Creando Ambientes Optimos Para Sanar Chapter 2

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12

Creating Optimal HealingEnvironments

David Rakel, MD, and Wayne Jonas, MD

Many health practitioners who go into primary care wantto both treat and heal, to care for the whole person, to bepatient advocates, to apply the best science, and to serve thesuffering. In short, we seek to be healers.

However, we often find in medical school and in ourpractice that the skills needed to be healers and the envi-ronment needed to execute those skills are not taught,available, or funded. We know, for example, the factorsthat increase the risk of disease, but we wait until illnessarrives. We understand that relationships, a positive atti-tude, and behavioral skills form the foundation for compli-ance and self-care, prevention, and well-being, but we findourselves without the time to develop them. We see thesearch for meaning in patients’ eyes when they suffer froma serious illness, and yet our science cannot help them findthe coherence they seek. For optimal healing to take place,we need to be proactive in creating an environment wherethese things can happen.

With every medical recommendation is a dynamic envi-ronment in which care is delivered. This environment consistsof both physical and nonphysical elements. It often includesa synergy among factors that can either promote or hinderthe healing process. Our goal is to describe foundationalcharacteristics of an optimal healing environment (OHE) sothat any therapy that is prescribed within this space (shownas a container in Fig. 2-1) will be more successful.

Creating an Environment ThatEnhances the Person's Abilityto HealA growing amount of research shows how an envi-ronment based in positive intention, wholeness, andrelationship-centered care can enhance the healing process

independent of the treatment used, be it drugs or acupunc-ture needles. 1,2

Optimal Healing EnvironmentsWe define an OHE as an environment in which the social,psychological, spiritual, physical, and behavioral compo-nents of health care are oriented toward support and stim-ulation of innate healing capacities and the achievementof wholeness. It is an expansion of Engel's biopsychosocial

model, which created a foundation for understanding thedynamic influences of health. 3 These components includeat least six domains, in addition to the physical and orga-nizational structures that support them, which are summa-rized in Table 2-1 .4–28 The six core domains of an OHE arethe following:1. Development of intention and awareness2. Experience of wholeness3. Relationship-centered care4. Health promotion with self-care and lifestyle skills5. Collaborative treatment6. Spiritual connection

Intention and AwarenessIntention can have an influence on motivation for change,understanding, and compliance. 9 Being fully presentwith positive intention for another human is perceivedby those we are with and enhances the healing effects ofthe encounter. 9 It is difficult to connect truly with inten-tion until we have explored our own inner nature. Patientcare starts with ourselves. As this connection grows, ourability to sit fully with another suffering human will beenhanced, and appreciation in our work will grow. Thisgrowth brings forward foundations in healing that includepositive expectation, hope, faith, and unconditional posi-tive regard. 4,29

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Chapter 2 Creating Optimal Healing Environments 13

WholenessHealth is a result of a dynamic balance of biopsychosocialand spiritual influences. To facilitate healing, it is neces-sary to develop insight into how these factors are expressedin each unique individual. The holistic model requires thatmind, body, emotions, and spirit are explored to understandbest how to facilitate positive change so the person can heal

most effectively.11

Relationship-Centered Care Relationship is the bond that removes isolation and fear. Itenhances insight, understanding, and sense of control. Whentwo people develop trust, significant benefit results by enhanc-ing social connection and by fostering communication,empathy, and compassion. Through relationship, unhealthyemotions are released and optimism and positive expecta-tion are born. 13,15 Patient-oriented, relationship-centeredcare has been found to improve efficiency of care by reduc-ing the need for medical tests and referrals. 30

Health PromotionEmpowering the individual to learn how best to take care ofhimself or herself so both the provider and the patient are activeparticipants in the healing process is a key ingredient. All heal-ing is self-healing, and we, as integrative medicine practition-ers, are at our best when we are able to facilitate individualsto care for themselves most successfully. This approach oftenincludes nutrition, physical activity, lifestyle choices, and man-agement of stress and anxiety. These factors can have epige-netic influences on the expression of a healthy phenotype. 18,19 Grounded in relationship and continuity of care, primary carepractitioners are in a unique position to influence healthy life-style changes before the onset of chronic disease.

