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The International Journal of Person Centered Medicine
79 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
FROM THE THIRD GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE:
SPECIAL INITIATIVES FOR PERSON-CENTERED CARE
Person-Centered Medicine: Theory, Teaching and Research
Giuseppe R. Brera MD MA
Rector of Università Ambrosiana and Director of the Milan School of Medicine and the Person-Centered
Medicine International Academy, Milan, Italy.
Abstract
Person-Centered Medicine (PCM) is a new interactionist, deterministic, extrinsic Paradigm of Medicine, born in 1999,
based on the theory of the “determinate and the quality indeterminate relativity of biological reactions”. Structuring a new
health epistemological model developed from the medical science base of interactionist investigations, it is consistent with
the Allostasis and Epigenetics epistemological changes in physiology and genetics and defines a new phenomenological
hermeneutics of human nature: Kairology, defining the person’s mystery and destiny. A complete epistemological definition
of a “Person-Centered Health interactionist and non-deterministic health model” was presented by the author in 2005.
Person-Centered Medicine in 1998 was officially presented as the leading epistemological structure of the Milan School of
Medicine, a priority for medical education in postgraduate courses, starting from the previous foundation of Medical
Counselling and its teaching method. Since 1998, the Person-Centered Clinical Method (PCCM), born as the PCM clinical
application, was introduced and taught in all of the postgraduate courses and in the University Quality System and assisted
the physician’s formation. The Person-Centered Clinical Method changes the operation of Clinics, introducing a three
dimensional, non-deterministic structured work on the person: “Diacrisis”, which in the “Person diagnosis” and in the
“Cross ratio” structured assessment of resilience and vulnerability, in the interlocutory physical examination, in the clinical
objectives assessment and in a literary clinical synthesis and portrait, ensures that information about the subjective and
objective person’s and hypotheses about their relations are depicted together. The learning objective of PCM and PCCM are
theoretical and practical and PCM teaching is characterized by a structured training in Università Ambrosiana, organized in
International Master’s and in “Licentia Docendi” courses.
In 2002, the first investigation of PCCM teaching effects on clinical practice by 20 trained physicians who assisted
16,000 persons was conducted. The results documented a substantial reduction in drug prescriptions, hospital admission
requests, technical examinations and an increase in physicians’ professional satisfaction.
Keywords
Effectiveness of person-centered medicine, epistemology, hermeneutics, humanism, medical education, person-centered
medicine
Correspondence address
Prof. Giuseppe R. Brera, Rector, Università Ambrosiana, Viale Romagna 51–20133 Milan, Italy.
E-mail: gbrera@unambro.it
Accepted for publication: 14 March 2011
The clinical and epistemological
roots of Person-Centered Medicine
teaching
The Person-Centered Medicine Paradigm [1,2] finds its
clinical and teaching roots in “Medical Counselling” [3]
and its clinical and teaching method (founded by the author
of this paper in 1991 at the Italian Center of Medical
Psychology) has from 1995 been taught at the Ambrosiana
University. Medical Counselling, born as a new discipline,
enabled Physicians to acquire new clinical skills,
beginning with studies on empathy and reducing
dependency on Psychologists and overcoming simplistic
notions of a clinical separation of body and mind. Its
method was inspired by Phenomenology, the humanistic
school of Psychology, Psychoanalysis and Counselling
theories in Psychology in a medical setting, but the new
approach emerged from a synthesis between kairological
hermeneutics and the traditional tendency of Medicine to
Brera
Person-Centered Medicine: theory, teaching and
research
80 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
find in clinics and in human nature an objective reality,
based on empirical and experimental structures. Medicine
typically searches for objective truth at ethical and
epistemological levels and appears to be only
complementary to the dominant and relativistic
subjectivism of psychology in the clinic. Medical
Counselling partially realized in clinical practice the
Humanistic-Existential approach as a new paradigm in
medical science, which was depicted in 1992 [4] in
opposition to the imperialistic and reductionist approach
focussed on the biological basis of Medicine, which
reduced the realm of health to the level of biological
variables [5], with inadequate attention given to evolving
disciplines such as Psychoneuroimmunology [6] and
Psycho physiology. Thus, a radical and structural
epistemological change in Medical Science as had been
postulated by George Liebmann Engel [7] appeared
increasingly urgent involving much more than a simple
enrichment of clinical method with optional
“communication skills”. The first Course in Medical
Counselling, delivered in 1991, focussed on clinics with
adolescents and was a great educational success using a
structured educational teaching theory well accepted by
generalists, pediatricians, adolescentologists and hospital
physicians. Its objective was to help physicians acquire
skills in empathy and in overcoming natural diagnosis
anxiety in situations where emergency biological problems
were absent and to help them learn to work on the person’s
resources to be able to assess his problems. Physicians
learn to cope also with the person’s ethical demands, in
and out of the clinic, and not to try to escape from
delegating these to, for example, psychologists or to
neglect the Hippocratic Oath principles as they relate to the
person. Interlocutory and relational and interpersonal skills
are taught and during the third year, the “Kairos program”
introduced a structured and very successful program,
inspired by “Kairology” to develop affective, cognitive and
creative resources. The counselling was called
“Kairological”, referring, as it does, and as described by
Brera [8-10], to Kairology Theory. According to this
theory, the phenomenology of human nature hides a
mysterious question of truth, love and beauty, calling for a
right choice among a world of possibilities, true or false,
which constitute the human experience and a second
mystery for their unpredictability. Human nature is
naturally oriented to a noble destiny and to “pathos” to
give objective answers to the fundamental questions of
existence which involve considerations of “truth”, “love”
and “beauty” and to the choice between true or false
possibilities in the realization of liberty and dignity and
individuality. These mysterious and natural questions
which belong to human dignity are pondered from
adolescence [11] through a hypothetico-deductive
reasoning (Piaget) [12], which allows the perception of “a
call” to objective truth, a call to personal ethical
responsibility and the quest for an objective meaning in
each human act. Here, psychosexual development (Freud)
[13] leads to the genital expression of love and to a call to
search for objective harmony as part of the perception of
reality and beauty. Health and disease belong to this reality
and are part of the person’s freedom and realization. In this
light, disease can be interpreted like an ontological
question finalized to reveal the presence of an objective
life meaning in human relations and suffering, such that
“pathos” can be interpreted not only like a limit, but also as
an existential possibility for realization, a disclosure to
perceive the person’s own dignity and freedom in
answering the fundamental questions of existence [14,15].
