Welcome to the latest essay in our “On Healing” series, where Dr. Wayne Jonas explores whole person care and the deeper dimensions of healing.
He came in carrying years of failure. A man with chronic shoulder pain, back pain, and recurring headaches—well insured, medically informed, and exhausted by the medical system. He had done everything right. He had seen the specialists. He had followed the evidence. He had tried nearly every treatment that guidelines recommended for chronic back pain, which is to say he had tried nearly everything, and nothing had worked.
By the time he walked into our chronic pain clinic he had acquired something else along with his diagnoses: a profound lack of trust that anyone could help him.
What he needed was not another treatment. He needed to be asked a different kind of question.
So, I asked him: What matters to you? Not what hurts, not what your imaging shows, not what you’ve tried before—but what do you want your life to look like? What are your goals in life?
He immediately told me about his church. He didn’t just want to attend on Sundays; he wanted to be involved, to contribute, to give something back. That single answer reorganized everything. We built a plan together—not around his diagnoses but around his life.
He had read about the anti-inflammatory effects of diet and was willing to try that, so we had him talk with a nutritionist and start on a Mediterranean eating plan. Yoga-style stretching went into the mix, along with some relaxation techniques and a small device called an Alpha-Stim. Finally, we looked at medication management, including reducing the NSAIDs I suspected were contributing to his headaches and substituting other medications that were carefully timed so he would get the most benefit when he wanted to be more active.
His headaches improved first. Then he started attending church more regularly. Then he found an easy task: helping families facing eviction access a fund that the church maintained to help them. He delivered checks to them and helped them think through their finances. He started giving back.
In the book “Wonder Drug,” physicians Stephen Trzeciak and Anthony Mazzarelli explain that giving back is one of the most healing things a human being can do. As my patient used his skills in finance to help families in need, his pain decreased and he needed less medication. He began to see that much of what he needed to relieve his pain was in his own hands.
What created this transformation? It wasn’t a single intervention. Rather, it was a relationship in which he felt safe enough to be honest, trusted enough to try something new, and respected enough to have his own expertise—about his own life—taken seriously. It was, in a word, healing.
Which raises the question I want to examine: How do we know when healing is happening? And how do we measure it?
Two Myths Worth Dispelling
Before we can measure healing, we need to be clear about what it is and is not. Two misconceptions dominate medical thinking, and both are wrong in important ways.
Healing is not the opposite of curing
The first myth is that healing and curing are at opposite ends of a spectrum. They are not. Instead, let’s think of them as a Venn diagram. Healing is the larger circle—a holistic, transformative process of repair and recovery in mind, body, and spirit resulting in positive change, finding meaning, and moving toward wholeness. Curing is a smaller circle that sometimes appears inside it and sometimes helps us get to it.
Curing means identifying a defined disease, finding its cause, and eliminating it. For strep throat, this works beautifully. For Gulf War syndrome, lower back pain, or other conditions for which there is no single cause, it doesn’t.
We have pushed the cure mindset into problems that are too complex for it, and in doing so we have made things worse. The patient who came to me had been suffering the effects of this thinking for years as he sought a magic treatment for his pain when what he needed was healing to increase the wellbeing in his life. Doctors had been trying to cure him, but no one had been trying to help him heal.
Healing is not the opposite of suffering
The second myth is that suffering and healing are opposites: If you are healing, you must no longer be suffering. This too is wrong—and the error runs deep.
Rebecca “Becca” Etz, PhD, a cultural anthropologist at Virginia Commonwealth University who has spent years studying healing relationships, makes this point. The word “healing” is a verb that signals motion, yet we treat it as a destination. Healing is a process, and you are always on a continuum between healing and suffering, always carrying some of both.
The Talmud teaches that to witness someone’s suffering relieves it by a little—and that, in and of itself, helps to heal. Healing does not mean the elimination of suffering. It requires the transmutation of suffering: moving through it, finding what must emerge from it, and incorporating the experience into who you are. You do not have to like suffering, and you can seek to alleviate it. But it must often be gone through to know what can help make it better.
As Kurt Stange, MD, a family physician and complexity scientist at Case Western Reserve University, put it to me: When people are asked what they want from health care, they start with cure. But when cure isn’t possible, they ask for something different—help in finding meaning and in integrating the experience of the illness or condition into what matters in their lives.
