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Optimal Healing Environments: The Next Natural Step. Wayne B. Jonas, MD President and CEO Samueli Institute 10 th Annual Force Health Protection Conference Force Health Protection Through Collaboration August 9, 2007. Goals of this talk.

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Optimal healing environments the next natural step

Optimal Healing Environments: The Next Natural Step

Wayne B. Jonas, MD

President and CEO

Samueli Institute

10th Annual Force Health Protection Conference

Force Health Protection Through Collaboration

August 9, 2007


Optimal healing environments the next natural step

Goals of this talk

1. To define healing and a healing-oriented model

in health care and compare it with cure-oriented

2. To describe the components that facilitate and

stimulate healing in an optimal healing environment

3. To illustrate research on healing and outline future

needs for the investigation of healing environments

4. To describe approaches for the application of optimal healing environments for military experiencing medical challenges

5. Don’t lose sight of the miracle of healing.


Optimal healing environments the next natural step

The Lancet V.360 November 16, 2002


Optimal healing environments the next natural step

The Lancet V.360 November 16, 2002


Optimal healing environments the next natural step

The Lancet V.360 November 16, 2002


Optimal healing environments the next natural step

The Lancet V.360 November 16, 2002


Optimal healing environments the next natural step

The Lancet V.360 November 16, 2002


Optimal healing environments the next natural step

The Lancet V.360 November 16, 2002


Optimal healing environments the next natural step

The Success of Biomedicine

1900

Tuberculosis

Pneumonia

Trauma

Influenza

2000

Heart disease

Cancer

Diabetes

Arthritis

Depression

2000

(developing countries)

HIV

Malaria

Malnutrition

Trauma

TB

45 yr

78 yr

39 yr


Optimal healing environments the next natural step

Problems with Biomedicine

  • Chronic disease and aging

  • Depersonalization

  • Technology

  • Specialization

  • Cultural dis-connects

  • Costs

  • Dissatisfaction with medical care

  • Patients

  • Payers

  • Professional burnout


Optimal healing environments the next natural step

Cure-Oriented Model

Specific Cause Paradigm

Disease

Illness

Cause

Agent

Person

Host

Outcome

Diagnostic

Threshold


Optimal healing environments the next natural step

What is the contribution to the human healing process?


Optimal healing environments the next natural step

Disease and Illness InvolveMultidimensional Outcomes

Social

Measures

Psychological & Behavioral

Measures

Functional &

Clinical

Measures

Biological Measures


Optimal healing environments the next natural step

Healing-Oriented Model

Whole Systems Paradigm

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

Disease

Illness

OE

Diagnostic

Threshold


Optimal healing environments the next natural step

Healing Model

Whole Systems Paradigm

Spirit

Mind

Body

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

Disease

Illness

OE

IE

Diagnostic

Threshold


Optimal healing environments the next natural step

Healing Model

Whole Systems Paradigm

Disease

Illness

Spirit

Mind

Body

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

Depression

Heart Disease

Diabetes

Cancer

Obesity

OE

DIG

IE

Diagnostic

Threshold


Optimal healing environments the next natural step

Healing Model

Whole Systems Paradigm

Disease

Illness

Spirit

Mind

Body

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

Depression

Heart Disease

Diabetes

Cancer

Trauma

Symptoms

Quality of Life

Biomarkers

Risk Factors

OE

DIG

IE

Diagnostic

Threshold


Optimal healing environments the next natural step

Consequences of Misapplied Models

(A focus on cure when healing is more appropriate)

  • Interactions and side effects

  • Lures us into complacency

  • Depersonalizes the interaction

  • Favors science over values

    • Objective measures [e.g. biomarkers]

      • over the hard to measure [e.g. hope]

    • Attributional evidence [e.g. RCT, Lab]

      • over qualitative/associative

  • Disempowers the patient

    • do to a person…

    • do or be with a person…

  • Separates prevention, treatment, rehabilitation

  • Encourages high cost

    • Late intervention

    • Technology/drug focus

    • Multiple treatments


  • Optimal healing environments the next natural step

    Consequences of Misapplied Models

    (A focus on healing when cure is more appropriate)

    • Failure to cure the curable

    • Complicates the interventions

    • Personalizes the disease [e.g. blame]

    • Favors anecdotes over evidence

      • Wants over needs

      • Risks false attribution

    • Restricts access to care

      • Readiness

      • Behavior change

      • Resources

    • Medicalization of life [Illich]

    • Wastes resources/lives

      • Delayed intervention

      • Time inefficient

      • Needs a team approach


    Optimal healing environments the next natural step

    The Place of Cure and Healing in Medicine

    Health

    stimulation

    Illness

    Specific Diseases

    OE

    IE

    Wellness

    DIG

    Salutogenesis

    Pathogenesis

    Health

    support

    Disease

    treatment


    Optimal healing environments the next natural step

    Healing

    The physical, mental and spiritual processes of recovery, repair and reintegration that increase order, coherence and holism in the

    individual, group

    and environment.