At the end of the three year course, the trained
physician is able to cope and resolve difficult
psychological questions and cases, without depending on
psychologists and on psychotherapists. During these
teaching experiences, physicians were encouraged to start
to apply the learned counselling method not only to
adolescents, but, like a general clinical method, to all
patients. The results obtained were important and a source
of great personal satisfaction [16]. Physicians used the
“Kairological medical counselling” method also with acute
and chronic diseases and to discover their patients as
persons. Early on, there was a risk of confounding
Medicine with “Health Psychology” and a strong
theoretical and institutionalized structure was necessary to
preclude this risk. In 1995, when Ambrosiana University
was founded, the principal objective was to prepare
medical students and physicians to adopt the “humanistic-
existential” paradigm in a climate culturally hostile to such
philosophy, by beginning a true battle on one side against
the subjective reduction of humanity to psychological
subjectivism far from any spiritual dimension of life and
on the other side against the erroneous technical reduction
of medicine to biomedical science with a need also to
confront ethical relativism in medicine. In 1998, the
Ambrosiana University Academic Year opening
celebration, which had adopted Iosef Seifert and Karol
Wojtyla’s personalism within its philosophical
foundations, was dedicated to the Person-Centered
Medicine (PCM) new paradigm and the Rector’s
contribution was dedicated to an illustration of the
importance of the Person-Centered Medicine new
paradigm for changing Medicine and medical science [17,
18]. For the first time, then, an University openly adopted
an extrinsic paradigm for the reorientation of medical
education, in open opposition to a reductionist medical
culture, the loss of objective ethical principles and
subjectivism in clinical psychology.
At an epistemological level, it is contended that the
PCM paradigm was generated by Psychoneuro-
immunology, by Kairology, by the discovery of new
physiological relation between brain-mind [19], and by
new epistemological concepts in Psychology like:
“Coping” [20] and “Resilience”, which later meet
Allostasis and Epigenetics. In 1996, the paper which
inspired Brera to write a new epistemological theory for
Medical Science: (“The Relativity of Biological Reactions
to possibility and quality of coping” [21,22]) (RBR theory)
was Launslander’s and Shavit’s exposition [23], whose
The International Journal of Person Centered Medicine
81 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
epistemological interpretation was evident: Selye’s [24]
and Claude Bernard deterministic mechanism, founded on
a simple Stimulus-Reaction (S-R) model, had fallen. The
epistemological evidence was that a variable introduced by
the experimental project and belonging to a philosophical,
existential and kairological domain expressed by the word:
“Possibility”, had determined two qualitatively different
“Biological Reactions”, relative to two different ways
offered to cope with a stress. Natural possibilities offered
to an animal mediate a dichotomized and “qualitatively”
different answer. Biological and clinically mechanicistic
determinism had indeed fallen. The History of Medicine
had changed. From the Popperian perspective, this was
enough to justify the necessity of changing clinical
applications. The person, from a psychological and
biological naturally pre-determined constant, could choose
among possibilities and this information is transduced into
biological signals, from the brain through neuromodulators
and hormones determining biologically qualitative
reactions, founding a qualitative relativity of biological
reactions to existence in a way poorly characterized to
date. Medicine and Medical Science are changed from a
theoretical conception based on “quantity” classical
inferential statistics to “quality” of the person. RBR theory
is consistent with the epistemological revolution in
physiology initiated by Sterling and Eyer introducing the
concept of “Allostasis” – “Stability through Change” in
opposition to the older concept of “Stability through
Constancy” [25]. Allostasis means that biological
parameters are indicators not of an adaptation to biological
stimuli, but of the organism’s work to change its
physiological reaction in relation to environmental stimuli,
predicted by higher nervous functions, through the
amygdala, PVA area and pre-frontal cortex. This changes
the traditional way to interpret biochemical parameters that
now must be interpreted as results of a qualitative change
of adaptation. Allostasis, like Psychoneuroimmunology,
introduces an important “Trojan horse” for Person-
Centered Medicine: the clinical concept of “Allostatic
load” [26]. Consistent with RBR theory and Allostasis
theory, a series of investigations has been published since
the 1990s emphasizing the role of emotions and affect on
health. This body of literature well demonstrates the
importance of positive affect and emotions on health,
predicting lower rates of diseases and slower disease
progressions [27].
RBR theory introduced into medicine and medical
science and in clinics, has generated new knowledge.
Firstly, it illustrates the link between biological and
existential variables which are only human resources and
possibilities: the inferences of laboratory investigations in
vitro or in vivo on animals cannot be simply transduced on
persons. Secondly, it supports the concept of “biological
reaction” demarcated by the concept of “biological
constants”. Thirdly, it demonstrates the qualitative and
relative weight of coping possibilities on biological
variables. Fourthly is indicates necessary importance to be
given to human protective factors; for example, teleonomy
or affectivity, or logical and psychosexual development are
higher human resources. RBR theory identifies the human
spiritual tendency to a personal reality and realization in
Medicine. The qualitative relation between biological
variables and coping, enunciated by RBR Theory, was
further confirmed in 1997 by Liu and colleagues [28].
These authors corroborated RBR theory, with the
demonstration of the qualitative relation of the endocrine
brain construction relative to the mother’s coping where
lucorticoid, GABA and CRH receptor synthesis in brain is
relative to the mother’s licking and grooming behaviour.
Moreover, genetically selected hypertensive rats nurtured
by wild mothers, do not develop hypertension. So culture
can be more powerful than nature. Recent epigenetic
studies in animals related chromatin change to quality of
maternal coping, confirming an epigenetic link of culture
with biological nature [29,30]. Genome is programmed by
epigenome and in this example by the environmental
biologically transduced messages. This is now also clear at
human level [31]. The genome myth is thus exposed.
Humans have only 25,000 genes, 5000 more than a worm.
Their biological functions are determined by proteins and
by transcription factors, which function only if a sufficient
level of energy (ATP) is available. To date, biological
research based on epistemological error, continues to
concentrate only on the results of genetic errors, not on
their causes [32]. Epigenetics represents the third strongest
epistemological change of medical science based on a
dominant biological determinism. The cell brain is not the
nucleus, but the cell membrane [33], which reads and
interprets environmental signals via receptors synthesis
and down-up regulations, determining the signal
transduction which activates regulator proteins which
determine gene expression. The neurone nucleus is
changed by learning processes. Social, relational, affective
and spiritual life and behaviour determine a hereditary
variability and a quest for changes in biological parameters
of the organization to cope with new stimuli through gene
expression. RBR Theory, Allostasis and Epigenetics are
interconnected and mutually reinforced. Social biology
relates this phenomenon to evolution, through the
hereditary transmission of hereditary changes [34].
On an epistemological level, we could affirm that
Medicine and Medical Science from the birth of the PCM
paradigm is founded on a “Person Centered Health
Epistemological Model” [35]. This contention leads,
epistemologically, to the necessity to introduce the concept
of “quality” in clinics and research, rediscovering the
importance of the qualitative clinical approach. The
“protection” possibilities for health, “protective factors”,
constructing resilience, are “real” resources if addressed to
life, or “risk” factors if addressed to death. A decrease in
the number of protective factors predisposes to an absence
of possibilities and gives rise to the occurrence of
problems. On a three dimensional level, patients’ problems
are generated by the absence of resources which are
qualitative possibilities for life and survival. This needs
clinical work of a nature that can create possibilities as
Brera
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82 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
new personal resources and not of a kind that reduces
persons to their problems. Indeed, the description of
patients as “Diabetic” or “Schizophrenic” in any other such
way reduces persons to their pathology and is an indicator
of a substantial reductionism. Often patients use their
pathology like a mask, as it were, to hide themselves and
physicians are often complicit in such actions. The concept
of a work on “resources” in clinics, before taking in to
consideration non-acute or non-emergency problems, has
been and is a true epistemological revolution, because it
allows persons to become aware of themselves: their
identity in a particular and mysteriously important moment
of their life. Body or mind and behavior, previously
“unknown friends” become “others” and reveal themselves
as part of the experience of concerns, pain, suffering and
anguish. Human nature builds its biological structure
thanks to possibilities and resources mysteriously received
or built by the person, which have, through the
symbolization processes, an epiphanic function of the self.