Collaborative Treatment The provider who has developed a relationship and an under-standing of the individual's story will then use the most effec-tive tools possible to facilitate health, be they conventional orcomplementary. This integrative approach begins with lessinvasive measures before costly invasive ones are needed, whenpossible. It often involves working with a team of providerswho are able to offer practices that help the body heal. It com-bines the best of technology, when needed, but is grounded inhumanism and compassionate care so the least harmful, mosteffective approach is implemented to influence health. 23–25

Spiritual ConnectionSpirituality is a journey toward, or experience of, connectionwith sources of ultimate meaning, as defined by each individual. Spirituality includes connection with oneself, withothers, with nature, and with a higher power. 31 If we provid-ers can help patients work toward facilitating awareness ofthese connections, spirituality will enhance a sense of pur-pose for living, reduce suffering, buffer stress, and optimizeself-healing (see Chapter 110, Taking a Spiritual History).Spirituality also is one of the most effective tools in helpingchange unhealthy behavior (see Chapter 99, MotivationalInterviewing Techniques). 32

Healing SpacesThe six key elements just discussed are enhanced by thephysical structure in which they are provided. Nature, color,light, fresh air, music, fine arts, and architecture should beused to create external influences that support the health andwell-being of those who enter the space.

Healing PlacesLeadership and teamwork are essential to the delivery of

OHEs. If employees do not respect and communicate withone another and feel safe to deal with conflict and empow-ered to contribute toward improvement, these deficiencieswill be experienced by patients and will therefore inhibithealing. A culture of healing starts with modeling self-careand core values by the leaders and then flows into the mis-sion, vision, planning, and behavior of health care teams.

Creating an Optimal HealingEnvironment in the Clinical SettingHow can we bring the components of an OHE into a busy prac-tice? Although transforming a practice into a healing environ-ment may seem like a daunting task, or one with little practical value, experience and evidence indicate that attention to sim-ple and inexpensive details often gradually moves the focus ofcare from cure only to one filled with healing activity. 33

The practitioner can develop healing-oriented sessionswithin the clinical space without having to go through majorrenovations. The primary care practitioner already has thefoundational tools needed to create an OHE. The nonphys-ical intention is much more important than the physicalspace. Healing can occur anywhere, whether it is in an$8 million healing center or in an underfunded inner cityclinic for the homeless ( Table 2-2).

Optimal Healing Environments

M e a n i n g W h o le n e s s R e l a t i o n s h i p

I n t e n t i o n A w a r e n e s s C o m p a s s i o n

P u r p o s e H o p e

P la c e a n d s p a c e

D r u g s

A c u p

u n c t u r e

C o u n

s e l i n g

S u p p

l e m e n t s

S u r g e r y

M a n u

a l T h e r a

p y

D r u g s

A c u p

u n c t u r e

C o u n

s e l i n g

S u p p

l e m e n t s

S u r g e r y

M a n u

a l t h e r a

p y

FIGURE 2-1Schematic showing that the therapy we prescribe comes from withina container of influences that can enhance its effectiveness.

Healing can be defined as the dynamic process ofrecovery, repair, reintegration, and renewal that increases

resilience, coherence, and wholeness. Healing is anemergent, transformative process of the whole person—physical, mental, social, spiritual, and environmental.It is a unique personal and communal process andexperience that may or may not involve curing. 2



14 Part One Integrative Medicine

TABLE 2-1. Optimal Healing Environments: Key Components and Skills and Tools to Create Them

COMPONENT SKILLS TOOLS

Intention and awareness 4 Familiarity with cross-cultural medicine and how tomaximize therapeutic effect for patients withinvarious cultural and religious traditions 5,6

Awareness of placebo literature and how to helpthe body self-heal 7,8

Use of intention in one's own practice9

Personal participation and guidance of others inmindfulness practices

Take a mindfulness course.Take a retreat to define your own spiritual

connection and develop awareness, to managethis appropriately with others (see Chapter 98,Recommending Meditation).

