Balancing Treatment of Disease and Promotion of Health

Health is largely a result of positive lifestyle behaviors that are often challenging to change. Addressing issues such as smoking, obesity, substance abuse, and inactivity can reduce premature death by 40% (McGinnis et al., 2002; Schroeder, 2007). Positive lifestyle behaviors not only prevent premature death but also extend the average life expectancy by 14 years (Khaw et al., 2008). Currently, approximately 4 cents of every dollar spent for health care goes toward prevention and public health, with 96% spent on treating established disease (Lambrew, 2007). Two thirds of chronic disease is behavior related and could be mitigated by working interprofessionally to help guide patients toward healthy choices (McGinnis et al., 2002).

Behaviors that have the greatest impact on preventing chronic disease and its progression are (1) reducing exposure to toxic substances (tobacco, alcohol, drugs, pollution), (2) movement and exercise, (3) healthy diet, (4) psychosocial integration and stress management, and (5) early disease detection and intervention (Jonas, 2009; McGinnis, 2003). For these behaviors to have an impact, the health home will need to be financially supported and have the goal of health as its primary focus. This will require new forms of funding that go beyond the disease-focused throughput model of payment. A primary care clinic that only works from this model will encourage shorter office visits while promoting reliance on expensive technology that often suppresses symptoms without addressing its cause. The health home will push the curve in Figure 2-1 to the left and will involve professionals who specialize in health promotion (or creation) to flatten the curve and reduce the need for the “disease care” teams currently well established in the tertiary care setting.

Figure 2-1 Profit in the current U.S. health care system is obtained focusing on the right of the curve. Investment toward the left of the curve will reduce disease burden and cost over time.

Establishing an Optimal Healing Environment

An optimal healing environment (OHE) involves the delivery and context of medical treatment rather than the specific treatment itself. It focuses on creating healing in the process of disease treatment. This means optimizing the “meaning and context” effects of the care process rather than ignoring or dismissing them as “placebo” effects. An OHE involves attending to three primary domains of care delivery: (1) the “inner,” personal environment of the team and patient; (2) the “inter,” personal or relationship environment of care delivery; and (3) the “external” behavioral and physical environment of the medical home (Jonas et al., 2003).

Often, a “medicine” itself is given the most credit in medicine. A prescribed medication is valued for its “specific” medical influence, as deemed beneficial by randomized (placebo-)controlled trials (RCTs). This research focuses on the effects of the drug and attempts to control the context in order to reduce “nonspecific” (placebo) effects that may compromise the results. This helps physicians understand the specific effects of the drugs they prescribe, but it does not value those nonspecific effects that surround the prescribing of a medication. It is impossible, even undesirable, to remove all nonspecific effects from the patient encounter.

“Meaning” and “context” effects are rooted in relationship-centered care, including empathy, trust, empowerment, and hope. Research on one of the most frequently prescribed drugs in primary care, selective serotonin reuptake inhibitors (SSRIs), shows that these work only about 6% to 9% better than placebo (Kirsch et al., 2002; Turner et al., 2008). Both placebo and drug work well and are often almost 60% effective. Therefore, if the drug only accounts for 9% of this effect, which factor accounts for the majority of the healing influence? Maybe researchers are not giving enough credit to the clinician and the nonspecific variables that surround the prescribing of the pill. Maybe it is simply the act of listening to people who are suffering and giving them a sense of understanding that there is something they can do to overcome the suffering. Maybe it is the interaction between two people before the medicine is prescribed that has the greatest healing effect. Psychiatrists gifted at developing a trusting relationship were found to have better effects with placebo in treating depression than their colleagues less talented at developing relationships who used active drug (McKay et al., 2006). Acupuncture delivered with a greater ritual produces better effects than the same points treated with less ritual (Kaptchuk et al., 2008; Kelley et al., 2009). Maybe it is the cost. Drugs that cost more (up to a certain point) work better in pain treatment than the same drugs that cost less (Waber et al., 2008).