Disease does not occur without symbols and symptoms.
Interpersonal relations built through diseases open up
possibilities to a hidden life, to the ability to reveal to
others a private world, to change behavior and to
understand life more deeply. The concept of health and
disease has moved to a “Constructivist concept” from an
“Adaptational one”. In clinics, it corresponds perfectly to
RBR Theory, Allostasis and to the revolution in
Epigenetics. Human biology changes as the organism
works to change its adaptational styles. Here, higher
nervous system function, through cognitive and affective
resources, sends biochemical messages which are
interpreted by the cell membrane and which lead to the
initiation of transcription. Health and disease contribute to
a new existential reality continuously built by the person
during his life and formed by his possibilities and choices
which work by integrating three component variables:
Subjective, Environmental, Biological. The person
interprets and elaborates these, integrating information
belonging to and deriving from these three domains. A
new Person-Centered Health System characterized by
interactionism and non-determinism is born. (Figure 1).
The mechanistic nature of, and the scientifically
reductionist determinism predicated by, the biomedical
paradigm has been overcome. It cannot be right to base
clinical decision making only on statistically significant
investigations built only on one biological order of
variables. Persons need an interactionist approach to
medical science, based on Engel’s systematic and
mechanicistic bio psychosocial model, but consistent with
a spiritual dimension of existence which reveals itself in a
natural quest for meaning, a “teleonomia” toward a
fulfilled existential reality. All human phenomenona and
diseases have a spiritual dimension, because they always
have a mysterious, unconscious and/or conscious meaning
lived by the person.
At the clinical level, RBR theory has been supported
by the results of important investigations where it appears
that immunological function in persons with cancer is
modulated by health education, stress management,
enhancement of illness-related coping skills and by
psychological support [36]. Paul Tournier [37] was the first
clinical investigator to show that Christian faith – a
religious and mystical answer to questions of existence,
funded on the anthropic principle that human behavior and
affects derive from God, is an important protective or
healing factor. Health and disease appear to be not a result
of an adaptation, the research of “constancy”, but a
constructive work, an hidden or manifest research for an
existential change. Viktor Von Weizsacker, Viktor Frankl,
Karl Iaspers, Alfred Adler and also Carl Gustav Yung,
interpreted well this dimension of disease. No person
wants to be a grain of sand on an infinite beach. This much
is evident from studying adolescents [38]. At the biological
level, how the need to be important for someone (love) and
something (originality) is related to pathogenesis, is a
mystery. Person-Centered Medicine finds in RBR theory,
Allostasis and Epigenetics and at a clinical level Paul
Tournier’s “Medécine de la personne”, the fundamental
basis for a new constitution of clinics, research and
medical education. This is not a humanistic option, but an
imperative for the correct evolution of medical science and
clinic work. Given the epistemological revolution of
Medicine and Medical Science, a true change of paradigm,
health appears like music played on a piano, a score is read
(DNA), and piano keys are pushing (receptors at biological
level) and emotions are generated (symbolic level). It is the
person who plays the keys.
The Person-Centered Medicine
Clinical Method. Clinics is a
maieutics of the person
The last forty years has seen the reduction of persons to
“clockwork oranges”, with a progressive reduction of
clinics to biomedicine and technology and the physician’s
role reduced almost to that of a technician. Hospitals
appear more like technical facilities than houses where
pain, concern and anguish become human suffering. We
need to return the human encounter to medicine, where the
person’s human identity is considered before his symptoms
and biological diagnosis. Family doctors and hospital
specialists, with some rare exceptions, look first at the
results of biochemical or technical assessments and fail to
give importance to other factors. They consider the person
in terms of a biological interpretation of clinical pictures
and look to empirical indicators or to biological therapies
as complete solutions. They do not help in changing
quality of life. To be sure, the adoption of only a
biomedical approach to clinical decision making is not
only not human, but scientifically wrong. The Media
typically portrays the image of an omnipotent physician
who through biotechnocracy, enters into and controls the
mystery of life and death in order to determine it, not a
The International Journal of Person Centered Medicine
83 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
humble ally of suffering people who uses modern
technologies and much more, to create possibilities to heal
persons. Physicians should be motivated to build truth and
love as possibilities for the weaker person, to be his
protagonist and to accompany him on the human and
mysterious adventure that is life. In opposition to a
biomedical reductionism, physicians should be prepared to
discover “with” suffering people, a new existential reality
which could change also the same physician’s quality of
life. An attitude to change from this existential perspective
is the physician’s first resource. The physician’s mission
involves a mysterious entrance into deep mysteries: life,
health, disease and death. We can depict them, but not
comprehend their meaning, with a scientific-empirical
approach. Greater understanding can be revealed only by
contact with persons-patiens, using a new clinical method,
phenomenologically oriented. Causes must not be
confounded with “meaning”: the divine Aristotle’s “ousia”.
In this sense, medicine is a metaphysical profession which
finds its substance in the suffering person. The paradox is
that medicine presents itself as the “suffering science”, but
this kind of “science” is impossible, because suffering is
not an empirical concept, to diagnose with computerized
tomography or biochemical tools. Medical culture, medical
schools and physicians must recover their irreducible
ethical and existential mission against a technical
conception of life and death [39].
To date, actions against life, normalized in many
countries, such as pregnancy interruption and euthanasia,
equate the value of individual human life to a “pill”
(RU486), indicating a sunset of an objective ethics and
revealing, perhaps, the loss of an understanding of
objective meaning by the health professions. Moreover on
a traditional level, it is startling that many physicians have
an ideological approach, without any concern about the
well documented psychobiological consequences of these
non-medical acts for persons. Pregnancy is not a pathology
to heal. Medicine has become submitted to a relativistic
sociology, the tool of a psychosocial adaptation of people.
There is widespread clinical reductionism in medical
practice (Table 1) and Person-Centered Medicine, with its
epistemological force and its human identity, is the right
paradigm for winning a battle against ignorance, ethical
reductionism and false conjectures about medicine and
medical science. To date, clinics are characterized by a
distance between doctor and patient. There is a sunset of
prevention, a genomic imperialism while its limitations are
well known, the enhancement of drug prescription and
technical examinations and a closure of health systems due
to financial problems and rationalizations toward a
financial and market domination. In opposition to these
developments, the new PCM paradigm involves body-
mind and spirit in the person’s teleonomia toward a real
person identity, characterized by freedom and dignity. The
clinical method is a tool to allow this natural tendency, like
“an enzyme”, not only a tool to asses a clinical picture or a
pharmacological therapy.
