stress tests

It was a fun morning on the Times site.  Let's do a round up of the latest craziness:

NYT Online, front page, top left column: "US Planning to Reveal Data on Health of Top Banks" -- the story is all about federally-sponsored "stress tests" designed to protect most big banks from toxic assets (created by the banks' own products divisions).  

And in the meantime, what is the "stress test" offered to the average person coping with illness in this country?  Nada.

Today's NYT Well features a parent who took his family in exile into Mongolia in order to provide his autistic son with access to nature-based therapy and shamanic healing.  Whether the healing is placebo-based or not, it seems to have worked well for the boy.  Next time you have an intractable mental disorder: M-O-N-G-O-L-I-A: it spells relief!

And we also learn today that if Americans have something more serious than chronic disease, say, cancer, insurance companies are happy to pay for chemo, but not the more expensive and more effective pill-based therapies.  Cost of a cancer patient's pill treatment: over $5k for the first month and roughly $2k per month thereafter.  No stress test for those patients either...

My motto for 2009: a commonly-used "stress test" for people, not for banks.  Preferably one designed by a caring, listening healer.

Obama & healthcare (part II): how to achieve "universal care"

As primary care doctors, what we can do to improve the health of our aging population is to take time to listen to all of the numerous symptoms reported, review medications, then decide upon necessary care and coordinate specialty care, if needed. 

This cognitive work is crucial to avoid unnecessary and costly procedures that may also be dangerous to a patient; yet, there little reimbursement for this essential aspect of care. Our system is geared toward more profitable, high-tech interventions and tests. 

Many family doctors are forced to see a patient every 5-10 minutes to support their increasing overhead.  The failure to provide quality care ends up costing the system more, because without adequate time to manage a patient’s problems, doctors send more patients to specialists where the care is more expensive.  Over 20% of Medicare patients have 5 or more chronic illnesses that require this comprehensive primary care management.

It takes only 3-5 minutes to write an unnecessary antibiotic for a cold and 15 minutes to explain why Penicillin is not effective for a cold and what other supportive medicines, herbs and vitamins may ease the symptoms. 

In the larger view, we as a country have become almost exclusively reliant on technology, prescription medications, and invasive procedures for our health.   A new vision of self-healing is needed.  

I have witnessed this new standard of care first-hand at the University of Arizona in  Dr. Andrew Weil’s Integrative Health program.  Dr. Weil trains physicians for the new paradigm, although in some ways, it represents a return to an earlier time.   His mission is to educate practicing physicians and medical residents about mind-body healing, spiritual aspects of healing, botanical remedies, exercise, and in-depth nutrition science. 

“Imagine a world in which medicine was oriented toward healing rather than disease" says Dr. Weil, "where doctors believed in the natural healing capacity of human beings and emphasized prevention above treatment. In such a world, doctors and patients would be partners working toward the same ends."

As we move away from a system that supports unnecessary interventions with little to recommend them in term of studies or evidence, we'll need to offer patients more in the way of health promotion.  So to achieve "universal care", medical school and residencies will train MDs to offer health promotion, integrative wellness, and nutrition classes, and not solely focus on disease-oriented approaches.

--submitted by Dr Deborah Campbell MD

Obama & healthcare part I: how to achieve "universal care"

I am a family physician who has been in primary care practice for over 14 years.  If you're a Obama supporter (like me) you're probably as pleased as I am that he is determined to extend healthcare coverage to all Americans.  But to achieve universal care, there are tougher challenges ahead than the obvious issues of enrollment.  

Based on what I'm seeing from day to day, we need to keep the adminstration focused on the following issues:

Shortage of primary care doctors.  MDs in my field are retiring faster than in previous times because of burnout from paperwork, and the constant struggle for documentation and pre-authorization.  Most medical students recognize this, and they are choosing not to enter the field.  They have large student loans, and are forced to choose more lucrative, procedure-oriented specialties.  No matter how common insurance coverage becomes under the new plan, there won't be universal care in the future if this trend continues.  

Routine use (and over-use) of specialty care.  Other countries where primary care is the main delivery system of healthcare have the same or better health in their citizens. We continue to be a country that expects specialty care, despite that this care is more expensive and may be more dangerous (because of more interventions that may lead to complications).

We have solutions, but it will probably take great political will to implement them:

Lighter loan repayment plans for students graduating in family practice would encourage more to enter the primary care fields.  Also, with a complete overhaul of the current reimbursement schedule, insurers should offer greater rewards for the health and wellness care delivered by primary care doctors. This will save the system even more money in the long run if we have a single-payer system. Current employer-based insurance coverages have no incentive to invest in the long-term, since employees switch jobs many times in their lifetime.