Wholeness 10 Attitude of unconditional acceptance of thoseseeking care

Ability to guide others toward understanding thebody's energetic as a mechanism for healing andgrowth

Personal participation in or ability to guide othersin personal growth enhancements 10

Philosophy of holism and patient-centered care 11,12

Interviewing practices that focus on all aspectsof the patient

Ability to create a healing team that has anunderlying holistic approach

Study and follow some of the followingresources:

Engel's biopsychosocial model 3

Ken Wilber's A Brief History of Everything*Information from the American Holistic Medical

Association (AHMA)Regular personal mind-body practices

Healing relationships13

Skills in relationship-centered care, empathy,and rapport building 14,15

Understanding how patients relate to theirsurrounding communities 16

Skill with involving family17 or other membersof the support system in patient care

Ability to guide support groups and help patientshelp each other

Make friends and see how it makes you feel.Look at your medical career as a privilege tobe able to make a living taking care of yourfriends who are also your patients.

Health promotion Personal experience with l iving a healthy lifestyleand helping others do the same; skill in helpingothers take personal responsibility in theircare 18,19

Solid background in preventive care and familiaritywith principles of nutrition, 20 exercise, 21 stressmanagement, 22 and addictions

Ability to educate patients and other providers

effectively through information technology,clinic-run education sessions, and so forth

Develop your own health plan.Expand your knowledge base of lifestyle choices

and health (nutrition, exercise, mind-body,spiritual connection).

Take the American Board of Integrative HolisticMedicine (ABIHM) review course.

Collaborative treatment 23,24 Skill in integrative approaches to practice 25

Familiarity with the variety of modalities availableand when or where they are most useful 26

Understanding the safety of various modalitiesAbility to draw together and contribute to

a diverse group of providers who can worktogether to create an optimal healingenvironment

Ability to facilitate positive team dynamics andresolve conflicts

Knowledge of the treatments available withinthe community

Skill in use of scientific literature, such as Cochranecollaboration ( www.cochrane.de ) in making

evidence-based treatment decisions

Develop relationships with a communityof providers whom you trust and with whomyou will enjoy working.

Obtain therapies first hand from your colleagues.This is a great way to learn about the therapy,the art of the practitioner, and its potentialbenefits.

Spiritual connection Incorporation of some of the following questionsin your history taking:

What gives your life meaning?If life were perfect and resources were limitless,

what would it look like for you?How do you want to leave your mark on this world?Who do you want to become?

Become familiar with spiritual assessment toolssuch as FICA, HOPE, SPIRIT, LET GO(see Chapter 110, Taking a Spiritual History).

Explore and define your own spiritualconnection.

Be careful not to project your beliefs onto othersinappropriately.

Healing spaces 27,28 Skill with using architecture, the arts, sensorystimulation, and ambience to maximize healing

Hiring an interior decorator to modify your clinic

Visit spaces that make you feel goodand incorporate key elements into your clinicalspace.

*Wilber K.A Brief History of Everything. Halifax, Nova Scotia, Canada: Shambhala; 2001.




TABLE 2-2. Optimal Healing Environment

OHE INGREDIENTS

Description of Sample Case Study

OHE PRESENT OHE ABSENT

General case description Mike is a 42-year-old man with low back pain for8 weeks. He has no history of acute injury, noradicular symptoms, and no improvement despite

chiropractic manipulation and over-the-counterNSAIDs.

Mike is a 42-year-old man with low back pain for8 weeks. He has no history of acute injury, noradicular symptoms, and no improvement despite

chiropractic manipulation and over-the-counterNSAIDs.

Relationship-centeredcare

Mike goes to see Dr. Smith because he knows andtrusts her. She helped him through his divorceseveral years ago.

Mike has no primary care provider. He goes to alocal health care clinic close to his home and seeswhichever physician is available at the time hevisits.

Healing space Mike likes Dr. Smith's office. It is warm andwelcoming and makes him feel at ease, safe, andcomfortable.

The clinic is cold and uninviting. You can hear trafficnoises from the busy street as you hear the pagingsystem overhead telling the physician that thepatient is ready in Room 3.

Self-care Dr. Smith seems to “walk the talk.” Mike seesher jogging around town at lunch, and she neverseems “stressed out” like so many other physicians.

Dr. Jones seems rushed and stressed by thedemands of all the patients backed up in the waitingroom. She appears to be overweight, pale, andfatigued.