Family physicians do not need to wait for further research to create an OHE for patient care. Physicians already know that the factors summarized in Table 2-2 will help encourage the healthy unfolding of complex systems. The most important part in influencing healing in others is focused on the left side of the table and starts with a self-reflective, internal process. Family physicians first need to understand the importance of continuously exploring their own health, so that they are prepared to do the same for their patients.

Table 2-2 Optimal Healing Environments

The Importance of Self-Care

To care deeply for others, we must know how to care for ourselves. As Cassell (2004) says, “… virtually all the doctor’s healing power flows from the doctor’s self-mastery.” True primary care, therefore, also includes what we do for ourselves. Up to 60% of practicing physicians report symptoms of “burnout” (Shanafelt et al., 2003; Spickard et al., 2002). This is associated with emotional exhaustion, depersonalization (seeing patients as objects), reduced empathy, and the loss of meaning in work.

The characteristics lost in burnout are important ingredients in facilitating health and healing in others. If the health team physician leader is “burning out,” the health home will not be healthy. When physicians practice healthy lifestyle behaviors, they are more likely to educate patients on the importance of these behaviors (Lewis et al., 1991) and to become more motivating to their patients toward positive change (Frank et al., 2000; Lobelo et al., 2009). Every family physician benefits from a self-reflective inquiry about personal balance toward health. This behavior will constantly be challenged and will require attention and “mastery.”

Most primary care physicians are attracted into the field to make a difference in people’s lives through continuous healing relationships. When the demands of the working environment tax the sense of control to maintain these relationships, stress and potential burnout can ensue. One remedy for this is to use the patient encounter to allow meaning to flow through the work. The healing-oriented primary care approach recognizes each patient as a unique individual with specific needs in the physical, emotional, and spiritual domains and sets aside both mental space and physical time to deal with those needs. To be aware of these personal needs is a mindful practice in which the physician is fully present in the moment with the patient, where each is able to reduce suffering in the other (Epstein, 1999). This “mindfulness” approach has been found to enhance well-being and physician attitudes in patient-centered care (Krasner et al., 2009). It requires that physicians create physical time in the health home to sit and listen to patient stories (Rakel, 2008).

Investing in Relationship

The medical home is just that, a “home” where someone feels welcome, known, and part of a community. The ongoing relationship with patients provides insight into the complexity of their health care needs and honors the interaction between multiple health perspectives. It allows the clinician to use evidence-based guidelines while realizing that variability is the norm. The best care for one individual may not be best for another. Patient-centered care recognizes that care should be focused on the needs of the individual patient, not simply on a disease state. Ideally, the goal should be “relationship centered,” encouraging attention to the unique needs of the patient to be well. Thus, creating healing relationships is a core goal of an effective medical home (Chez and Jonas, 2005).

The evidence for the benefits of continuous, relationship-centered primary care is solid and growing. It has been found to improve quality of care (Starfield, 1991), reduce expenditures on diagnostic testing (Epstein et al., 2005), reduce hospital admissions (Gill and Mainous, 1998), and lower total health care costs (De Maeseneer et al., 2003). Having continuous, ongoing relationships with patients is often cited as the most rewarding aspect of being a family physician (Fairhurst and May, 2006). A systematic review of controlled trials on effective “team care,” where relationship-centered factors are formalized in the care process, has demonstrated reduced mortality and morbidity, improved morale of health care workers, and reduced costs of health care (Safran et al., 2006).

One health care system that restructured its whole organization around establishing long-term, trusting, accountable relationships is the Southcentral Foundation Alaska Native Health Care model (Eby, 2007). This was the main request of the leaders of native Alaskans when they were asked what they wanted most in their public-owned health care system. Above all else, they valued the relationship with their physician, someone who “listens to them, takes time to explain things and who is able to coordinate effectively their overall care” (Gottlieb, 2007). The system made this its primary objective. After transforming their health model in 1999, urgent care and emergency department utilization decreased by 40%, specialist utilization by 50%, and hospitalization days by 30%. Customer satisfaction surveys showed that 91% rated their overall care as “favorable” (Gottlieb et al., 2008).