In case my post seems to be simply self-serving, here's a story to show the implications for the average patient.  One of my over-90 patients who is currently in care for coronary disease, has undergone cardiac catheterization TWICE in the past 6 months despite the fact that she and I have agreed on treatment with medicines, and not surgery or invasive stents.  The cardiologist has little incentive not to perform these tests since Medicare reimburses very well for them. 

In this situation, the cardiologist acted more like a highly paid plumber than a physician, in not looking at the entire situation and taking into account what is best for this elderly patient.

More examples of the over-use of specialists can be found in a recent New York Times article by Jane Brody: “More Isn’t Always Better in Coronary Care.” Surgical invasive management has been expanded without any data that these expensive interventions extend life for the majority of patients who receive them.

-- submitted by Dr. Deborah Campbell MD

spinal chord

I've been journaling about Vedic chant and its perplexing, strong effects on the health and well-being of my students (and on mine, too, of course).  Then, out of the blue comes last week's Sunday NYT article:  Composing Concertos In the Key of Rx:

"I broke vertebrae 11 and 12, missing the spinal cord by a millimeter... The doctor said I can't do much for you for a while, but you can sing if you like" says Vera Brandes, a researcher in the field of music therapy.  She was sharing her room with a Buddhist whose friends came and chanted daily.  After just two weeks at the hospital, an MRI showed her spine was completely healed.

According to the article, doctors at leading research hospitals are designing studies to learn how music therapy works for conditions such as depression.  Based on the assessments from these studies, one said:

Physiologically it's perfectly plausible that music would affect not only psychiatric conditions, but also endocrine, autonomic, and automimmune disorders.  I can't say music is a pill to abolish these diseases ... [but] so many pills have horrible side effects.  Music has no side effects, or no harmful ones.

 

bologna

Great new post on the Daily Beast about the shortage of hands-on, old-fashioned, family doctoring  ... alas this kind of thing was once performed by physicians who didn't need to feed their MRIs, and infusion centers with "customers". 

Fewer graduates today choose family medicine because PCPs are forced by insurers to sandwich patient after patient into bologna-thin slices of time, and they do it for far less reimbursement than their specialist and surgical colleagues.  Dr Abraham Verghese makes suggestions to remedy the problem (quite easily) by creating a quid pro quo between new PCPs requiring scholarship debt relief and the government, which has a pressing need for a "physician corps" to practice in rural and underserved areas.  

Question for the day: has the mechanized care model won our hearts and minds so much that we will refuse to consider Dr. Verghese 's simple, effective proposal ... only because it promotes an archaic style of care?  

Some of my friends have had unnecessary MRIs.  I wonder whether the choice was made heedlessly, because of underlying anxiety that might have been addressed by a truly "attending" physician.  

And I have had one (perhaps) unneeded and very expensive biopsy, so I have to make some adaptations, too.  If my OB-GYN had had the time to call me before the decision was made with the surgeon, my choice might have been different.  Indeed she tried, but by then it was too late, and it's nearly always impossible to reach her by phone to return calls.  The choice of tight scheduling is not hers to make.  I'm sure she'd like to be more available. 

To create change, there has to be a will to wean ourselves off the fantasies surrounding high-tech care: that these procedures provide certainty in diagnosis (not always) and cost effective care (not necessarily).  

We can all agree that regular screening is a boon for many conditions.  But being sliced and diced into films, slides, and images is not equivalent to receiving good medical attention.  As a nation, we need the political will to keep private insurers who profit from high tech as far away as possible from the design of the new system.  One economist described the market effects of insurers' competition in healthcare:  "Competition can sometimes fragment value ... and even destroy it."

Final word today from the good doctor:

"Health reform must take away the incentives to do to and replace them with incentives to do for the patient and to be with the patient.  As the debate heats up and the lobbyists warm to their tasks, let's listen to the patients, because they can tell us what's wrong.  Yes they can."

"Hello Health" (can this be serious?)

Imagine an electronic medical system that's physician-friendly and patient-friendly ... and it comes with neighborhood doctors who "care about the whole you."  

That's the promise offered by Hello Health, a new, concierge-model, primary care service in Brooklyn, with a new branch in the West Village.  It uses email communication between MDs and patients to break the artificial standard of a 15-25 minute office visit, a stricture commonly imposed by private insurers.  The goal, according to the site, is to renew the personal attention and old-fashioned relationship we patients once enjoyed with our family doctors.