Intention and awareness What Mike likes best about his physician is that sheseems totally present when she sees him. He feelslike he is the most important thing on her mindduring his visits.

Mike feels sorry for the overworked physician andwants to give her information in an efficient mannerso that she can do her job quickly. She remainsstanding, offers little eye contact, and seemsdistracted by the many demands on her time. Mikefeels disconnected.

Holism Dr. Smith does a full physical examination thatshows muscle spasm in the right quadratuslumborum muscle group but no other concerningsigns. Mike feels comfortable telling Dr. Smithabout the loss of his job a few months back. Sheeducates him about how the body can sympathizeand experience symptoms when the mind is understress.

Dr. Jones focuses on Mike's back pain and asksdirected questions related to his discomfort.Time does not allow for questions beyond Mike'sphysical symptoms. The examination showsmuscle spasm in the right quadratus lumborummuscle group, but no other concerning signs arenoted.

Collaborative care Dr. Smith refers Mike for counseling to developfurther insight into how his life situation caninfluence his health. He will also see a massagetherapist to loosen up his muscle spasm.

Dr. Jones is concerned about the length ofMike's symptoms without resolution. She ordersan MRI scan and refers Mike to an orthopedicsurgeon for further evaluation. She educatesMike about the potential benefits of an epiduralblock.

Lifestyle Dr. Smith sees that Mike has gained 18 lb inthe last year and discusses the need for him tostart a gradual exercise program and work ongetting back to his ideal body weight. She alsorecommends a book that discusses the relationshipbetween back pain and stress.

Mike is given a prescription for hydrocodoneand a patient education handout on low backpain exercises. He is told that if nothing helps,he may be a candidate for long-term opioid painmanagement.

Spiritual connection Dr. Smith knows that Mike has a love ofphotography and the outdoors. Many of hisphotographs can be found around town in

local shops. She encourages Mike to take thisopportunity to direct his career to fulfill thosethings that he loves to do.

Mike leaves hopeful that the medication will reducehis pain and discomfort.

Compare and Contrast OHE Present OHE Absent

Outcome Dr. Smith encourages the development of personalinsight into how Mike's life situation is influencinghis health. He understands what Mike can do tohelp this situation resolve.

With Dr. Jones’ approach, the lack of a holistic viewand of relationship-centered care result in a focuson the physical symptom without encouraging thepatient's insight.

Goal The initial goal is symptom resolution. The initial goal is symptom suppression.

Continued




influences found within the clinical encounter create inten-tion toward health that should be the foundation of the med-ical home (Fig. 2-2).46

The Medical HomeThe term medical comes from the Latin word medērī, which means “to heal.” Unfortunately, this word has been

shaped by our culture to be perceived as a medicine or anexternal treatment that is given to the patient. The heal-ing power of the medical home comes from the heal-ing intention of a team of professionals who understandthat both inner and outer environments are necessary forhealth (Table 2-3). One of the most important ingredientsis the social connection with a team of people who can sup-port positive lifestyle behaviors while also diagnosing andmanaging disease. The positive behaviors have been found

to have the most significant impact on longevity and thereversal of chronic disease if the disorder is caught early.Behaviors such as avoidance of smoking, weight manage-ment, improved nutrition, adequate physical activity, suf-ficient sleep, and avoidance of substance abuse can reducethe incidence of premature death by 40% 46 and extend lifeby 14 years.47 To create this positive change, the medicalhome environment must empower individuals to do this for

themselves. Empowerment requires a self-reflective processthat results in a choice to act in a new way. The importanceof this approach is exemplified in the care of diabetes, inwhich 98% of the care is patient directed. 48 Empowermentfor behavior change is best facilitated through trusting rela-tionships in which the clinician and the health care teamrecognize the unique needs of the individual and help createa supportive path toward health. It also honors the uniqueskills of the team to foster this growth.