That is the question that healing answers. It’s fundamentally different from anything most of our health care system is designed to provide, and we rarely measure it or note when it happens. Yet sometimes, the health care system does bring healing.
Healing Is Not an “I”—It’s a “We”
One of the most important things Etz said to me is something medicine has systematically ignored: Healing is not something an individual does. It is a social creation. It exists in exchange with other people, not in isolation. It is a relationship.
Anthropologists and sociologists define a person only within the context of community. An individual, stripped of their social environment, is not really a person in the full sense, because personhood is constituted by relationships. Medicine, by contrast, has built its entire system around treating the individual in isolation.
This matters for healing because healing emerges in what we might call a “mutual caring space”—the space between two people (or between a person and their community, their natural world, or their inner aspirations) in which genuine care flows in both directions.
This space has specific characteristics: safety, which means I will not do you harm; trust, which means that what I hear I will listen and respond to; respect, which honors the clinician as an expert in science and the patient as the expert in their own life; and responsiveness, which means that I will seek to help.
A caring space can be created in many places, not only in the office, between the patient and clinical team, but outdoors as friends fish or watch birds together, in a regular game of online chess, in long friendships, and in getting together for spiritual practice. An exercise class or a horse barn can be a caring space—and a healing environment—as readily as a doctor’s office.
Research on the healing journeys of Americans recovering from trauma and illness shows that relationships with health professionals are not necessarily more important to the process than relationships with family, friends, pets, and neighbors.1 The clinical relationship matters, but it is one thread in a larger tapestry.
For my patient with chronic pain, the healing space was partly the clinical relationship and partly his church, his community, and his opportunity to contribute. What the clinical encounter had to do was open the door for more than medical treatments of the disease.
This understanding also changes how we think about what clinicians do. Stange describes it as learning to “act as far as you can see in the fog.” Healing is a complex, nonlinear, emergent process. Even as a seasoned clinician, it’s important to recognize that you cannot predict what will arise or control the outcome. Evidence from research based on the responses of a group of participants is important, but for an individual patient, it only goes so far. What you can do is cultivate the conditions that allow healing to emerge. Attend carefully. Try something. Observe the response. Learn. Try again. This iterative process of sense-making is not a failure of scientific rigor. It is the only method appropriate to the task.
Safety, Trust, and Feeling It
Here is one thing I know from clinical experience: Patients feel it when healing is happening. They may not be able to present you with a checklist, but when they have an encounter in a genuine caring space, they come out knowing it. They may say something like “I felt safe. I trust this person. They listened to me. We have a plan that feels right.” Something shifted.
That subjective felt sense is not soft data. It is, in fact, the most direct signal that the conditions for healing are present. The challenge is capturing it in a way that is credible to health systems, policymakers, and payers.
This is the challenge that Stange, Etz and others have spent years trying to solve. And I believe they have made genuine progress.
Measuring the Conditions for Healing
Etz is emphatic about one framing point that I find crucial: Any useful measure of healing is not an outcome measure. Healing, by its nature as an emergent phenomenon, cannot be measured the way blood pressure or a tumor marker can be measured. What can be measured are the preconditions: the conditions that allow healing to emerge. Etz calls this a vector – not a destination, but a direction. Are the right conditions present? Are we moving in the right direction?
With that framing in mind, here are several measures that I believe point meaningfully toward the caring space where healing occurs.
The Person-Centered Primary Care Measure (PCPCM) is the most significant.² Developed by Stange, Etz, and colleagues, it is an 11-item patient-reported measure of the primary care relationship. Its premise is deceptively simple: “My doctor knows me as a person. My doctor and I have been through a lot together. Over time, this practice helps me meet my goals.”
Those statements capture the elements of safety, trust, continuity, and mutual respect found in a caring, healing space. The PCPCM has been validated across multiple countries, endorsed simultaneously by patients, clinicians, and payers—a combination that is nearly unprecedented in health measurement—and adopted by the Centers for Medicare and Medicaid Services (CMS) as a core measure that can be used with payment attached.
The Vitality Signs project is a next-generation effort, developed by Etz in collaboration with CMS, which builds on the PCPCM to capture whole person health for Medicare beneficiaries. It began as a comprehensive patient-reported measure of mental, behavioral, and social health, but has evolved into something more fundamental: a way of facilitating the whole person care conversation itself. CMS approved and funded it with the explicit understanding that the measure would evolve each year as the researchers learned more. That CMS agreed to fund a project whose end state was explicitly unknown is a signal worth noting.