Emails could reduce unneeded office visits in this new model.  By using graduated units of care (beginning with a simple patient query by email as the minimum unit), their approach can increase office visit length when required, and without long waits.  It would permit the docs to appropriately price and offer many levels of service, even house calls.  The cost to the patient rises with the time and the level of individual attention involved in a single consult.  The EMS software that allows for emails and access to patient records will also link MDs to colleagues and their own community of providers.   (Maybe a few yoga teachers too?)

Oh, by the way, other physicians can purchase the Hello Health system. That makes me wonder -- is the software the real news here or is it actually a workable clinical model?  And why do they have a name that reminds me of the ubiquitous Hello Kitty?  How serious are they?

 Hello Health also means goodbye to security because it's strictly pay as you go: there's no insurance billing.  But when you consider that almost 20% of Americans under age 65  lack insurance at the moment, that's not a bad market share.  Here's the article about it on Health Affairs.

What's missing?  Maybe some realism about how to maintain clear boundaries with patients.  What happens when the patient's credit card runs out?  Will the "personal attention" and the doctor-patient relationship they touted on the site terminate (like shutting off the tap when you haven't paid your water bill)?  That's the troubling scenario that insurance often helps us to avoid with our PCPs.  Imagine having the "relationship" ... and then when funds run out, your emails bounce back.  That's ugly.  

Hello Health is a new model worth exploring, but it may be another way to sell clinical software.  I'm not sure that they've solved the underlying problem: how to determine the amount and type of services offered to a patient according to need AND capacity to pay.  In an ethical system there has to be a good way to balance out this equation, and I'm not sure the heuristics are there yet! 

Still if emails can help doctors avoid unnecessary visits and patient backlogs .... it's not a bad start after all.

integrated vs. integrative health: which comes first?

A source at NIH told me that their share of the stimulus has been allocated within days of the President's announcement.  Basically every approved project in the pipeline will receive funding.  And as I type, staffers at NIH and on the Hill are completing final touches on the design of the much-ballyhooed, national, electronic medical records system.

So much for the yoga principle of reflection before action.

Evaluated  in the context of 2009 medical information technology, the "new" records system will be B.C.  Of course this stone-age system has some advantages.  It will reduce medication error and it will probably be coming soon to a medical center near you.  So let us rejoice in small blessings.

  If you want to get a glimpse of where we need to eventually take the system, that is,  if we are to have uniform, research-based standards of care in the U.S., visit the Harvard Catalyst site.  Catalyst is the portal to an extraordinary bioinformatics system being honed and refined around the ethical practice of computational information gathering [ie: bioinformatics, with a focus on genomic research and clinical records, and collaboration from the Divinity School on ethical guidelines].  Furthermore Catalyst assembles "information from every scientific core into an indexed, searchable data base."  When we realize that Harvard's "scientific core" includes the Medical School, the Dana Farber Cancer Institute,  and 16 leading facilities surrounding Cambridge, we have Harvard's permission to gasp in awe.  And they Twitter!

One question rages on, for me at least.  Can there be integrative (mind-body) care as part of a treatment plan unless we have integrated care (records sharing with patient privacy protection)?  And how can my services be incorporated into the primitive national system that's now in the works?

Patients don't like talking about their alternative care with their PCPs, and until they do, and until we all share and measure outcomes within the same electronic records system, there will be an unconscionable amount of waste in CAM (complementary alternative medicine).  I don't see why Medicare or private insurers should pay for yet another failed, disease-management approach.  CAM has not reduced costs in California where it is widely reimbursed.  Shared information and timely case management would have saved money.  

If you want to read about more CAM practitioners engaging in salutary self-criticism visit one of my favorite stops online The Health Care Blog, and Matthew Holt on the recent meeting on integrative health at the Institutes of Medicine.  Also check out the recent blog entry on employers masochistically funding market inefficiencies.  Because employers have no database to find an insurance program with the best fit, the "invisible hand" of the market fails to operate in medicine (once again!).

In the meantime, let's say a little prayer for all the possibilities that were wasted in this week's panicky rush to approve some -- any -- electronic medical system.  Perhaps it's another sign of lost trust in this society.  Advocates for quality healthcare feel they must sprint headlong to endorse an inadequate information system.  Otherwise the media howl their jeremiads and destroy public goodwill toward a more rational, comprehensive, and thoughtful approach that can't be summarized in a soundbite.

Breathe in, breathe out and say "whatever".