Health TeamsNew models of care are being defined to improve value andaccess and reduce cost in the United States. The practition-

ers of integrative medicine will be leaders in this movementbecause its philosophy places health creation as its high-est priority. Both integrative medicine and conventionalmedicine will need to create teams of professionals basedon the health needs of the community they serve, however,not simply a potpourri of professionals working indepen-dently in proximity. For example, if 30% of a communitysuffers from obesity, metabolic syndrome, and diabetes, thestrategic medical home will recruit professionals best suitedto address this need. This team may include nutrition-ists, exercise physiologists, spiritual guides, psychologists,health coaches, and physicians. These team members needadequate communication so that services of each are usedwhen the patient will benefit most. When professionals

from varied disciplines come together, shared knowledgeallows for insight from different perspectives that can stim-ulate an “ah ha!” moment in which new ideas allow them totranscend old models of care. When this happens, an inter-disciplinary team becomes a transdisciplinary team, andnew models of delivery are defined. 49 Multifaceted team-based interventions in primary care are more effective ininfluencing positive lifestyle behaviors than is isolated spe-cialty care50–52 (Table 2-4).

Contributions to the Healing Process

Intention

Conditioning

Regression

Bias

Other

TreatmentRelationship Wholeness

The HealingEnvironment

LifestyleCollaboration Spiritual connection

FIGURE 2-2Influences on the healing process.

TABLE 2-3. Optimal Healing Environments

INNER ENVIRONMENT TO THE OUTER ENVIRONMENT

Healing intention Personalwholeness

Healingrelationships

Healingorganizations

Healthylifestyles

Integrativecollaborative medicine

Healingspaces

ExpectationHopeUnderstandingBelief

MindBodySpiritFamilyCommunity

CompassionEmpathySocial supportCommunication

LeadershipMissionCultureTeamwork

DietMovementRelaxationAddictions

Person orientedConventionalComplementaryCulturally appropriate

NatureLightColor Architecture

Enhancedawarenessexpectancy

Enhancedpersonalintegration

Enhanced caringcommunication

Enhanceddelivery process

Enhancedhealthy habits

Enhanced medical care Enhancedhealingstructure

Modified from Jones WB, Chez RA. Toward optimal healing environments in health care. J Altern Complement Med. 2004;10(suppl 1):51–56.

Creating an optimal healing environment will bringmore joy to your work. It will allow you to connectwith those key elements that attracted you to healthcare, and in doing so you will find more meaning andpurpose.



18 Part One Integrative Medicine

Environment's Influence on GeneticExpressionThe goal of an integrative medicine health-oriented team isto work together to create OHEs. Environments can have aninfluence on the genome of the living beings that live withinthem. The scientific evidence of this epigenetic influenceis exploding and gives power and hope to the individual tomake positive lifestyle choices by attending to and changingtheir environment ( Fig 2-3).

Animal studies showed that genetically identical agoutimice bred to develop obesity and diabetes could have thisexpression suppressed when the mothers were fed methyl-donating foods (genestein) before they gave birth. 53 AnAmish community assessed to see whether carriers of theFTO obesity gene would become overweight found that car-riers who averaged 18,000 steps a day remained at a normalweight. Their lifestyle habits trumped their genetic risk. 54

Telomers are the protective DNA-protein complexes atthe end of the chromosomes that promote stability. Lossin their length has been associated with increased risk of

disease and premature mortality. Telomere shortening iscounteracted by the enzyme telomerase, and more of thisis beneficial. Ornish et al 55,56 looked at telomerase levels in30 men with prostate cancer. After 3 months of healthy life-style changes, including moderate exercise, a low-fat plant-based diet, and social support, the telomerase levels rose, 55 and oncogene expression was inhibited. 56 Exercise alone canincrease telomerase activity 57 and brain volume. 58 Stress candecrease telomerase levels,59 whereas practicing the relax-ation response can have a positive influence on geneticexpression. 60Although these behaviors are powerful, theyare not the sole dictator of outcomes. The body-mind iscomplex and mysterious. The clinician should be careful notto instill guilt regarding lifestyle habits when cancer or heartdisease is diagnosed. Instead, the clinician should reassurethe patient that, even when disease progresses, improvedwell-being and function are more likely if he or she contin-ues or adopts healthy behaviors.

Health as a ContinuumThe continuum of health starts with ourselves, is supported byothers, is influenced by lifestyle choices, and is shaped by ourinner and outer environments. This continuum recognizesthe importance of the interconnectedness of all things. Healthis not found in isolated parts but throughout the whole. Beingan integrative medicine practitioner means recognizing thedynamic and complex ecosystem in which we live and work-ing to support its health. In doing so, we occasionally pauseto witness the mystery of how nature continuously strives forbalance despite the odds we have created for it.