    Healing may or may not result in cure.


    Optimal healing environments the next natural step

    Optimal Healing Environment

    A system and place comprised of people, behaviors, treatments and their psychological and physical parameters.

    Its purpose is to provide conditions that stimulate and support the inherent healing capacities of the participants, their relationships and their surroundings.


    Optimal healing environments the next natural step

    OPTIMAL HEALING ENVIRONMENTS

    Inner Environment

    (Personal)

    Interpersonal Environment

    (Social)

    Outer Environment

    (Behavioral)

    Cultivating Healing Relationships

    Developing Healing Intention

    Practicing Healthy Lifestyles

    Enhance Awareness

    Enhance Health Habits

    Enhance Caring

    Diet

    Exercise

    Relaxation

    Balance

    Compassion

    Empathy

    Social Support

    Communication

    Expectation

    Hope

    Understanding

    Belief

    Applying Collaborative Medicine

    Experiencing Personal Wholeness

    Creating Healing Organizations

    Enhance Process

    Enhance Integration

    Enhance Medical Care

    Leadership

    Mission

    Culture

    Teamwork

    Mind

    Body

    Spirit

    Energy

    Conventional

    Integrative

    Traditional

    Person-centered

    Building Healing Spaces

    Nature Color Light Artwork Architecture Aroma Music

    Enhance Natural & Sustainable Structures


    Optimal healing environments the next natural step

    1A. Developing Healing Intention

    Awareness: The habitual practice of attention to the present and its full complexity.

    Intention: The conscious determination to improve the health of another person or oneself.

    Expectation: Belief and anticipation of improvement.

    Hope: The expectation that a desired goal can be achieved.


    Optimal healing environments the next natural step

    The Washington Post, Nov 22, 2005


    Optimal healing environments the next natural step

    The Sick Role and Healing

    • The sick role = dis-empowered

    • Belief

      • expectancy in healing

      • management of intention

    • Hope

      • confidence, competence

      • belief congruency – listening

    • Meaning

      • of illness and suffering

      • what does it mean to recover?


    Optimal healing environments the next natural step

    From Pain to Self-Awareness

    • Population was 60 patients with chronic, refractory pain.

    • A 12-week group program designed to change perception:

      • the body ‘as a talking subject’ rather than focusing on pain;

      • the wholeness of participants’ situation rather than pain as either physical or psychological;

      • using everyday language and ways of expressing themselves;

      • respecting, seeing, listening and trusting the group participants;

      • challenging the participants to evoke their internal control rather than use the health care personnel.

    • A year later the participants had:

      • an increased awareness of self,

      • more constructive ways of handling life’s situations; and,

      • less pain

    Steen e et al Patient Educ Counsel 2001; 42(1): 35-46.


    Optimal healing environments the next natural step

    2B. Experiencing Wholeness

    Healing Presence

    A deep emotional presence that enhances recovery and the experience of wholeness.

    West: the physical and emotional wholeness from which deep personal engagement, caring and communication emerge.

    East: sometimes conceptualized as “bioenergy”, and is said to be accumulated, stored and transmitted between healer and healee.


    Optimal healing environments the next natural step

    The Experience of Wholeness

    Integration of Person

    Integration of Self

    • Mind

    • Body

    • Emotions

    • Spirit

    • Past – Traumas

    • Present – “Why me?”

    • Future –Hope, purpose

    • Connectivity

    • Coherence

    • Control

    • Commitment

    Hardiness

    Resilience


    Optimal healing environments the next natural step

    Effect of Structured Writing by Disease: Asthma or Rheumatoid Arthritis

    Asthma

    Forced Expiratory Volume in

    1 S, % Predicted

    Rheumatoid Arthritis

    Asymptomatic

    Mild

    Moderate

    Severe

    Overall Disease Activity

    Smyth, J. M. et al. JAMA 1999;281:1304-1309.


    Optimal healing environments the next natural step

    Positive Emotional Change:

    Effects of Self-forgiveness and Spirituality

    Levenson MR et al. Explore 2006; 2(6): 506.