St Francis's hovel

I'm on a mini-retreat at Casa Chamisa a B&B in Los Ranchos de Albuquerque.  Every day I spend a few hours with my teacher and enjoy hours of personal practice every morning ... what a treat!  I was looking outside at dawn in a fairly rosy mood, and discovered something quite delightful on the verandah wall:  a lovely Mexican tile mural of St Francis feeding the birds. 

There seems to be a St Francis inspiration at this B&B.  Casa Chamisa has 5 chickens, two horses, 3 roosters, four cats and an "attack parrot" (that's the sign on her cage but Tildy is a sweetheart with a G-rated vocabulary). The furniture in my room floats on a cloud of cat hair.  Arnold Sargeant's hospitality and cooking are outstanding, but if you don't like critters, don't come here! 

 

On the plane to NM I read that fine, fine article in Harper's magazine (Luke Mitchell "Sick in the Head: Why America won't get the health care system it needs" February 2009).  

Mitchell shows why the health insurance lobby enthusiastically backs Obama's healthcare plan (universal coverage w/no single payer).  The new system will ride on the coattails of insurance company vendors who provide the multibillions' worth of computerized prescription and clinical records every year.   As they expand their industrial healthcare business model they'll achieve near-total mechanization of primary care treatment, a "streamlining" process that will eliminate most family physician-patient visits.

In the article, insurance industry leaders say they'll create economies in the new system by reducing the (already attenuated) amount of contact time between patient and physician.  

How will they begin?  Through a highly-regulated system of patient-doctor communication.  The article describes the prototype of an email system enabling patients to contact doctors ... the system integrates with an ATM-style, fully automated, pill-distribution system.  This plan may reduce medication error (that will be its selling point).  And it will be much easier for clinicians to over-prescribe unnecessary meds to patients without examining non-pharmaceutical treatments such as "talk" therapy, PT, yoga acupuncture (non-automated care).  

Only a very small part of the Obama stimulus law will try to measure the efficacy of meds vs. treatments that require lots more hands-on, personal, clinical care.  And insurers are trying to block this provision because even a small amount of research supporting non-pharmaceutical treatments could halt the gradual mechanization of care. 

Oh, and we can forget about doctor's visits as a standard part of insurance coverage: most symptoms that are anything less than acute or emergent will be emailed  by patients (that is, by those patients lucky enough to be part of the broadband system).  Maybe the really really lucky patients will be able to be "seen" on the doc's videoconference device.    

These changes are only a heartbeat away from implementation.  Patients complain all the time that the private-insurance model undermines their relationship with docs.  Things look to be getting worse.

We need to remember St Francis's home -- a "hovel" (in the words of one of his biographers).  There are apochryphal stories about how clerical examiners from Rome arrived in Assisi and were dismayed by St Francis's enthusiastic return to the vows of simplicity and poverty.  Shocked by the friars' tenement, and irregular housekeeping, the examiners nearly had the place condemned, ecclesiastically speaking.  The friars kept no customary "hours" because they were mendicants, begging for alms.  They trusted that prayer, and their relationships to their flocks (human and animal) would pull them through.  Francis's vow of poverty was a healing corrective to the entrenched materialism of the medieval church.

My point: there is a certain amount of  improvisation in healing relationships.  A student lets a small fact slip, an hour after my orderly, written intake, and as a result, I see the case in an entirely different, and clearer light.  Or I run into a doctor in the hallway, and remember to follow up about a student; important information is exchanged and the doctor finds good reason to call and check on the patient/student.

The unexpected connection, a serendipitous observation, the everyday accidents and slips that are part of an authentic communication experience will be LOST in the new automated system. 

Francis's example as a compassionate healer reminds us to be generous with ourselves not our material assets, to find surprising solutions together, and to aspire to be fully present in our connections to each other.  

If, as now seems inevitable, Americans allow medicine to be comprehensively automated, then alternative practitioners like me who preserve this authentic messiness in communication, need to be included despite issues of credentialling and expense. 

recovering our balance

OK, today's silly, hypothetical question (from too many hours spent teaching yoga perhaps?):

Given our inclination NOT to ... move in slow, deliberate ways ...to walk rather than drive ... to wean ourselves from drugs that interfere with our motor capacity ... or to do a daily personal yoga practice... I have to wonder whether we're collectively losing our chops as successful bipeds.  Instead of legs, we'll have long slender fins to push the car pedals.

Modern life is making us lose our balance.  According to author Scott McCredie, America is facing a near-epidemic in debilitating falls. I took a look at McCredie's newish book (new to me), Balance: recovering the lost sense. It's a collection of essays on the evolution evolution of balance, and contemporary masters of this sixth sense (see the Amazon page). 