In 1998 in the Conference promoted by the Italian
Society of Adolescentology and the Adolescentology
Department of Ambrosiana University: “The physician
and the adolescent person”, the author of this paper
presented the “Person Centered Clinical Method” which,
starting from the previous Medical Counselling Method,
was a structured step by step clinical method which
integrated the traditional one, and aimed to realize in
clinics new epistemological applications. During the same
year, the “Person-Centered Medicine Manifesto [40] was
formulated and presented at the inauguration of the
Ambrosiana University Academic Year as the
epistemological basis of all the basic sciences
(interactionism) and all the clinical courses of the
Ambrosiana University Milan Medical School. The
Manifesto presented the Person-Centered Medicine
Paradigm and founded medicine, medical science and
medical education on new principles indicating these as
necessary knowledge objects of Medicine. These eight
principles are as follows:
1. The person’s teleonomy (the natural tendency to search
for a meaning in life and for self-fulfillment) which urges
in Medicine, a rehabilitation of the traditional Hippocratic
and Christian medical ethics tradition.
2. The three-dimensional structure of the person,
introducing the clinical and scientific consideration of the
relations between biological, psychological and spiritual
variables, seen as determinants for health or disease
construction.
3. The necessity of considering health as a individual
qualitative work based on the person’s three-dimensional
protective factors, an action addressed to neutralize or
cancel risk factors. Health is not a mechanicistic result of
an impersonal balance outside of the person’s world.
4. The definition of Medicine as a mission addressed to (a)
care, (b) cure and (c) to study the sick person and not the
opposite “c-b-a”, introducing a new existential concept of
prevention such as, “providing possibilities” for
individuals.
5. The individualisation of the individual, and with
reference to the three dimensional resources of the person
as the priority objective of the clinical method. Clinical
TABLE 1
INTRINSIC EPISTEMOLOGICAL
PRINCIPLES OF MEDICAL PRACTICE AT 1998 AND OF
CONTINUING RELEVANCE TO DATE
• LOSS OF THE OBJECTIVE AND ETHICAL
FUNDAMENTAL BASIS OF MEDICINE
• RADICAL CARTESIAN DUALISM
• BIOMEDICAL REDUCTIONISM
• DETERMINISTIC EMPIRICISM
• FRAGMENTATION OF INDIVIDUALS WITHIN
BIOLOGICAL SYSTEMS
• S-R EPISTEMOLOGY
Brera
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84 The International Journal of Person Centered Medicine
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pictures are defined as the result of a person’s cohesive
body-mind-spirit teleonomic interaction.
6. The dangerous deficiencies that result when the person’s
three-dimensional conception is omitted in clinical and
scientific work.
7. The necessity of medical education: (a) to teach ethical
possibilities and (b), to teach the epistemological
fundamentals of medical science, theories and studies as
they relate to healthy and sick persons within their cultures
and social contexts
8. The necessity to achieve methodological rigour in
biomedical research and clinical work, introducing and
simultaneously considering biological, psychological and
spiritual variables.
The Person-Centered Medicine Clinical Method [41]
develops the traditional one with the formulation of new
clinical methodology embracing what Brera has termed
“Diacrisis”, a Greek word meaning “discernment” (Table
2). The “Diacrisis” time starts with the creation of an
“Anthropic effect” at the beginning of the clinical relation-
ship corresponding to the physician’s affective disposition
to accept, comprehend and help the person in front of him.
After this, the “diacrisis” clinical objective is the “Person’s
diagnosis” which comprehends the person’s empathic
assessment finalized to discover a non-verbally transmitted
person identity “revealed” at that moment (empathic
diagnosis). Here, gathering information about existential
resources and possibilities (protective factors), clinical
problems to date and from the past, exploring significant
values, interests, spiritual life, relations and affects, coping
styles, quality of life and habitudes, physiology, giving
importance to the dynamics of resources and problems and
identifying the patient’s strengths and weaknesses are all
of fundamental importance. The person’s diagnosis is
assessed by building a cross/ratio between the person’s
strengths and weaknesses, resources and problems to date
and in history with a three dimensional approach depicting
protective factors and risk factors and giving structure to
the operational concept of resilience (protective factors
action) and vulnerability (risk actor action). The person’s
diagnosis is re-assessed after physical examination and the
time that is required to update the cross model, which
shows the dynamic between resilience and vulnerability.
The “SMRP Cross Model” offers many inputs to research
and Diacrisis must clearly be adapted to the acute
symptoms presented. In emergency situations, attention
must be given firstly to biological survival problems,
without omitting Diacrisis when the patient is conscious. In
emergency psychiatry, Diacrisis can be applied if there is a
relational possibility and the first aim is to create
possibilities for it. The education of the psychiatrist in
PCCM is very important. The question which allows
PCCM application is “Who is the person I’m in front of?”
and not “What is the patient presenting with?”. This is the
first principal learning objective and it asks for the
physician to overcome diagnostic anxiety as part of clinical
picture assessment. The concept of the “person” comes
before that of “the patient”. This distinction is postponed in
emergency situations when the principal aim is an urgent
assessment of a life threatening condition, but if the patient
is conscious, the anthropic field production is necessary,
because such an effect transmits positive emotions, which
immediately modify allostatic processes and gene
expression. The existence of a “subtle energy”, transmitted
through emotions, affects and healing intentions behind
space-time dimensions and transmitted faster than light
speed is exciting increasing interest, even though its basic
principles and mechanisms of action are far from
universally recognized or well worked out and remain
largely conjectual. This kind of energy, anticipated by Max
Plank in 1944 and described by Tibetan Monks, (they call
it “compassion”) and St Paul (Charity) is suggested as
capable of modifying DNA electrical charges and cell
replication. These first, courageous and original
investigations opened new fields of knowledge [42]. These
types of studies are consistent with investigations on the
relationship between coping and epigenetics. The “placebo
effect” documents well an evident relationship between
affects (hope-trust) and biological variables, enabling a
deeper understanding of the clinical phenomenology of, for
example, Lourdes, where the existence of a true mystery
between the person’s subjective phenomenology (religious
faith, suffering, death anguish, trust, hope) and disease,
like a third intervening variable, between subjectivity and
clinical picture, is empirically evident [43,44].
The major difference between the PCCM and the
traditional method is that the PCCM already constitutes a
therapy, because it at the same time acts at a spiritual,
affective, emotional and biological level through the
Resource-Problems analysis (Cross model), allowing the
person to reveal himself to another person, becoming
aware of his own life-constituting work, to which also his
clinical problems belong and to begin a quest to discover
and build his own new personal reality through an
TABLE 2
DIACRISIS
1. GENERATION OF THE ANTHROPIC FIELD (ACH)
(Generation of the Acceptance-Comprehension-Help
affective field)
2. PERCEPTION AND ASSESSMENT OF EMPATHIC
PHENOMENA
3. BUILDING A PERSONAL RELATIONSHIP
4. LISTENING TO THE PERSONAL PROBLEM
INTERLOCUTORY BEGINNING
5. CLINICAL EPOKE
6. THE PERSON DIAGNOSIS: ASSESSING THE
PERSON’S STRENGTHS, WEAKNESSES,
RESOURCES AND PROBLEMS ON A THREE-
DIMENSIONAL LEVEL
The International Journal of Person Centered Medicine
85 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
existential change, probably related to pathogenesis,
beginning with symptoms presentation, almost as products
of his bodily or mental suffering. The higher purpose of
PCCM is to consider a disease like an existential event that
could open new possibilities for the person if physicians
are able to do a “maieutical” operation. The “Haec cum ita
sunt” Person-Centered Clinical Method is thus a maieutics
of the person, from an individual human biopsychosocial
nature, not an adaptation, which means the birth of a new
human reality. A problem of every nature, is a call for life,
where “life” is intended to be the fulfilment of the noble
destiny of truth, love and beauty, discovered from
adolescence. Clinics hide this transcendent meaning of life
present in all persons. The concept of “Restitutio ad
integrum”, as the principal objective of clinical acts, is
obsolete and wrong. The healing process is a constructive
work to enter into with the patient, creating new
possibilities such as spiritual, affective, relational and
biological resources. This is the meaning of the
“therapeutic alliance”. The Person-Centered Medicine
clinical epistemology is consistent with the new medical
epistemology. The PCCM model poses new questions for
clinicians:
1. How does the person relate with close people, the
physician(s) and the caregivers (empathy, diagnosis and
verbal communication), his symptoms-symbols and the
environmental stimuli he receives. How do we understand
the emotional and affective world of the patient, his work,
interests, ideals, aspirations, the inner and outer conflicts?
