Organizations connected to two of the most significant researchers in the movement for integrative health and healing, Brian Berman, MD and Wayne Jonas, MD, held separate events recently to announce reports that offer insight into patients’ experience of health and healing. Samueli Integrative Health Programs, which Jonas directs, examined patient views of health in the context of their relationships with their primary care doctors. Berman’s Institute for Health and Healing – in collaboration with the Institute for Functional Medicine – dove deeply into selected patients’ perceptions of what their “healing journey” to develop a model. Both examinations highlight processes not typically part of the clinical encounter. Outcomes illuminate potential characteristics of a system focused on health creation.
TIIH/IFM: Healing from the Patients’ Perspective
“Community” was identified as the key factor in this intensive qualitative analysis of interviews with 23 patients patients selected for their healing experiences. The authors of the paper in BMJ Open, Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness, define healing as “recovering a sense of integrity and wholeness after experiencing illness and suffering.” University of Vanderbilt professor of ethics Larry Churchill, PhD calls the model advanced by the researchers “the best, brief phenomenological portrait of healing we have available.”
After an initiating trauma or “wounding event,” those who heal tend to engage “an erratic, long-term process, experienced uniquely by each person” based on their circumstances:
“Through persistence, the suffering person forms safe, trusting relationships with helpers, who in turn, enable the person to gain resources, such as positivity. The cycle of acquiring relationships and resources repeats indefinitely, fostering beneficial attributes, such as self-acceptance. These contribute to a restored sense of wholeness and integrity, which constitutes healing.”
The interviews with the subjects made clear that their healing – a “recursive, not step-wise” process – did not lead to the absence of illness. Rather, each, in the context of community, found ways to live with their conditions. Study co-author Kurt Stange, MD, MPH strikes a hopeful note in speaking to the potential impact: “Greater understanding of patients’ journeys may positively inform the way health professionals, caregivers, and communities support those who are ill.”
Other authors included two Institute for Integrative Health Scholars, Paul Dieppe, MD, FRCP, FFPH (University of Exeter Medical School) and David Jones, MD (The Institute for Functional Medicine), as well as Sara L. Warber, MD (University of Michigan Medical School), and John G. Scott, MD, PhD (Northeastern Vermont Regional Hospital – no photo available). Dieppe, Jones and Stange are each TIIH Scholars. The study model was developed through a secondary analysis of Scott’s prior work.
Samueli: Patients’ Perceptions of Health Urge Expanded Primary Care Relationships
Primary care doctors and patients in systems wherein commitment to “patient-centered care” or “creating a culture of health” is more than empty advertising will find ammunition for change in this Harris poll. Funded through the Samueli Foundation’s commitment to integrative health, results were rolled out in an October 13, 2018 webinar with Samueli’s longtime leader in this area, Wayne Jonas, MD. A take home message: “The narrow range of dialogue between primary care doctors and their patients emerged as a significant barrier to health for significant subsets of the population.”
The Samueli-Harris poll surveyed 2027 English-speaking adults September 11-13, 2018. Jonas noted that the “core issue that motivated us [to do it] is to discover to what extent is health care producing health – and if not what will get us there.” In these survey findings are avenues to addressing two legs of the Quadruple Aim: patient experience and practitioner well-being. The changes prompted here could also influence those other two quarters of the 4-part challenge: bettering population health and lowering per capita costs.
The disconnect of the disease-focused medical industry’s model of primary care with health creation was on display. Patients experience a disconnect between how they personally define health and how they talk about their health with their doctors. A full 45% of respondents with a primary care physician (PCP) say they wish they talked with their doctor more about why they want to be healthy. For those aged 18-44, 57% want their PCPs to talk “to them about treatments that do not involve medication.” While 92% believe health is about more than being sick, their communications with their PCPs tended to focus only on their bothersome conditions, their lab results, and drugs. Jonas noted the young adults’ interest:
“Surprisingly, even more younger adults wanted to talk to doctors about their behavioral determinants of health more than they did. It appears that we need a more whole person approach to health and healing and there is a growing awareness that those kind of behaviors are key to not only staying healthy but reversing conditions.”
One somewhat astonishing finding suggested that US citizens may be borderline deluded. Despite the actual health profile and incidence of obesity, diabetes, and etc. in the US, almost 9 in 10 (86%) “think they have a lot or a great deal of control over their health.” How is this to be understood except as I know when I do more unhealthy things I can make myself worse. That would be a form of control.
In the Q & A portion of the Jonas webinar, a participant asked about the time needed to address health. Jonas acknowledged the issue then pointed to the irony in how insurance routinely reimburses for multiple, disease based short visits when it could potentially save if PCPs were funded for longer visits that might engage health-enhancing changes. Jonas captured the general misfit:
“The system is caught in the cycle of volume. We jump in with highly expensive approaches. We need to restructure our system and pay for value.”
Comment: The idea of combining these two studies in one article began with intrigue that in the same week in 2018, organizations led by two of the mkid-1990s’ leading “CAM” trialists were similarly tracking. In varied and overlapping ways, each was engaged in more direct pursuit of the health and healing that has always been a beacon of integrative philosophy, if not always of practice. The space in the PCP visit Jonas is trying to wedge open is a prerequisite if medical delivery is to help and support the kind of healing for which Berman’s group was developing a model.
The time issue and Jonas comment on the “cycle of volume” in response to the caller reminded me of a corrupting, fundamental building block of the present system. It was first brought to my attention by a long-time integrative PCP in this field who abruptly had the opportunity to begin to be covered by insurance in 1996. The informant was my spouse, Jeana Kimball, ND, MPH. When the Every Category of Provider law in Washington State suddenly turned a willing subset of the state’s naturopathic physicians into insurance-covered PCPs, she gave herself a crash course on insurance practices. This landed her a volunteer rtole as co-chair of the ND’s insurance committee. A key learning that she shared:
At a formative moment in medical insurance, some insurer-delivery cabal – I call it a cabal because the decision is shrouded in mystery – decreed that a minute of a PCP’s time in a short visit is more valuable than a minute of a PCP’s time in a long visit. There appears to be no clinical evidence to support this assertion.
This fundamental building block of payment is not evidence-based. Yet this business-based assertion is the “thou shalt have no other god before me” law of medical-financial management in the industry’s construct of primary care.
This groundless dictum has messed things up big time. Once this valuation is accepted, it is only a matter of multiplication to show that jamming PCPs into short visits is the best way for a medical-industrial entity to produce the most revenue. We’re off to the races. Health and satisfaction be damned. The rift has immediate impacts on the aims of patient experience and practitioner well-being.
A next level the payment-delivery construct built on these sands is the postulation that the PCP should only be used at the top of his/her license. This further blocks the PCP-patient relationship as a foundation for health creation. What if the best and most cost-effective, health creating and satisfying work for a PCP is to allow them the time and relationship to engage non-pharma, behavioral determinants like nutrition, stress, sleep, exercise, coaching and habit change? The corrupting assumption shoulders hard against both patients and providers who seek to engage actual health care, and thus find the well-being and resilience attached.
Without breaking from this dictate, the medical industry will not accommodate either the health interests of patients as identified in Samueli-Harris report or the healing processes captured in the TIIH/IFM-involved study.