I would rather live in a world where my life is surroundedby mystery than live in a world so small that my mindcould comprehend it.

Harry Emerson Fosdick

E

N V I R O N M

E N T

Genotype

Ailments

Pollutants

Lack of nutrients

GOOD DECISIONS

E

N

V I

R O N M

E

N

T

Food

Weather

Success

Family

Air

Acceptance

Rest

Exercise

Belief

Economy

Nutrients

HEALTH

DISEASE

POOR DECISIONS

FIGURE 2-3Depicted is a balance representing the person's unique geneticconstitution and the direction into which his or her decisions willpoise the organism's well-being, determined by the presence ofnutrients, ailments, or pollutants. A nutrient can be understood asany element that nourishes the body and mind.

TABLE 2-4. Defining Disciplinary Teams

TERM DEFINITION

Multidisciplinary team Additive. “Comprising more thantwo professionals from differenthealth care disciplines who work withthe same patient, set of patients,or clinical condition, but provide

care independently of each other”(interdisciplinary team building). Forexample, a patient may have visitswith both a primary care practitioner(PCP) and a physical therapist (PT).Although the PCP may view clinicalnotes or a report from the PT, the twodisciplines usually do not interact.

Interdisciplinary team Interactive. “Dedicated to theongoing and integrated care of onepatient, set of patients, or clinicalcondition” (interdisciplinary teambuilding). Team members developcollegial relationships with sharedgoals and joint decision making. Theyinteract, support, as well as question

each other's opinions, and negotiateto develop health strategies based onthe needs of the individual.

Transdisciplinary team Holistic. Professionals learn from eachother and in the process transcendtraditional disciplinary boundariesthat may result in the emergence ofnew knowledge. Often, the greaterthe difference between professions(epistemologic distance, e.g.engineering and humanities), themore likely insight will developtoward the creation of a new wayto solve a problem.

From Rakel DP, Jonas W. The patient-centered medical home. In: Rakel

R, Rakel D, eds. Textbook of Family Medicine. 8th ed. Philadelphia:Saunders; 2011; data from Choi BC, Pak AW. Multidisciplinarity,interdisciplinarity, and transdisciplinarity in health research, services,education and policy: 3. Discipline, inter-discipline distance, andselection of discipline. Clin Invest Med . 2008; 31:E41–E48.




ReferencesReferences are available online at expertconsult.com .

Several years ago, a primary care clinic in Englandintroduced a spiritual healer into its practice. Thiswas done quietly, without advertisement. Patientswho had refractory, chronic illnesses, who were highhealth care users, and who were taking multiple drugswere offered 12 sessions with the healer. Health careuse costs, symptoms, and well-being were measuredbefore and after the study period. Almost all patientsgot better: health care visits decreased; patientsimproved in their energy and well-being; and althoughthe diseases were not actually cured, suffering wasrelieved. Costs were reduced by $2000 per patientper year. Most interesting, however, was the changethis approach had on the physicians in the practice.When the investigators examined what the healerdid during sessions, the procedures were simple.The healer spent a long time listening intently tothe patients and hearing what their concerns were

about the illness, linking it up with family events, andchallenging patients to perceive their connectivitybeyond themselves, to imagine a future that was betterand improved. The healer then spent time doing somebioenergy work, holding her hands over the patientin the traditional laying-on-of-hands manner. Thephysicians in the clinic soon realized that many of thesesame behaviors were similar to things they had beentaught to value in medical school but had not oftenbeen able to incorporate into their own practice. Thesephysicians then found themselves spending a few moremoments with patients and asking them about socialand family issues that earlier they would have glossedover or ignored, getting and giving feedback aboutthe meaning of a person's illness, and listening andresponding in a warmer fashion. In other words, thephysicians realized that they, too, could become healersin the classic sense of the term. 61

KEY WEB RESOURCES

Samueli Institute. http://www.siib.org/research/research-home/optimal-healing.html

The Samueli Institute has sponsored research in the developmentof optimal healing environments. This site contains researchpapers and resources on the topic.



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