Estimations of limits and possibilities are information and
necessary for the person’s diagnostic process. The clinical
objectives are assessment over time and therapy.
2. How does the person answer or not answer to the
existential call to his noble human destiny (truth-love-
beauty): the meaning he is giving to his own mystery and
the mystery of life?
3. How does one interpret the person’s spiritual, cognitive
and affective symbolic world and perceived internal and
environmental stimuli?
4. Which is the relationship between the clinical picture
symptoms and symbols and environmental stimuli and the
person’s subjectivity, life philosophy and quality?
(Medicine cannot be reduced to Psychology or Sociology).
5. What is the hypothetical meaning of his disease at that
moment of his life?
6. How can the person’s biological variables be related to
subjectivity and how do they influence his behavior?
This operation generates hope, an important health
protective factor.
After Diacrisis PCCM, the next steps are the physical
examination, conducted in an interlocutory way and with
attention to the patient’s word, the general clinical
assessment, defining eventual diagnostic further steps
addressed to define the clinical picture, the three-
dimensional clinical plan assessment, the clinical
“portrait”, which is a clinical synthesis of the precedent
clinical steps starting from empathic phenomena depiction.
Clinical follow up measures the extent to which clinical
objectives are realised.
Educational Programs
In 1998, before the move to develop a Medicine degree,
oriented to the PCM paradigm, the Milan School of
Medicine dedicated its medical education plan to form
physicians in postgraduate courses, teaching the Person-
Centered Clinical Method [45] (Table 3) and Medical
Counselling, taking into account that PCM introduction
into clinical activity of one generalist or pediatrician was
intended to give an important contribution to the health of
1500 and 800 people, respectively. This action fits very
well with the WHO concept of “People Centered Care”. To
date, in the Milan School of Medicine, there are three
curricula years dedicated to teaching Person-Centered
Medicine and Medical Counselling, with a particular
attention given to Adolescents, according to the PCM
paradigm and PCCM Clinical Theory, forming a practical
training in the Person-Centered Clinical Method.
TABLE 3
THE PERSON-CENTERED CLINICAL METHOD
1. DIACRISIS: (GIVING BODY TO WORD)
Anthropic effect (generation of a feeling of acceptance,
comprehension, help). Person Diagnosis “Who?”: Empathic
assessment, Clinical Epoké, Maieutics and analytical method
(cross ratio) addressed to assess Resilience – Vulnerability in
a three-dimensional cross structure (Mind-Body-Spirit) in a SP-
R-M-P dynamics – (Cross model) – biographic anamnesis with
the historical analysis of life positive and negative life stressors
(Semantic-symbolic procedure-development of maieutical and
analogical skills)
2. PHYSICAL EXAMINATION (EMPIRICAL
“What?”)(GIVING WORD TO BODY) (Semantic-empirical
procedure with attention to symbolization)
3. CLINICAL SYNTHESIS: “WHO, WHAT, WHY?”
MEANING: “What for?”
Evaluation of hypothetical relations about the person
subjective resources and three dimensional problems or
menaces evidenced by person diagnosis leading to an
hypothesis about the interaction between protective
(resilience)and risk factors (vulnerability). This step must teach
the integration between maieutical-analogical-hypothetico-
deductive skills)
4 ASSESSMENT OF CLINICAL OBJECTIVES (AN
UNDERSTANDING DERIVED FROM PHYSICAL,
BIOCHEMICAL AND TECHNICAL EXAMINATION)
5. CLINICAL PORTRAIT
6. PERSON-CENTERED THERAPEUTIC PROGRAMME
That comprehends Medical Counselling (after education in
PCCM)
7. CLINICAL ASSESSEMENT OVER TIME
Brera
Person-Centered Medicine: theory, teaching and
research
86 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
Physicians, through a step-by-step teaching method, began
to apply PCCM, gradually integrating it with and
modifying the traditional clinical method. A two year
international course has been recently founded. In 2003,
the educational procedures were inserted into the
University Quality System. Assessment method of PCM
learning were applied from 1999. A three year program to
form clinical teachers in Person-Centered Medicine, a
Licentia Docendi Diploma, was instituted. Educational
procedures received quality certification in 2003. For the
first time in medicine, clinical teaching received a quality
certificate. From 2003, international courses to educate
clinicians in the Person-Centered Clinical Method were
organised.
Learning is both is theoretical and practical. On a
theoretical level, the general learning objective is to teach
the new interactionist teleonomic understanding of human
nature and medical epistemology, new operational
concepts and the PCM and PCCM theoretical structure.
(Table 4)
On a practical level, the general learning objective is to
teach the Person-Centered Clinical Method. (Table 5). The
PCCM steps are taught in three phases corresponding to
three years of learning procedures [46]. Physicians learn
the “Diacrisis procedure”, generating, perceiving and
modulating the PCM positive “Anthropic field” made by
the “Acceptance-Comprehension-Help” attitude and the
“Empathic Assessment” applying the “Analogical
Thinking”. They learn to “put into commas“ (Clinical
Epokè) the empirical “diagnosis anxiety” (if there is not a
biological emergency) and to learn the art and method of
the “person diagnosis”, to conduct a physical examination
and how to interact with the person and to apply three-
dimensional findings in the “Cross Model” form, studying
resilience and vulnerability. They learn how to formulate a
“Clinical Hypothesis”, studying the interaction of
environmental–subjective-biological variables and how to
develop “Person-Centered Clinical Objectives” (using
variables belonging to Mind-Body and Soul) and a
“Clinical Synthesis”, defined as a “Clinical Portrait”.
“Soul” is understood here as the quest for an existential
meaning and religious faith is considered as a subjective
existential resource (protective factor). Physicians learn to
apply the PCM clinical sheet. Learning assessments are
conducted each year: In the first year there is the Theory
and first PCCM phase. In the second year there is the
second PCCM phase and in the third year the third PCCM
phase. That teaching method is concurrent with training
and consists in role playing organised by a trained or in-
training clinical teacher (in this case under the
“Magister’s” supervision). Case reports presentation and
discussions on-line are employed as part of the assessment
method. The final examination with a dissertation on a
clinical case is preceded by the PCCM clinical skill
assessment with a standardized procedure.
