4. THE POWER OF YOUprojects.hsl.wisc.edu/SERVICE/sites/final/2017/Day... · No Visit Standard Enhanced No Visit Standard Enhanced VETERANS HEALTH ADMINISTRATION Rakel, Barrett, Zhang,

Whole Health in Your Practice - The Power of You: Your Healing Presence

March 2017

1

4. THE POWER OF YOU: YOUR HEALING PRESENCE

Whole Health in Your Practice

“Me” at the

center is both

you as an

individual and

the Veterans

that you serve.


March 2017

2

The Clinician Effect

You Trump Pills!!

VETERANS HEALTH ADMINISTRATION


March 2017

3


From Jerusalem to Jericho: A study of situational and dispositional variables in helping behavior

Group #1

Group #2

Group #3

J Personality and Social Psychol. 1973;27:100-108

Extra time

On time

Late


Non-Specific Variables

Specific Variables

March 2017


March 2017

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Let’s explore the power of non-specific variables that work through you!

-Perception -Expectancy -Empathy -Listening -Purpose and Intention

Perception


March 2017

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Perception Shapes Reality

Cloud of Probability

Reality

Observation,

Consciousness

Foter.com/CC0


March 2017

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Expectancy


March 2017

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Simotas, et al. Neck pain in demolition derby drivers. Arch

Physical Med Rehabilitation. 2005;86:693-696.

Public = 10% Derby = 0.25%

Why don’t these guys get “whiplash” neck pain?

10 mg

Morphine

10 mg

Diazepam

Colloca L, et al. Lancet Neurology. 2004;3(11).


March 2017

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Your Expectations Have Power Too

• Study of acupuncture for pain

• 9900 patients, 2781 different physicians

• Controlling for everything else, if a physician had high expectations – Pain intensity decreased

– Physical functioning improved

• Even when controlling for disease severity. Two patients, exactly the same, still seemed to be influenced by their clinicians’ expectations

Witt, et al. Eur J Pain 2012;16:1455–1466.


March 2017

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Empathy


Empathy

Definition:

• A clinician can understand their – Situation

– Perspective

– Feelings of another person

• They can show the other person they understand

• They can act on this understanding

Pinterest.com


March 2017

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Empathy: Research

2013 systematic review • 7 studies

• Over 3,000 patients and 225 physicians

• Conclusions

“There is a relationship between empathy in patient–physician communication and

patient satisfaction and adherence, patients’ anxiety and distress, better diagnostic and clinical outcomes, and

strengthening of patients’ enablement.”

Pinterest.com

Derksen F et al. Br J Gen Pract, 2013;Jan:376-84.


McKay K, et al. Psychiatrist effects in the psychopharmacological

treatment of depression. J Affect. Disord. 2006;92:287-90.

Practitioner Effects For Depression: Good Therapist + Placebo > Poor Therapist + Imipramine


March 2017

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NIH Placebo Research (Harvard, University of Wisconsin)

Good Doc

“Standard” Doc

No Doc


Acupuncturist Effects on IBS

• Wait List Control............................28%

• Limited Clinical Visit........................44%

• Augmented Clinical Visit.................62%

Kaptchuk TJ. et al. Components of the Placebo Effect: RCT in patients

with IBS. BMJ 336 (7651), 2008

IBS Pts Randomized to: Improvement in Symptoms;


March 2017

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UW Cold Study Perception of Perfect Empathy

IL-8 Neutrophils

No Visit Standard Enhanced No Visit Standard Enhanced


No Visit < Perfect Perfect P Value

Duration 6.75 days 7.0 days 5.89 days 0.003

Severity 262.19 270.58 223.38 0.04

UW Cold Study: Effects of Perceived Empathy

Rakel, Hoeft, Barrett, et al. Fam Med. 2009; 41(7):494-501

Rakel, Barrett, Zhang, et al. Patient Ed & Counseling. 2011; 1-8.


March 2017

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Reduction in Empathy with Medical School Training

Newton et al. Acad Med, 2008;83(3)

Listening


March 2017

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We have two ears and one mouth so we can listen twice as much as we speak. -Epictetus

• 1984 study: The average doc interrupts after 18 seconds

• 2002: 23 seconds

• How long will patients talk with no interruption?

