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Des données actuelles de la science à leur application en pratique ambulatoire. L'adoption d'un modèle holistique proposée par la WONCA en 2002 – Revue de littérature –

Abstract : INTRODUCTION: Following its 2002 convention, W.O.N.C.A. Europe (European Society of General Medicine - Family Medicine) has published a statement entitled "The European definition of general medicine - family medicine". At the heart of this publication: medicine and the subject matter. Year after year, congress after convention, article after article, general practitioners have accompanied and brought this paradigm shift. This ethical affirmation that places the human being above the absolute goal of science or art: In 1977, Georges L. Engel (1913-1999) proposed "a biopsychosocial model" which continues to be developed both theoretically and in terms of adaptation to field practices. A similar approach was made by Bernard Gay at the inaugural meeting of WONCA Europe in Strasbourg in 1995. He proposes a theoretical model where the will to focus the approach on the patient is asserted from the outset; a model in which health is considered a complex phenomenon. This global model, open to the outside, considers disease as the result of organic, human and environmental factors. This statement is also clearly observed in the chronological reading of the definitions of general medicine: from the Leeuwenhorst group (1974), to that of Olesen (2000), to that of W.O.N.C.A. (1991) and the definition of O.M.S. which in its 1998 Framework Statement describes a system of features to provide integrated patient-centered care. "Biopsychosocial model", "global model centered on the patient": here are two names, "two flags" which, until now, represented the will to center the discipline around the patient; the decision to assume the complexity resulting from the integration of the physical, psychological, social, cultural and existential dimensions. In 2002 in the "European definition of general medicine - family medicine" a new terminology appears: the text proposes that the practitioner masters a fundamental capacity: the adoption of a "holistic model" - "holistic modeling". This sixth skill: "the adoption of a holistic model" is the subject of this thesis. To refer to holism in France during scientific work inevitably triggers a controversy. And, ultimately, draws the line between opponents and supporters seduced by this term. Why, then, have you changed from "global patient-centered model" and "biopsychosocial model" to "holistic model"? What are the advantages, the disadvantages? PROBLEM: The only question that served as a guideline during this thesis was: "to focus on the subject of the practice of general medicine, is it appropriate to adopt a holistic model? ". METHOD: I conducted a literature review and analysis of the proposed adoption of a holistic model in the definition of general medicine proposed by WONCA Europe in 2002. At the same time, I studied the concept of "holism" very precisely from my review of literature and sources from the human sciences. RESULTS: I retrieved 758 bibliographic references of scientific articles of general medicine that uses the notion of holism. I performed an analysis on a sample of 132 articles (those indexed by PUBMED). My main criterion was, on the one hand, the existence of a clear indication of the "holism" meaning used. And on the other hand, the presence, absence or neutrality of the opinions expressed in the article around the concept of holism. The "Result" is the constitution of a review of the literature of 758 bibliographic references, of which 132 are indexed by PUBMED: 70% of the articles refer to holism without clearly defining this concept. Of these, 87% present this notion in a positive light; 12% remain neutral and 1% criticize. In the other arm, 30% of articles define their acceptance of holism. Of these 55% consider holism applied to general medicine positively; 24% do not take a position; 2% are opposed to it. I note that 19% make a proposal outside of the classic alternative of holism and reductionism. DISCUSSION: On the one hand, I have found that there is a strong need and desire for the adoption, by the discipline of general medicine, of a scientific basis for responding to health problems in their physical and psychological dimensions. , social, cultural and existential - The call for the foundation of a method able to describe the passage of current scientific data and their application in ambulatory practice. On the other hand, I became aware of the constant controversy between approaches that call for holism and those that claim reductionism. And I also discovered that, beyond vain syncretic attempts, researchers were proposing approaches of a different nature to get out of this dualism. Finally, I have identified six fundamental flaws in the epistemological proposition of adopting a "holistic model" as a theoretical foundation for focusing on the subject of the practice of general medicine: 1. Ambiguity related to the polysemy of "holism", "holistic": Stemming from metaphysical debates that date back to antiquity, the terms holism, holism, holism have multiple meanings: From formal epistemology to mysticism. Some even consider these terms as buzzwords. In search of this "whole person" everyone can add dimensions and highlight their own interests. The polysemy of the term "holism" is therefore a source of ambiguity. However, my study shows that most authors - 70% in my results - do not explicitly define the use they make of this concept: Here is a fertile ground for debates, endless, reductionist against holists. Does not everyone risk to summon the other to choose his side? Is there not a risk, then, of dividing the discipline into opposing schools, chapels and strongholds? 2. Epistemological Inconsistency of Cohabitation Holism and Reductionism: Holism and reductionism are mutually exclusive epistemological conceptions. The WONCA text refers to the epistemological holism opposed to Popper's falsificationism. A paradox then arises: to make cohabit, for the same scientific discipline, a historically reductionist epistemology (to found the clinic) and a holistic model (to treat this patient). How can it escape from this internal scientific incoherence which consists in defining itself on the basis of two opposing and contradictory epistemological conceptions? Other disciplines encountered this epistemological problem (In human sciences it was the school of Max Weber opposed to that of Emile Durkheim, In biology, we find these secular polemics about debates on evolution mainly) Is there not a risk of burying the theoretical foundation of general medicine in these pre-modern debates of pro and contra-reductionist and holistic-and thus slowing down the desired paradigm shift? Does not general medicine have any interest in getting out of this dilemma, like other disciplines before it that have founded new methods, such as the systemic Humberto Maturana or the complex thinking of Egard Morin. 