In 2002, the first investigation of the effects of PCCM
learning in medical practice was conducted with striking
TABLE 5
THE PHYSICIAN’S NEWLY DEVELOPED SKILLS IN
PERSON-CENTERED MEDICiNE
Development of analogical skills for inner perceiving and
assessing the use of empathic phenomena and the embrace
and development of the clinical relationship (cf: the mirror
neurons development).
y The ability to identify, using the history, clinical events as
the result of the interaction of environmental-relational-
subjective-biological variables, modulated by the person
and concurrent in constituting health quality and quality of
life.
y The ability to perform the physical examination, giving full
attention to the person’s word
y The ability to understand the maieutics of resources,
possibilities, the antagonists and problems dynamics in a
clinical dialogue and the ability to build the individual,
structured cross model of the interaction between
protective/risk factors.
y The ability to constitute an individual person-centered
diagnostic hypothesis procedure and clinical plan,
integrating subjective - environmental - biological
variables.
y The ability to describe the person diagnosis result, clinical
hypothesis and objectives integrating a literary depiction
with clinical style.
y The Ability to fulfill the Person-Centered Medicine Clinical
Sheet
TABLE 4
PCM THEORETICAL LEARNING OBJECTIVES TAUGHT IN
THE MILAN SCHOOL OF MEDICINE
a. Epistemology and new interactionist medical principles of
medical science based on Psychoneuroendocrine-
immunologypsychophysiology and the theoretical elaborations:
Relativity of biological reactions (RBR Theory, Allostasis,
Epigenetics and other modern theoretical contributions.
b. Teleonomic principles of human nature and health
enunciated by Anthropoanalysis, and not reductionist
Psychoanalysis, Logotherapy, American Humanistic
Psychology and Phenomenology applied to clinics.
c. Kairology, which depicts a mysterious teleology in human
life revealed to humans from adolescence. Here, questions of
love, truth and beauty, the conceiving of existence as a
mysterious revelation of the human being and consequently
disease and suffering as a mysterious, dramatic and
ontological subjective possibility for experiencing an objective
meaning (love and truth) in own individual life all become of
fundamental importance.
d. A New Health Paradigm and operational concepts in
medical science like Resilience and Vulnerability, Protective
Factors versus Risk Factors and their implications for
diagnosis.
e. Person-Centered Medicine Manifesto, Person Centered
Clinical Method Manifesto and Structure (PCCM)
The International Journal of Person Centered Medicine
87 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
results [47, 48]. The aim of this study was to investigate
the first application of the Person-Centered Clinical
Method by a three year trained physicians sample. It was a
descriptive pilot study. 20 Physicians (7 medical
practitioners, 6 paediatricians, 3 hospital doctors, 4 private
doctors) agreed to complete a questionnaire on “PCCM
Quality in Medical Practice”. Answer rates relating to the
perception of a change in medical practice and the
associations with the physician’s role were studied with
descriptive statistics and cross tabulations. Physicians
stated that PCCM improves patient’s understanding (95%)
and patient’s quality of life and health, (75%), avoids
useless examinations and drug prescriptions, (70%) avoids
unnecessary hospitalizations (55%), but requires more time
to dedicate to patients (55%).
The effectiveness of the PCCM in avoiding useless
examinations and drug prescription is significantly
associated to medical role (P=0,02). Medical Practitioners
(100%) and paediatricians (85%) declare that PCCM is
effective in avoiding useless examinations, drug
prescriptions and unnecessary hospitalizations.
TABLE 6
ITEMS %
Permits a better understanding by patient of his
problems 95
Improves the finalization of specialty referrals and
technical examinations 30
Saves useless examinations and drug prescriptions. 70
Spares unnecessary hospitalizations 55
Reduces hospitalisation times 10
Improves professional realization 40
Is effective on patients’ quality of life and health
improvement 75
Reduces doctor -dependency 45
Creates new possibilities for research 30
Shortens improvement times 30
Necessitates more time to dedicate to the patient 55
TABLE 7
Paediatrician
trained
Differences in %
with other
Lombardia
Region, Italy
Paediatricians
N° of drug
prescriptions 420 -77,33
Prescription/benefici
ary 0,42 -76,21
Total Cost (euro)
6.208,97 -89,05
Cost per capita
6,28 -88,5
No. of items
prescribed 590 -82,10%
No of items per
capita 0,6 -80,45
Mean value of items
10,19 -99,99
Mean value of
prescription 14,78 -51,67
There is general agreement about the necessity and
importance of learning and recommending the PCCM.
This investigation, where results were presented for the
first time in 2003 [49], demonstrated that PCCM leads to
true medical practice quality improvement (Table 6). Data
assessments by the Lombardia Region analyzing drugs
prescriptions confirmed the described reduction of drug
prescriptions in an extraordinary way, giving strong
support to the argument that the more widespread adoption
of Person-Centered Medicine could lead not only to the
improvements in the patient’s wellbeing, but also to
important financial savings in health systems (Table 7). A
major obstacle to the progress of the PCM revolution,
according to the Ambrosiana University program, is to
form clinical teachers and tutors who are able to apply
PCM and PCCM in clinics and to teach it in pre- and post-
degree courses.
Conclusion
At the time of writing, and failing to take into account
epistemological knowledge, medical schools, with the
exception of the Milan School of Medicine, cling to an
intrinsic bio-medical paradigm producing biotechnocrats,
whose knowledge and formation does not include a “Real”,
“Vera” and “Véritable” interpretation of human nature. A
disease means a change in existence and research for an
objective answer to it should be based on a scientific
interpretation entrusted to RBR Theory, Allostasis,
Epigenetics, psychoneuroimmunology endocrinology and
Kairological human nature hermeneutics. The problem is
the general absence of teachers, all over the world,
prepared to teach Person-Centered Medicine. The birth of
the Person-Centered Medicine International Academy will
help to address this need. New journals like the
International Journal of Person-Centered Medicine and
the Person-Centered Medicine International Journal
(published on-line by the Universita Ambrosiana) and
continuous and sustained efforts [50] will build a culture
which assures progress. The person is an irreducible end
and the object of all human actions. We must continue,
with vigour, to communicate this new truth about Medicine
and Medical Science.
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variables and
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R
eferenc
1
] Brera G.R.
M
edicine.
M
edi
c
2
] Brera G.R.
(
o
rmazione dei
m
o
sef Seifert: I
M
edicine and
M
n
troduction of
i
sa:IEPI-Unive
r
3
] Brera G.R.,
d
olescents. Mil
4
] Brera G.R.
c
ience.
M
edici
n
5
] Ibidem 2
6
] Ader R
.
s
ychoneuroim
m
ondon, Sydne
y
7
] Engels G.L.
h
allenge for bi
o
8
] Brera G.R.
M
ind. 8, (2):5-9.
9
] Brera G.R.
o
ssibility and
R
C
ISPM.
1
0] Brera G. R
a
tura umana.