VA Well-Being Signs is another measure of interest for healing. It offers a set of four tested, validated questions designed to ask: “Are you living the life that you want, and how does that connect to the health services you receive?” That formulation—centered on the patient’s own goals and the relationship between care and life—reflects the same orientation as the PCPCM.
The National Institutes of Health (NIH)/National Center for Complementary and Integrative Health (NCCIH) Wellness Measurement Radar Screen is another more basic measure. It was developed through a consortium of the NIH, led by work that grew out of palliative care programs at the NIH Clinical Center and led by the NCCIH. The initiative sought to capture healing in a highly integrative, whole person framework for programs that focused on healing but found themselves without adequate tools to measure what was happening. A request for applications to study this approach has recently been issued.
At the heart of healing relationships is undivided attention. So, is there a metric for undivided attention? Can we detect, from data that already exist in the electronic health record, the likelihood that a “caring space” was created in a clinical encounter? Whether the physician was truly present? Such a metric has been reported.3 This is less developed than the others, but it points toward something important: the possibility of measuring not just patient-reported relationship quality but the structural conditions within the encounter itself. More on that later.
A Moment of Opportunity
Stange describes our moment in health care through four simultaneous lenses as articulated by philosopher Ken Wilber: the inner worlds of individual and collective experience; the outer worlds of facts and systems. Medicine and world of policy and payment systems have long privileged measurable impersonal biomedical facts at the expense of the inner, relational, and communal dimensions where much healing occurs, and the systems that support healthy and healing environments.
But there are real signs of change. The PCPCM is now a CMS core measure. The Vitality Signs project continues to be funded. The Well-Being Signs are being more widely used by the VA, and research on the NIH Wellness Index is being funded. The Medicare annual wellness visit could be redefined as a whole person healing visit. Center for Medicare and Medicaid Innovation (CMMI) has authority to run one-year experiments within existing projects with no prior evidence base required. This way, the nation could advance the policy data on healing more rapidly.
Multiple offices within CMS are working to build a shared language around whole person health—largely without knowing about each other. It is time to bring them together.
And what about learning from other systems? I spent 20 years practicing medicine in the military, where payment was not an obstacle and the mission required attending not just to disease but to prevention, performance, and what mattered to the person in front of me. The system’s goals were aligned with what the patient needed. Certain elements of the VA, direct primary care, and integrative medicine have been doing similar work for years, often without the recognition, the science infrastructure, or the policy support they deserve.
The question before us now is whether we can move this approach from the margins to the center: by measuring what actually matters, by paying for the conditions that allow healing to occur, and by recognizing that healing, in all its complexity, its social reciprocity, and its resistance to simple prediction, is not a soft aspiration. It is the central purpose of medicine.
Stange told a story about his first visit with a new family physician, a doctor who had trained with him decades ago. She set aside the structured Medicare wellness visit and said, “Let’s get to know each other.” She took his family history. She noticed a test from three years ago that nobody had followed up on. She spent 40 minutes doing what good primary care has always done: seeing the whole person in front of her. She didn’t ask “What matters to you?” but she addressed what mattered.
What allowed this to happen? He had a trusting relationship with her; the test result had been collected, and she took notice of it; and she took time with him. The trust, the test, and the time created an environment for shared decision-making based on what mattered to him.
For my patient with the chronic pain, what mattered was getting to his church and being able to give something back. Getting to know him opened the door, and he was able to walk through it toward healing.
Resources
Person-Centered Primary Care Measure
NIH/NCCIH Whole Person Health Index
References
- Scott JG, Warber SL, Dieppe P, Jones D, Stange KC. Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness. BMJ Open. 2017;7(8):e016771. doi:10.1136/bmjopen-2017-016771
- Etz RS, Zyzanski SJ, Gonzalez MM, Reves SR, O’Neal JP, Stange KC. A New Comprehensive Measure of High-Value Aspects of Primary Care. Ann Fam Med. 2019;17(3):221-230. doi:10.1370/afm.2393
- Chen Y, Adler-Milstein J, Sinsky CA. Measuring and Maximizing Undivided Attention in the Context of Electronic Health Records. Appl Clin Inform. 2022;13(4):774-777. doi:10.1055/a-1892-1437.
Photo by Aarón Blanco Tejedor on Unsplash