– Mean: 92 seconds – Median: 59 seconds

– In all 335 sessions, the info was rated as ‘useful.’

1ohww.org

Beckman et al, Ann Intern Med 1984;101:692-6.

Langewitz et al. BMJ 2002;325:682-3.

Attention is the rarest and purest form of generosity.


March 2017

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LITTLE MISS SUNSHINE VIDEO CLIP

Purpose & Intention


March 2017

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To Sum Up: pg 26

• Your presence, in and of itself, is an important nonspecific variable.

• Use all of these elements to enhance what you can do!

– Relationship

– Empathy

– Listening

– Insight

– Expectation

– Values

– Empowerment


To Sum Up

• Your presence, in and of itself, is an important nonspecific variable.

• Use all of these elements to enhance what you can do! – Relationship Know their story.

– Empathy Humanize the person.

– Listening Don’t interrupt. Listen deeply.

– Insight Take time to reflect.

– Expectation Consider agendas.

– Values Explore what really matters.

– Empowerment Help them drive their care.


March 2017

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4. THE POWER OF YOU: WHERE WE’VE BEEN, WHERE WE WANT TO GO

Whole Health in Your Practice


Why Are You Here? Every hero has an origin story – what’s yours?

• With a Partner, Answer these AS YOU PREFER

• Pause to reflect: Why are you here?

– In health care

– In the VA

• What do you love about this work? What’s challenging?

• Each person will share for a few minutes

Zimio.com


March 2017

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Brief Exercise – A Group Reflection

Personal Reflection • What are the strengths of the healthcare system? • What are the opportunities for improvement in healthcare?

• What are the possibilities for healthcare going forward?


Challenges

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http://www.flickr.com/photos/128733321@N05/

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http://creativecommons.org/licenses/by/2.0/


March 2017

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Challenges: Information Technology / Data

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Challenges: Metrics


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March 2017

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Challenges: Incentives

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Challenges: Retaining Quality Personnel

https://www.flickr.com/photos/huffstutterrobertl/4039672587/

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https://www.flickr.com/photos/119023622@N04/13106103515/

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March 2017

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Challenges: Reduced Opportunities for Collaboration

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Challenges: Health Disparities

https://www.flickr.com/photos/54159370@N08/7188177257/

http://foter.com/







March 2017

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Challenges: Health Literacy

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Challenges: Polypharmacy


http://foter.com/







March 2017

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Challenges: Direct to Consumer Marketing


Challenges: Microbial Resistance

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March 2017

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Challenges: Scheduling

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A Brief History of Medicine

• Ancient healers

• Chinese medicine

• Ayurveda

• Ancient Greeks

• The Romans

• Middle Ages

• 19th century

• 20th century

• 21st century


http://foter.com/





March 2017

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History: The Rise of “Modern” Medicine

• 1812, first article in NEJM

• Treatise on angina pectoris

• Patient treated with bloodletting, stimulants, topical ether, opium, laxatives, blistering agents over sternum, caustics to provoke draining blisters on thighs and arms

• Symptoms did not improve – sent on therapeutic voyage to the warmer climate for winter, returned in spring.

• Attacks returned. Bloodletting, arsenic, tobacco not helpful.

• The patient died

N Engl J Med 2012;367:1077-82.


History – Skip to 1800s

Oliver Wendell Holmes (1860) –

“…if the entire materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind – and all the worse for the fishes.”

N Engl J Med 2012;367:1077-82.

Internet Archive Book Images via Foter.com / No known copyright restrictions


March 2017

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Many

years…

1800s

1842 - Anesthesia

1870s - Germ theory

1899 - Aspirin

Early 1900s

1901 - Blood transfusion

1913 - EKG

1928 - Penicillin



1950s

1952 - Pacemaker

1953 - DNA

1954 - Kidney transplant

1955 - Polio vaccine

Mid-late 1900s

1967 - Human heart transplant

1983 - HIV identified

1996 – Sheep cloned

2000s

2003 - Human genome released

2015 - Woolly mammoth genome sequenced

2016 - T. Rex DNA


March 2017

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Medicine – Yesterday, Today, Tomorrow

Since the days of bleeding and mercury to today’s molecular medicines, clinicians have sought new and better therapies.

