To better illustrate this process let us consider the case of an individual who presents for the first time with the symptoms of atherosclerotic heart disease. The initial triage would suggest that the age at which this disease presents itself and the intensity and severity of this particular illness indicates the need to consider, at a minimum, biomedical and mind/body healing. Further inquiry, which may continue over weeks, will clarify whether this specific individual is amenable to viewing the implications of his disease within the framework of a spiritual perspective. Initially the appropriate steps related to treatment, diagnosis and therapy, are pursued. Concurrently, an inquiry into personal attitudes and lifestyle are initiated. Finally, if appropriate, a dialogue can be initiated which is directed towards seeking an understanding of the meaning, purpose, significance, and implications of this disease for the individual's life.

In this case the development of a comprehensive plan would include a mixture of approaches: the use of appropriate diagnostic and therapeutic interventions (the treatment system), the introduction of attitudinal and lifestyle changes in the areas of stress management, nutrition, exercise, and insight based psychological counseling (the mind/body system), and an ongoing consideration of the impact of this illness on previously held values, beliefs, and priorities (the spiritual system). The goal for the practitioner is to begin to perceive disease and the individual in a larger context. For the individual, the goal is to use disease as a doorway into a more considered and expanded life - one that both serves to remedy the problem at hand, reverse the personal factors that have contributed to the development of the illness, and enhance the overall quality of life.

The Clinical Setting
At this juncture it is reasonable to ask, "How can such a model be integrated into the contemporary health care setting, and more specifically the biomedical model?". As a consequence of the introduction and expansion of managed care delivery systems, individuals have increasingly lost their capacity to directly access specialty care practitioners. As a result, the primary care practitioner has become the door of entry into the medical care system. Therefore, it is the primary care practitioner who will become the critical triage officer. This most important and highly trained individual must have the capacity and skill to triage problems according to the levels of care required, and to train and supervise others to do the same. Although the primary care practitioner should coordinate and overview the various aspects of care, the individual components of the health care plan can be implemented by a variety of individuals trained in each of the specific healing modalities. This would require a re-orientation of the clinical setting to allow for a variety of intervention formats in contrast to the exclusively biomedical approaches of our current system. It is important to recognize that mind/body and spiritual healing approaches are largely educational in contrast to therapeutic. It is therefore preferable that practitioners can easily access educational programs, off-site or on-site, which provide these services in group formats. To a considerable degree the resources of mind/body and spiritual healing, which are not currently considered in clinical settings, are best provided for in educational, non-clinical environments, and that the distinction between medical therapeutics and person centered education slowly disappear as we shift towards the latter levels of healing.

Practitioners and Clients: Partners In a New Perspective
This proposed model has very definite implications for practitioners and their clients. If primary care practitioners are to carry out the role of triage officers as proposed here, they must be provided with an integrated systems based education. Such a physician must be knowledgeable in the dynamics of each of the four healing systems, but the distinctive aspect of his education will be an understanding of the principles, concepts, and structural issues that underlie a comprehensive approach to healing. We are not seeking experts in specific domains. The level of data and information available makes that task impossible. Rather, we are seeking practitioners, conventional and "alternative", whose training is expanded to include an understanding of each of the essential aspects of healing complimented by a strong emphasis on integrative studies. The latter is not merely an emphasis on structure and organization, but contains a value system that emphasizes synthesis and wholeness, a perspective that is largely absent from current educational programs.

Similarly, our clients must also re-look at their monotheistic and fragmented approach to health care. It will be increasingly necessary to view health as an artistic creative act, one that is engaged for the duration of the life cycle. The expansion of consciousness, self-knowledge, capacities, resources and skills is the very process of health itself. In these terms health becomes more a verb than a noun, an intentional and proactive orientation to life that values personal growth and development. Health is then viewed as a lifetime journey rather than as a response to illness. In this context, a consciously lived life cycle will engage an individual in exploring each of the healing systems and in this manner maximize their contributions towards enhancing the quality and duration of life while simultaneously compressing morbidity into the final years of life.

Shifting Paradigms
Thomas S. Kuhn in his seminal work, The Structure of Scientific Revolutions¹¹ suggests that scientific paradigms which serve to tightly organize and structure the development of a particular field of study will in-time progressively fail to account for anomalous findings. The tenaciousness of an entrenched paradigm will, through denial, discounting, or other attempts to sustain itself invariable delay the crisis that will inevitably confront an increasingly inadequate model. Eventually, more comprehensive models will develop, and a competitive battle will ensue between old and new This is our current circumstance. The biomedical treatment model, as a direct result of its very successful reductive approach, cannot adequately incorporate the significance of psychological, psychosocial, and spiritual factors on health. It cannot make sense of and respond to the extensive literature that documents the effect of social support and socioeconomic influences on morbidity and mortality.^12,13,14,15 It cannot easily acknowledge and integrate an exceedingly well documented lifestyle and psychosocial based program for the non-pharmacologic reversal of coronary atherosclerosis.¹⁶ There is no accommodation for the increasing research in the field of psychoneuroimmunology which is demonstrating the relationship between mental attitudes and physiologic change, and no explanation for the well documented reversals of what are considered terminal diseases.¹⁷ Finally, there is no consideration of the potential efficacy of "non-conventional" therapies, or the emerging and growing public interest in health promotion.