E
cerca in adol
e
a
ture theory:
a
radigms in
dolescence. 10
,
e
rson-cente
Stimuli;
Reactions (eg.
e
Stimuli (eg: q
u
o
ns, affects,
s
).
e
Reactions
ntal Stimuli
ironmental vari
a
y individuals] e
g
al care - cultur
e
environmental,
e
ntal Reactions
…time x x =
e
s the assess
m
h
e person’s act
i
een corroborat
e
g
ical model is
“
v
ity and enviro
n
r
ation, belongs
is reciprocally
c
es
(1999). The
c
ine, Mind and
A
(
2001). La me
d
m
edici nel terz
o
sette scopi
M
edical Educa
t
Iosef Seifert
T
r
sità Ambrosia
n
(1991) Cour
s
an,CISPM-IM
E
(1992). Epis
n
e and Mind. 7,
.
, Felten
m
unology. Sa
n
y
, Tokyo, Toro
n
(1977). The
n
o
-medicine. Sci
e
(1993). The k
a
(1994).The
R
eality in adol
e
. (1995). Per
u
E
pistemologia,
e
scentologia.
(
Epistemology
Adolescentol
o
,
2:5-16
88
red health
gene
u
ality
a
bles
g
:
e
-
social and poli
t
the unpredicta
b
m
ent of variable
s
i
on on the varia
e
d by neurobiol
o
“
interactionist”
b
n
ment. The m
o
to existence a
n
c
hanged by the
m
manifesto o
f
A
dolescence. 1
d
icina centrat
a
o
millennio. C
o
della medicin
a
t
ion in third
M
T
he seven ai
m
n
a.
s
e in Medica
l
E
PA.
temological a
5-12
L.,Cohen
n
Diego, N
e
n
to: Academic
P
n
eed for a ne
w
e
nce 196, 129-
3
a
iros of exist
e
kairos of
e
e
scence and h
u
u
na teoria dell’
a
fenomenologi
(
For an adole
s
, phenomenol
o
gy it.)
M
e
d
Interaction
t
ical events
b
ility constant
s
during the pe
r
bles.
o
gy, physiolog
y
b
ecause the o
b
o
del is “indeter
n
d is unpredict
a
m
. In humans,
h
f
Person Cen
t
4, 1-2.
a
sulla persona
o
n l’introduzio
n
a
Person Cen
t
M
illennium wit
h
m
s of Medicin
e
l
Counselling
spects of me
N. (1
9
e
w York, B
o
P
ress.
w
medical mo
d
3
7
e
nce.
M
edicine
e
xistence. Mi
s
u
man nature.
M
a
dolescenza e
a e paradig
m
s
cence and h
u
ogy and res
e
d
icine, Mind
ist-indeter
m
r
son’s lifetime.
y
, epigenetics a
n
b
jects to invest
i
ministic” becau
a
ble. It is “cons
t
h
ealth appears
t
ered
e la
n
e di
t
ered
h
the
e
it.)
with
dical
9
90).
o
ston,
d
el: a
and
s
tery,
M
ilan:
della
m
i di
u
man
e
arch
and
[11
]
Ce
n
16,
[12
]
adu
l
Soc
[13
]
dev
e
ed.
N
[14
]
me
a
90.
[15
]
p
az
i
M
o
r
[16
]
p
ro
f
Me
d
[17
]
teo
r
Me
d
Am
b
sci
e
Hu
m
Giu
[18
]
Me
d
[19
]
A
n
15-
1
Perso
n
The Internati
o
m
inistic-co
n
The direction
o
n
d psychoneur
o
i
gation are sim
se phenomeno
t
ructivistic” bec
a
more a constr
u
]
Brera G.R,
n
tered Adolesc
e
1-2
]
Piaget J. (19
8
l
twood. In:
R
iety; New Yor
k
]
Muus R.E. (1
e
lopment. In
M
N
ew York: Mc
]
Brera G.R (1
9
a
ning of life in
]
Brera G.R.
(
i
ente (Sufferin
g
r
ale. 1, 46-57
]
Zanon Aldo
(
f
. G. R. Brer
a
d
ical Counselli
n
]
Brera G.R. (1
r
ia della Medic
i
d
icine theory).
b
rosiana:” U
m
e
ntifico, meto
d
m
anization,scie
n
gno; Milano, I
t
]
Brera G.R.
d
icine.
M
edici
n
]
Benson H. (1
9
n
ew study illu
m
1
8.
n
-Centered
M
o
nal Journal
o
n
structivis
t
o
f the arrows in
d
o
endocrineimm
u
ultaneously va
r
logy of variabl
e
a
use the perso
n
u
ct than a dete
r
(2001). The
a
e
nce Theory.
M
8
0). Intellectua
l
R
.E. Muus edi
t
k
: Random Ho
u
996). The Psy
c
M
uus R.E. edit
o
Graw-Hill: p.
1
9
85). Il senso
d
the medical pr
a
(
1987). La so
g
in the docto
r
-
p
(
1998). Il Cou
n
a
(The prof
G
n
g it.) Milano:
U
995). Relativit
à
i
na (Relativity
Atti del Con
v
m
anizzazione
d
o clinico e
q
n
tific paradig
m
t
alia
(1999). The
m
n
e, Mind Adole
s
9
83). The rela
x
m
inates mecha
n
M
edicine: theo
r
o
f Person Ce
n
Volume 1
I
t
ic model
d
icates the acti
o
u
nology.
r
iable in intera
c
e
s’ perception,
n
directly acts
o
r
minate adaptat
i
a
dolescent as
M
edicine, Mind
l
evolution fro
m
t
or. Adolesce
n
u
se.
c
hoanalytic the
o
r. Theories of
A
1
8-41
d
ella vita nell’a
g
a
xis).
M
edicin
a
fferenza nel
r
p
atient relatoi
n
n
selling medic
o
G
iuseppe R.
B
U
niversità Am
b
à
del sapere bi
o
of bio-medical
v
egno inaugura
della medi
c
q
ualità delle
c
m
and qualit
y
m
anifesto of
s
cence. 14, 1-2,
x
ation response
n
isms. Integrat
i
r
y, teaching a
n
resea
r
n
tered Medic
i
I
ssue 1 pp 79-
8
o
n of variables
c
tion belonging
necessary for
t
o
n the interacti
o
i
on to pre-existi
person. Pers
o
and Adolescen
c
m
adolescence
n
t, Behavior
a
ory of adolesc
e
A
dolecence. V
I
g
ire medico. (
T
a
e Morale. 1,
8
r
apporto medi
c
n
ship).
M
edicin
a
o
nelle lezioni
d
B
rera’ lessons
b
rosiana.
o
-medico: per
u
knowledge: fo
r
l
e dell’Univer
s
c
ina, paradig
m
c
ure”. (Medic
i
y
of care )
Person Cente
r
and epinephri
n
i
ve Psychiatry.
n
d
r
ch
i
ne
8
9
on
to
t
he
o
ns
ng
o
n-
c
e.
to
a
nd
e
nt
I
th
T
he
8
0-
c
o-
a
e
d
el
on
u
na
r
a
s
ità
m
a
i
ne
24
r
ed
n
e.
