self-management and autonomy, (4) therapeutic interventions, (5) governance, (6) staffing, (7) staff attitudes, (8) institutional environment, (9) post-discharge care, (10) caregivers, and (11) physical health care. (Turton, 2010)    The authors also found that there was generally a high consensus between groups and countries with some modest differences in priorities noted. (Turton, 2010)    Interesting, the most highly rated aspect of care was therapeutic interventions, a central piece of the more traditional medical model of care. (Turton, 2010)  The authors suggest that stakeholders may still hold therapeutic interventions as the most important aspect of care because such interventions form the foundation and ‘raison d’être’ of health care. (Turton, 2010)    Thus, it may be difficult for practitioners to step away from convention and embrace a new paradigm.

Incorporating various aspects of the BPS and recovery model of patient care, a patient-centered care (PCC) model has evolved over the last several years to replace the conventional biomedical model of care. (Laird-Fick, 2010)  The Institute of Medicine (IOM) has stated that embracing a PCC model will help to close the “quality chasm” often present in the care provided to patients. (IOM, 2001)  In a PCC model, the patient’s individuality is central. (Wolf, 2008) The patient has the right to have his or her needs, desires, beliefs, values, and goals respected and placed at the centre of the care plan. (Laird-Fick, 2010; Wolf, 2008)  Such respect of the patient’s individuality is part of the team’s commitment to understand the patient’s perspective of his or her own health status and subsequent care. (Wolf, 2008) The underlying ethos of this model of care is that the patient has the right to respect, dignity, and care that focuses on the person and situation versus the disease process. (Wolf, 2008)

Our hypothesis is that the medical and bio-psycho-social models act as an essential foundation on which a more patient functionality centered model evolves: the Collaborative Patient/Person-Centric Care Model (CPCCM).  This has a paradigm shift in the deliverables of patient care which involves talking to patients and family, listening to their desired outcomes, collaborating with allied health team members in order to help facilitate these patient goals, and finally formulating an individualized care plan that combines the patient’s wishes with the clinical endpoints derived from a uniform therapeutic thought process.  The root of this theory is enmeshed in goal driven outcomes, as are the other models. However the goal is driven by the patient and then filtered through the professional lenses of the members of the treating team versus the converse. This evidence-informed versus evidence-based approach is more patient centric than when outcomes are determined independently by clinicians in a traditional hierarchical structure. This also allows the current structure to be realigned along a linear axis. (Lamoure 2008)"