    Optimal healing environments the next natural step

    Mind-Body-Energy Practicesand the Relaxation-Response

    • Yoga

    • Tai Chi

    • Bioenergetics

    • Cranial Sacral

    • Alexander

    • Johrei

    • Polarity

    • Reiki


    Optimal healing environments the next natural step

    Mindfulness-Based Stress Reduction Meditation for Early Stage Breast and Prostate Cancer Patients

    59 patients with breast cancer and 10 with prostate cancer enrolled in 8-week program that incorporated relaxation, meditation, gentle yoga and daily home practice

    • Significant improvements in overall quality of life,

    • Side effects included reduced stress symptoms, improved sleep quality and beneficial changes in hypothalamic-pituitary-adrenal axis functioning

    • Was this due to increased time and attention?

    Carlson LE, et al. Psychoneuroendocrinology 2004; 29:448-474.


    Optimal healing environments the next natural step

    Neural Immune Connections

    Integrative Neural Immune Program

    http://neuralimmune.nih.gov/index.html


    Optimal healing environments the next natural step

    2A. Cultivating Healing Relationships

    • Consist of two domains that involve those designated clinical or socio-cultural.

    • Primary domain is social support and service for the household, family, friends, support groups and community.

    • Therapeutic alliance: the embodied social and psychological interactions between healer and healee that facilitate healing.


    Optimal healing environments the next natural step

    Social Support Lowers Cardiovascular Reactivity

    to an Acute Stressor

    Change from Baseline (mmHg)

    Lepore SJ et al. Psychosomatic Med 1993; 55: 518-524.


    Optimal healing environments the next natural step

    Relationship Effects

    SPECIFIC

    Tone and affect of encounter

    Communication and listening

    Non-verbal behavior

    THE EFFECTS OF OUR DOING

    NON SPECIFIC

    Intention, attention

    Mindfulness

    Healing presence

    THE EFFECTS OF OUR BEING


    Optimal healing environments the next natural step

    Effect of Type of Physician Consultation

    Improvement

    Thomas KB. Br Med J.1987; 294: 1200-2.


    Optimal healing environments the next natural step

    Physician Knowledge Affects Outcome

    Gracely RH. Society for Neuroscience Abstracts. 1979; 5: 609.


    Optimal healing environments the next natural step

    Developing a Healing Alliance

    • Self-care – “in a good space”

    • Compassion and caring skills

    • Communication skills

      • Listening, feedback, language, culture

    • Partnerships and continuity

      • Person-centered

      • Relationship-centered


    Optimal healing environments the next natural step

    The Therapeutic Instrument

    “… virtually all the doctor’s healing power

    flows from the doctor’s self-mastery.”

    Eric J. Cassell, MD,

    The Nature of Suffering and the Goals of Medicine.

    2nd Edition, 2004.


    Optimal healing environments the next natural step

    2B. Creating Healing Organizations

    • Leadership, staff, vision, mission

    • Organization, team building, payment


    Optimal healing environments the next natural step

    The Washington Post Health Section 12.12.06


    Optimal healing environments the next natural step

    Healing Relationships as the Core of Health Care Quality

    The call for “providing patients with appropriate services … with good communication, shared decision making, and with cultural sensitivity” ...

    Crossing the Quality Chasm: A New Health System for the 21st Century

    Institute of Medicine 2001


    Optimal healing environments the next natural step

    A Model of Relationship-Centered Organizations

    Safran DG, et al. J Gen Intern Med 2006; 21: S9-S15.


    Effect of teamwork on mortality risk

    Effect of Teamwork on Mortality Risk

    • Teamwork model included:

      • a structured collaborative communication protocol,

      • daily rounds attended by every team member,

      • the patient and available family members.

    • 56% reduction in risk-adjusted mortality among cardiac surgery patients after introduction of a new “interdisciplinary care team” model

    Uhlig PN et al. Joint Comm J Qual Improv 2002; 28: 666-72.


    Optimal healing environments the next natural step

    Organizational Dimensions

    of Relationship-Centered Care

    • Has an Effect on:

      • Reduced mortality

      • Improved functional health outcomes

      • Shorter length of stay

      • Workforce morale and turnover

    Safran DG, et al. J Gen Intern Med 2006; 21: S9-S15.


    Optimal healing environments the next natural step

    3A. Practicing Healthy Lifestyles (Behavioral Medicine)

    The employment of adequate amounts

    and types of exercise, diet, relaxation, creative outlets, and balancing work and leisure.