1,
The International Journal of Person Centered Medicine
89 The International Journal of Person Centered Medicine
Volume 1 Issue 1 pp 79-89
[20] Lazarus R.S. ,Folkmann S. (1984). Stress, appraisal and
coping. New York: Springer.
[21] Brera G.R. (1996). A revolution for medical science and
biomedical research: the determinate and the quality
indeterminate relativity of biological reactions, Milan : Università
Ambrosiana.
[22] Brera G. R. (1997). The relativity of biological reactions and
the first formulation of and interactionist epistemological
paradigm for medical science and its application in clinical
research and medical education. Medicine, Mind and
Adolescence. 12, 1-2: 7-15.
[23] Laundeslangers M.L.,Ryan S.M.,Drugan S.F.F et al. (1983).
Coping and immuno suppression : inescapable but not escapable
shock suppresses lymphocytes proliferation. Science. 221, 568-
570
[24] Selye H. (1956). The stress of life.New York: McGraw Hill.
[25] Sterling P.,Eyer J. (1988). Allostasis: a new paradigm to
explain arousal pathology. In: Fischer S Reason J. editors.
Handbook of Life Sciences, cognition and Health. New York
J.Wiley and Sons. p. 629-649
[26] Seeman, T.E., B.H. Singer, J,W. Rowe, R.I. Horwitz, and
B.S. McEwen (1997). Price of adaptation –allostatic load and its
health consequences: Mc Arthus studies of successful aging.
Arch.Int.Med. 157, 2259-2268.
[27] Ryff C.D and Burton H. Singer. (2003). The role of emotion
on pathways to positive health. In R.J.Davidson,
K.R.Scherer&H.H. Goldsmith Eds. Handbook of affective
sciences. New York: Oxford University Press. p. 1083-1997.
[28] Liu D., Dorio J., Tannembaum J. (1997). Maternal care,
Hypocampal Glucorticoid Receptors and Hypotalamic-Pituitary-
Adrenal Responses to stress. Science, 277:1659-1662
[29] Szyf M. and Meaney J.M. (2008). Epigenetics, Behaviour,
and Health. Allergy Asthma Clin. Immunology. 4 (1):37-4
[30] McGowan P. O., Sasaki A., D'Alessio A.C. , Dymov S.,
Labonté B., Szyf M., Turecki G., Meaney M.J. (2009). Epigenetic
regulation of the glucocorticoid receptor in human brain
associates with childhood abuse. Nat Neurosci. Mar;12 (3): 342-8
[31] McGowan P. O., Sasaki A., D'Alessio A. C., Dymov S.,
Labonté B., Szyf M., Turecki G., Meaney M. J. (2009).
Epigenetic regulation of the glucocorticoid receptor in human
brain associates with childhood abuse. Nat Neurosci. Mar;
12(3):342-8
[32] Wilet C. Walter, (2002). Balancing Life Style and Genomic
Research for Disease Prevention. Science. 296 -26 ù
[33] Strohman R. (2002). Manoevring in the complex path from
genotyipe to phenotiype. Science. 296, 701-4
[34] Lipton B. (2005). The biology of beliefs. Bruce Lipton ed.
[35] Robinson E.G.,Fernald R., Clayton D. (2008). Genes and
Social Behavior.Science. 322, 896-900
[36] Brera G.R. (2005). Epistemology and medical science:
change of the paradigm. In Brera G.R. editor. Return to
Hippocrates: Quality and Quantity in Medical Education.
Proceeding of the second Conference on New Perspective in
medical Education, May 27-28, Milan, Italy , Università
Ambrosiana ; 2005. p 19 (abstract)
[37] Fawzy F.L., N.Y. Fawzy, and al. (1994). Short term
psychiatric intervention for patients with malignant melanoma:
effect on psychological state, coping and the immune system. In:
C.E. Lewis, C.O’Sullivan, and J. Barraclough eds. The Psycho-
immunology of cancer. Oxford, New York, Tokio: Oxford
University Press. p. 291-320
[38] Tournier P. (1983). Medicine de la personne. XII° edition
Neuchatel: Delachaux et Nestlié.
[39] Brera G. R (2001). The adolescent as person. Person
centered adolescence theory. Medicine Mind and Adolescence 16,
(1-2): 5-19
[40] Berti L. (2009). The current value of the Hippocratic oath.
Forum on line: Person centered Medicine Education and
Research. December 12-19 Campus on line, Università
Ambrosiana, Milan Italy. www.unambro.it.
[41] Brera G.R (1999). The manifesto of Person Centered
Medicine. Medicine, Mind Adolescence. 14, 1-2,
[42] Brera G.R. (2001). Il Metodo Clinico centrato sulla Persona.
In: Brera G.R. La medicina centrata sulla persona e la
formazione dei medici nel terzo millennio. Con l’introduzione di
Iosef Seifert:I sette scopi della medicina Person Centered
Medicine and Medical Education in third Millennium with the
introduction of Iosef Seifert The seven aims of Medicine it.)
Pisa:IEPI-Università Ambrosiana.
[43] Rein G. (1996). Effect of conscious intention on human
DNA. Proceedings of the International Forum of New Sciences.
October 1996 Denver. CO. USA.
[44] Mangiapan T. (2010). Guérisons de Lourdes (nouvelle
edition). Lourdes: NDL.
[45] Carrel A., (1950). (Nobel prize) The voyage to Lourdes.
(with the preface of Charles Lindberg). New York: Harper and
Row.
[46] Brera G.R. (2001). La medicina centrata sulla persona e la
formazione dei medici nel terzo millennio. Pisa, IEPI (with the
intoduction of Iosef Seifert: I sette scopi della medicina
[47] Università Ambrosiana. Sistema Qualità (Quality sytem)
Milano; Universita Ambrosiana; 2003
[48] Brera G.R. (2005). Person-Centered Medicine and Person-
Centered Clinical Method Teaching. In: Brera GR editor,
Proceedings of the Conference: “Return to Hippocrates. Quality
and Quantity in Medical Education; Milan 28-29 May” Milan,
Italy p 39 (abstract)
[49] Brera G.R: and ITFOP * Education in Person-Centered
Clinical Method and Perceived Quality of Person-Centered
Clinical method. In: G.R. Brera, editor. Assisi 2003 .Proceedings
of the first International Symposium on New Perspectives in
Medical Education; 2003 October 23-25; Assisi, Italy, p 34. (The
Italian Task Force in Person Centered Medicine)
[50] Brera G.R. (2003). Person-Centred Medicine Educational
Objectives – an announced revolution. In: SIAdve editor.
Proceedings of the Conference: Youth Health Center and Person-
Centered Medicine, December 20 Cittadella (PA), Italy,p 2-7.
[51] Mezzich J.E, Snaedal J. Van Weel C., Heath I. (2009). The
Person Centered Medicine International Network. Backgrounds
and first steps. Forum on line: Person centered Medicine
Education and Research. December 12-19 Campus on line,
Università Ambrosiana , Milan Italy. www.unambro.it.
[52] Brera G.R. (2001). La medicina centrata sulla persona e la
formazione dei medici nel terzo millennio.IEPI, Pisa (with the
introduction of Iosef Seifert: I sette scopi della medicina.