The task and complexity of the mission are extraordinary.

N Engl J Med 2012;367:1077-82.


And Some Things Don’t “Get Old”

“Only connect! … Only connect the prose and the passion, and

both will be exalted, and human love will be seen at its height.

Live in fragments no longer. Only connect, and the beast and the

monk, robbed of the isolation that is life to either, will die.” -EM Forster

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March 2017

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The Privilege of Being a Healthcare Provider

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Service VA Style

• Largest integrated healthcare system in the U.S.

• 150 medical centers

• ~ 1,400 community-based outpatient clinics, community living centers, Vet Centers and Domiciliaries.

• Over 53,000 licensed practitioners • And they are caring for more than 8 million Veterans yearly


March 2017

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VHA’s Path of Transformation


Patient Driven: Interdisciplinary Teams and Beyond

• Veteran

• Partner, Family, Friends

• Community, Neighborhood, Groups

• Clinicians

– Primary care, PACTs

– Specialty care

– Inpatient, outpatient

– Integrative Health

Photo: VA.gov website


March 2017

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The Past

“What’s the matter with you?”

Physician Dependent

Case-Based Paper Medical Record

“We’ll address your immediate concern.”

Moving Toward Personalized, Proactive,

Patient-Driven Care

“What matters to you?

Clinical Team, PACT

Electronic Medical Record Focused on

Disease/Injury/Illness

“You have a risky problem, please follow this plan to improve by

your next visit.”

Personalized, Proactive, Patient-Driven Care

“How can we help you live the life

you want to?”

Veteran, Family and Health Care Team

Electronic Health Record

(with Personal Health Goals)

“Let’s work together to create a plan that fits your

life.”

Changing Approach to Care

Multi-Disciplinary Inter-Disciplinary Trans-Disciplinary


Beyond the VA Crisis – Becoming a High-Performance Network

“Our “whole health” model of care is a key component of the VA’s proposed future delivery system. This model incorporates physical care with psychosocial care focused on the veteran’s personal health and life goals, aiming to provide personalized, proactive, patient-driven care through multidisciplinary teams of health professionals.”

David J. Shulkin, M.D.

N Engl J Med 2016; 374:1003-1005


March 2017

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Pathways: Whole Health Partnership

Whole Health Partnership:

Systematic approach to form a lasting partnership with Veterans at the point of enrollment, and support their whole health, integrating their self care and clinical care, where ever it is received.

Includes: Whole Health Pathway

Health & Well-Being Center

Healthcare Clinic


Integrative Health Coordinating Center

• Guide and support development of Integrative Health throughout VHA

– Clinical Innovation, Research & Evaluation, Education

– Policy, Human Resources, Veteran Benefits, Metrics

– Seamless integration with existing OPCC, VHA, VA initiatives

• Demonstrate improved health outcomes and return on investment


March 2017

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Whole Health Education

Clinical Program

Coaching Program

Peer Group-Based Program

Whole Health Engagements

On-Line Modules

Community of Practice Calls

W

H

O

L

E

H

E

A

L

T

H


Each one of you is an integral part of the largest healthcare system in the nation.

The VA: A team to be Celebrated

Depositphotos_24650107_xs


March 2017

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Moving Toward the Future…

“I am only one, but I

am one. I cannot do

everything, but I can

do something. And I

will not let what I

cannot do interfere

with what I can do.”

~Edward Everett Hale


Passion, Expertise, Commitment


March 2017

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Self-Assessment: How Whole Health-y is Your Practice So Far?

• Binder pages 23-24

• Take time to answer the 20 questions with the following scale: – 1 Never happens

– 2 Occasionally happens – a few times a month

– 3 Often happens – a few times a week

– 4 Frequently happens – a few times a day

– 5 Always happens – part of every patient encounter

• When you are done, you can go to lunch!

• We’ll discuss them after lunch

Documents

4. THE POWER OF YOUprojects.hsl.wisc.edu/SERVICE/sites/final/2017/Day... · No Visit Standard Enhanced No Visit Standard Enhanced VETERANS HEALTH ADMINISTRATION Rakel, Barrett, Zhang,