    Optimal healing environments the next natural step

    Health PromotionBehavioral Medicine

    • The Healthy Lifestyle:

    • Addiction management

      • Smoking, alcohol, food, drugs, sex, violence

    • Exercise

      • 30 minutes aerobic 3 X week; strength; balance

    • Diet content and amount

      • Low fat, high-fiber, 5 fruits and vegetable-a-day diet

    • Stress management and life balance

      • work/school-personal life balance

      • relaxation response for 20 minutes, 1-2 X day


    Optimal healing environments the next natural step

    Behavioral Medicine

    • Success at Lifestyle Change:

    • Clinical

    • Requires special training

    • Family and social aspects

    • Public health

    • Worksites/schools

    • Homes/places of worship

    • Commercial pressures


    Optimal healing environments the next natural step

    Workplace Program Reduces Illness & Healthcare Utilization

    Rahe RH et al Psychosomatic Med 2002; 64(2): 278-286.


    Optimal healing environments the next natural step

    Health Promotion at the Worksite

    Return on Investment

    Comprehensive Programs $3-8 ROI

    Disease management $7-10 ROI

    Risk Management $4-5 ROI

    Participation?

    Disease Treatment?

    RW Whitmer, et al., JOEM. 45: 2003


    Optimal healing environments the next natural step

    3B. Applying Collaborative Medicine(Integrative Medicine)

    • Conventional Medical Care

    • Person-centered Health Care

    • Complementary Medicine

    • Traditional and Folk Medicine


    Optimal healing environments the next natural step

    CAM

    (excluding prayer)

    Any CAM

    CAM

    (excluding megavitamins)

    Barnes, P.M. et al. Advance Data from Vital Health Statistics. Number 343, May 27, 2004. CDC p.4


    Optimal healing environments the next natural step

    CAM: American Use

    NHIS: 2002

    Interventions:

    • Prayer by others

    • Prayer for self

    • Natural products

    • Breathing exercises

    • Prayer groups

    • Meditation

    • Chiropractic care

    • Yoga

    • Massage

    • Diet therapies

    • Progressive relaxation

    • Guided imagery

    • Homeopathic treatment

    • Tai chi

    • Acupuncture

    • Energy healing/Reiki

    • Naturopathy

    • Biofeedback


    Optimal healing environments the next natural step

    Non-mainstream Medicine

    • Popular (1997 and 2002)

      • 80 % use world wide (WHO)

      • 40% of Americans use (50% of women)

      • 50-75% of cancer patients; AIDS users

    • Paid - $24 Billion out-of-pocket in 1997

    • Concealed - 72% don't talk about it to doctor

    • Combined - 83% used conventional treatment


    Optimal healing environments the next natural step

    Herbs and Drugs Interact

    • Anticoagulant and coagulant* activity:

      alfalfafeverfewpoplar

      angelicafucusprickly ash

      aniseedgarlicquassia

      asafoetidagingerred clover

      celeryginsengwillow bark

      chamomilehorse-chestnuts agrimony*

      clovehorseradishgoldenseal*

      enugreeklicoricemistletoe*

      feverfewmeadowsweetyarrow*

      Newall, 1996


    Optimal healing environments the next natural step

    Quality of Supplements

    140

    120

    100

    80

    60

    40

    20

    0

    % of Label

    1 2 3 4 5 6 7 8 9 10


    Optimal healing environments the next natural step

    Cochrane Collaboration


    Optimal healing environments the next natural step

    4. Building Healing Spaces

    • Light, air, nature, color, art, music

    • Function, flow, privacy and community


    Sunny hospital rooms expedite recovery

    Sunny Hospital Rooms Expedite Recovery

    In an inpatient psychiatric unit:

    • Those in sunny rooms had an average stay of 16.9 days compared to 19.5 days for those in dull rooms, a difference of 2.6 days (15%): P < 0.05

      In post-operative recovery:

    • Rooms with windows decrease length of stay by 1 day. (p<0.05)

    Beauchemin KM et al. J Affective Dis 1996; 40: 49-51.


    Music as a healing space

    Music as a Healing Space

    • Music can

      • promote a sense of well-being and distract patients from pain

      • improve mood and decrease anxiety, pain in acute and chronic conditions

    • Music may

      • help premature babies to gain weight

      • improve depression in the elderly

      • enhance care-giving behavior

    Kemper, K. et al. South Med J 2005; 98(3): 282-288.