Beyond these issues are the social and cultural consequences of the biomedical treatment model which have become progressively detrimental to the human experience. The social roles assumed by the practitioner and his client, roles which are a direct consequence of the professionalism and authoritarianism of modern medical practices, and the "medicalization" of many aspects of human life, for example, socially deviant behavior, have undermined the development of personal autonomy and responsibility, the very qualities that are essential for both human development and for access to the extended aspects of healing. Further, the cultural view of essential human concerns such as disease, health, pain, suffering and death, are increasingly defined in medical and pathological terms. For example, pain and suffering which can be viewed as an existential issue to be lived through and grown from have now become something adverse to fix and remove. They have shifted from personal concerns to technological medical problems, from a source of knowledge and wisdom to an unwanted disruption in life.

In response to these concerns we have seen the development of various new models and approaches: the wellness model, the biopsychosocial model, and mind/body, holistic, and alternative practices. Each of these initiatives is a response to our current dilemma: the inability of the biomedical treatment model to fully respond to the needs of our time. The model I am proposing incorporates these ideas into a singular expanded vision of the future, one that is inclusive, comprehensive, accessible, and functional. This model can serve to responsibly integrate conventional practices with the emerging interest in mind/body and spiritual healing, alternative therapies, and health promotion initiatives, provide a theoretical basis for new system based research methodologies, assist with the development of an expanded curriculum for practitioners, and serve as the template for an innovative and flexible approach to healing that responds to both individual and social needs as they have emerged in our time.

1. Eisenberg D, Kessler R, Foster C, Norlock F, Calkins D, Delbanco T. Unconventional Medicine in the United States; Prevalence, Costs, and Patterns of Use. New England Journal of Medicine. 1993: 328:246-252.

2. Weiss P. The system of nature and the nature of systems: empirical holism and practical reductionism harmonized. In Toward a Man-Centered Medical Science. Edited by Schaeffer, KE, Hensel H, Brody R. Mount Kisco, New York: Futura Publishing Company: 1977.

3. von Bertalanffy L. General Systems Theory. New York: Braziller; 1968.

4. Engel G. The Biopsychosocial Model and Medical Education. The New England Journal of Medicine. 1982: 306:802=805.

5. Engel G. The Clinical Application of the Biopsychosocial Model. The American Journal of Psychiatry. 1980: 137:535-544.

6. Williams GC, Neese RM. The Dawn of Darwinian Medicine. The Quarterly Review of Biology. 1991:66:1-22.

7. Ader R, Felten DL, Cohen N. Psychoneuroimmunolgy. 2nd ed. New York, New York: Academic Press; 1991.

8. Antonovsky A. Unraveling the Mystery of Health. San Francisco: Jossey- Bass;1988.

9. Antonovsky A. Health, Stress, and Coping. San Francisco: Jossey-Bass; 1991.

10. Kobassa SC. Stressful Life Events, Personality, and Health: An Inquiry Into Hardiness. The Journal of Personality and Social Psychology. 1979:37:1-11.

11. Kuhn TS. The Structure of Scientific Revolutions. Chicago: The University of Chicago Press; 1970.

12. House JS, Robbins C, Metzner HL. The Association of Social Relationships With Mortality: Prospective Evidence From the Tecumseh Community Health Study. American Journal of Epidemiology. 1982:116:123-140.

13. Berkman LF, Syme SL. Social Networks, Host Resistance, and Mortality: A Nine-Year Follow-Up Study of Alameda County Residents. American Journal of Epidemiology. 1979.109:186-204.

14. Williams RB, Barefoot, JC, et al. Prognostic Importance of Social and Economic Resources Among Medically Treated Patients With Angiographically Documented Coronary Artery Disease. JAMA. 1992:520-524.

15. Adler, NE, Boyce Wt, et al. Socioeconomic Inequalities in Health. JAMA.1993:269:3140-3145.

16. Ornish D. Dr. Dean Ornish's Program For Reversing Heart Disease. New York: Random House; 1990.

17. O'Regan B, Hirshberg C. Spontaneous Remission: An Annotated Bibliography. Sausalito, California: Institute of Noetic Sciences; 1993.