3. Strategic risk of division of general practitioners between pro and contra holism: How to avoid sinking into the endless debate and secular polemics of holism: The pro: doctors publish work that aims to establish this concept both theoretically and clinically. They commit themselves to this designation and defend the "holistic" banner against the criticisms that are made of them: ambiguity linked to the polysemy of the term, epistemological incoherence, proximity to the holism of pseudo-scientific movements. The contra: other authors, have always disagreed with this concept opposed to reductionism and recall that the work resulting from reductionist and analytical methods have been very successful in their medical applications. How to solve this antinomy? How not to associate global holism with a mutilating reductionism? How to bring together the parts and the totality? How to connect while distinguishing? How to take up the challenge of taking human complexity into account in clinical practice? Faced with identical questions, academic disciplines have confronted the reductionist obscurity of isolated and isolated plots without paying for the holistic glare of a totality where no part could be distinguished. These academic disciplines have created new methodological propositions (systemic approach, complex thinking). 4. Inscription of medicine in favor of a thesis of a metaphysical nature: To be holistic (or reductionist) is, ultimately, to express an opinion about the metaphysical debates relating to the nature of reality: finalist against deterministic, monistic versus dualistic, vitalist against mechanist, agnostic against Gnostic, etc. So, on a philosophical level, should the general medicine risk (by the reference it makes to holism at the very heart of the definition it has adopted) engage in the metaphysical debate on nature of reality? While, at the same time, physics and mathematics are gradually withdrawing? Do these debates have any utility for medical "praxis"? Should not the discipline of general medicine adopt a terminology more operative - and perhaps more secular? 5. Methodological weakness: The work of reductionist and analytical methods has been successful in the sciences of the inanimate and has been a great success in their medical applications. In order to rebalance the excesses of a mechanistic vision of medicine and to consider the psycho-socio-cultural determinants of health, is it strategic to oppose to reductionism the few practical results of holism? Would it not be better to take note of the successes of the mechanistic (reductionist) approach and incorporate them into a method more apt to consider the complexity of the system of determinants of health? Would not the excesses of reductionism be more soluble in a "meta-method" that incorporates the best of reductionist and holistic approaches and can communicate the laboratory and the field-from current science data to their application in ambulatory practice. 6. Strong ideological connotation: A search on Google of "holistic" shows the frequent use of this word for mercantile, sectarian and obscurantist purposes. The heirs of Jan Christiaan Smuts are the contemporary supporters of the "intelligent design" - "Intelligent design", rationalist branch of the controversial American creationist movement. The "holism" of these milieus represents a certainty, a "mystic heaven of totality", the totality as a final solution. On the other hand, three sects quoted by the parliamentary report No. 2468 of 1995 of the National Assembly use the term "holistic" in their name. Others, for the most part, refer to holism, as do anti-science advocates and obscurantist therapists. Does not general medicine, which refers to holism without specifying its meaning, take the risk of gender confusion? Is this ideological proximity not a major strategic and ideological pitfall? CONCLUSION: This patient-centric approach is at the center of WONCA 2002's definition of general medicine - it is performed daily by physicians who know how to harmonize reason and compassion and realize that "the Real always resists in essence the idealities that are necessary to his understanding. "On the other hand, our theoretical view is that ultimately the epistemological choice of a "holistic model" is neither relevant nor efficient nor strategic to meet modern "of general medicine. This is not the proper way to question the excesses of reductionism and to focus on the subject the practice of general medicine. So, how to consider health issues in their biological, psychological, social and existential dimensions? How to ensure bi-directional communication between current science data and their applications in outpatient practice? Or find a method that would ensure complementarity and dialogue between linear and systemic conceptions? A method specific to general medicine that integrates and transcends the legacies of reductionism and holism? A method capable of linking, contextualizing, globalizing, and at the same time recognizing the singular, the individual, the concrete. Able to design the organization while dealing with uncertainty. Able to focus on the subject the practice of general medicine. McWhinney emphasized that in all clinical disciplines, general practice operates at the highest level of complexity and uncertainty. To center the approach of general medicine on the patient is to accept a multidimensionality of interactions between quantitative and qualitative determinants of health. Physicists would say that it's about learning to decide and act by assuming the complexity and uncertainty of a chaotic environment. This questioning is topical in the field of fundamental sciences (Ilya Prigogine, Joel de Rosnay ...) human sciences (Edgar Morin, ...), philosophy (Michel Serres, ...), and during the "ontological" work of societies of general medicine. Some authors work on this path. They show that to adapt the current data of science to the endless intrications of human affairs, to the irreducible complexity of the living, there exist proposals more relevant than the holistic approach: Systemic analysis - as defined in the works published by Humberto Maturana and his French equivalent "the complex thought" of Edgar Morin, are methods that do not require to have a philosophical opinion on the nature of the Real. They are debated and respected in academic circles. Rich in many works, they deal with decisions and actions within the uncertainty of complex environments. These are pragmatic ways to link and distinguish at the heart of the dynamic network the physical, psychological, social, cultural and existential determinants of health. At the end of this work, my conclusion is that we need to found a method specific to general medicine that integrates and goes beyond the legacy of reductionism and holism. For my part I wish to participate in this adventure. General medicine must engage in a methodological, interdisciplinary, mutually fertile dialogue. She must base her method for "Distinguish & Connect"!
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André Dizien. Des données actuelles de la science à leur application en pratique ambulatoire. L'adoption d'un modèle holistique proposée par la WONCA en 2002 – Revue de littérature –. Médecine humaine et pathologie. Université de Rennes 1, 2007. Français. ⟨tel-02175832⟩



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