    Optimal healing environments the next natural step

    Designing the Outer

    with the Inner and the Inter in Mind


    Optimal healing environments the next natural step

    Healing Environments

    in Military Operations


    Ohe in the military setting

    OHE in the Military Setting

    • There are no universal metrics for OHE assessment used in the military

    • The delivery of OHE in a military settings is likely no better or worse than in a civilian settings.

      • Recent Walter Reed situation

      • VA/DoD and PTSD syndrome management

    • Outside of the health care system programs for delivery of human optimal performance is active in the military


    Optimal healing environments the next natural step

    Examples of OHE Domains

    in the Military

    • INTERNAL

      • 1. Mind – Mission and meaning, spiritual care

      • 2. Experience – little formal focus

      • 3. Relationships – Camaraderie and community

    • EXTERNAL

      • 4. Lifestyle - Health Promotion, addiction Rx

      • 5. Treatments – Collaborative, little Integrative

      • 6. Spaces and 7. Places – mission oriented


    Optimal healing environments the next natural step

    Integrative Medicine

    Emerges in the Military

    • CIM, WBAMC, Ft. Bliss

    • Chiropractic in VA and Military

    • MIL-CAM, VET-HEAL – Samueli Institute

    • DARPA, Persistence in Combat

    • MIL-PIM – University of Arizona

    • Acupuncture

      • PMR Departments

      • Naval Medical Center, San Diego

    • VA – Integrative Medicine Unit, SLC

    • DOD-FDA Dietary Supplement Committee


    Cultivating healing relationships

    Cultivating Healing Relationships

    • Development of a Pilot Study to Develop and Test Improved Communication Training Strategies in the Care of Military Populations

      • Walter Reed Army Medical Center

      • Jeffrey Jackson, MD, PhD

    • Development of a Military Empowerment Program- a program that would empower families by teaching mind/body practices that could be shared with returning loved ones (injured soldiers) while residing at the Fisher House. 

      • Walter Reed Army Medical Center

      • National Naval Medical Center

      • Mark Chapin, MD


    Experiencing personal wholeness

    Experiencing Personal Wholeness

    • Yoga as an Adjunctive Therapy for Post-Traumatic Stress Disorder: A Feasibility Study

      • Walter Reed Army Medical Center


    Optimal healing environments the next natural step

    Ear Acupuncture for Acute Pain in the ER

    P=0.503

    P<0.001

    Goertz, CM et al. Auricular Acupuncture in the Treatment of Acute Pain Syndromes: A Pilot Study. Military Medicine, 2006;171(10):1010-1014.


    Optimal healing environments the next natural step

    Samueli Institute OHE Program(Current Activities)

    • In-depth case studies of eight hospitals and their experiences implementing ‘healing initiatives’

    • Systematic review of the ‘healing-oriented’ literature, looking specifically for cost-value data

    • Environmental scan of hospitals across the country (electronic survey n=2000)

    • “Living Laboratories.” Collaborative relationships with healthcare systems to access and assess health services that measure clinical, professional and economic outcomes of OHE components


    Optimal healing environments the next natural step

    Partnership Opportunities

    AHA Health Forum

    April 10-14, 2007

    San Diego, California

    “Evaluating Optimal Healing Environments”

    Contact Information

    Barb Findlay, RN, BSN

    Vice President, OHESM Program

    Samueli Institute

    [email protected]

    703-299-4800


    Optimal healing environments the next natural step

    Organizations with Health Care Quality Initiatives

    • The Samueli Institute

    • The Picker Institute

    • The Institute for Health Care Improvement

    • Corporate Health Improvement Program

    • Robert Wood Johnson Foundation

    • Bayer Foundation

    • Commonwealth Fund

    • The Fetzer Institute

    • Pew Trust

    • Planetree

    • The American Hospital Association

    • Centers for Medicaid and Medicare Services

    • The “Medical Home” concept in Primary Care Medicine

    • “TransforMED” of the AAFP

    • The Institute for Patient and Family Centered Care

    • The Agency for Healthcare Research and Quality

    • The Veterans Health Administration


    Optimal healing environments the next natural step

    What is the contribution to the human healing process?


    Optimal healing environments the next natural step

    Acknowledgements

    Barbara Findlay, R.N.

    Sita Ananth, Ph.D.

    Ian Coulter, Ph.D.

    Mike Finch, Ph.D.

    Kelly Gourdin

    Katherine Smith

    William Beckner, M.S.

    Ronald A. Chez, M.D.

    Christine Choate, D.C, Ph.D.

    And the innovative leaders of the patient-centered

    healing-oriented initiatives


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