Poor balance is common among students who come to the studio, so I treat it seriously.  Just one fall can lead to death within months for the very old.  But more often than not the falls begin in late youth and middle age.  The effects are cumulative, and they can make life very unpleasant through head injuries, torn ligaments, plates to hold together broken bones ... every serious injury increases the odds for future impairment (meaning less walking, balancing activity: the cycle that leads to the next fall is strengthened).

When students tell me they're having dizzy spells, or have fallen, I'm moved by their vulnerable, self-incriminating sadness. The guilt is strikingly common. And sometimes it results in the blame of others, "unsafe" surfaces, weather conditions etc.

Maybe a fall is one of the few times we can actually see a consequence from our inattantion, pretty much as the lapse occurs.  

Balanced movement is much harder when we're in a state of obsession, preoccupation, or anxiety, such as overreacting to an overreactive media.  

Yoga helps balance of course.  But it takes a kind of inner equilibrium to do an appropriate daily practice, which is what's required for any real progress.  When your balance is out of whack, that commitment comes hard, especially if you lack a close relationship with a teacher. So, balance deficits resist a "quick fix".   The sense remains an elusive combination of so many skills and faculties  (vision, attention, proprioception, and the vestibular functions of the inner ear, and can be affected by so many other factors, illness, hormonal changes etc).  So we need to practice, practice, practice.

Losing our balance may mean losing a lot more than firm feet on the ground.  From the mind-body perspective, it's associated with changes in thinking and judgment.  Biped alignment is one of the signal, evolutionary leaps that distinguish human consciousness. Placing the spine upright at a right angle to the ground, has had extraordinary consequences.  In this position, humans can more easily meditate and enjoy the "relaxed alertness" that leads to profound concentration, insight, and bliss.   

art therapy for cancer (post-surgery)

Today from Reuters, an illuminating article on a small, Swedish study that demonstrated significant clinical improvements in breast cancer patients from art therapy (link here). What caught my eye: the protocol offers time and space for expression and reflection.  Sounds like meditation to me.   Through an introspective and personal process guided by the teacher, patients gradually abandoned false ideas about the gender stereotype of a perfect, healthy female body.  And that gave them more hope.  Consequently their physical healing improved according to standard, quality-of-life measures.  Having worked with cancer-diagnosed students for some time now, I'd infer that  the art therapy was similar to meditation: a form of reflection and stable attention that can provide authentic insight and positive life changes.  

Personal anecdote: I recently attended a one-day art workshop with Lee Alter, one of Charlottesville's favorite watercolor painters.  Lee's work is light in touch, minimalist and abstract, and yet she reveres our sensuous world.  She favors subjects such as figures, flowers, her beloved musician friends, and nature.  

I learned so much from her teaching, especially from her demonstrations of using breath as a guide for each brushstroke.  This technique, and her gentle method of encouragement, seemed to generate a slow, intense hum of concentration through the sunny afternoon in a local studio ... several personal discoveries and breakthroughs followed.  One participant, a post-surgery cancer patient, is a devoted student and relies on these classes to further her healing.  

I felt I was actually seeing things differently (literally) the next day.  Hard to describe how: a bit more right brained, impressionistic, less conditioned vision.  It's so good, so lucky that an artist-teacher we know can help us discover parts of ourselves that are new and regenerate.

there's gonna be a revolution ... oh yeah

A pilot program in Arizona, based on the "medical home" model,  will give primary care physicians more authority and money than usual to monitor their patients over time and check on the outcomes of outpatient, specialist services.  That is, doctors will be paid to act more like doctors and less like gatekeepers to an expensive maze of services. Instead they'll be paid to ensure that patients have the appropriate care, at the right time and in the right order.

IBM of Arizona is the employer backing this effort.  Impressive corporate sponsor.  According to Dr. Paul Grundy,  IBM's director of health care, "We're not doing this because we expect to see savings ... I think it's the right thing to do."

At the studio I hear about quality of care from my students, who are usually patients, doctors, or nurses.  Based on their complaints, ANY model that increases the time spent attending and listening to patients has to be given a fair trial.  As patients we're swamped with overwhelming information online and we're underexposed to experience and guidance.  Trust in doctors inevitably disappears when they can't spend time to help patients put information in perspective.

Florida doctors declined to participate in a previous pilot of the "medical home" from the same insurer, United Health Group, because they were being asked to do too much for too little reimbursement.  It's a reasonable point, and it displays the power of the current paradigm which mandates almost no money for low-tech, compassionate care.   Some experts on health care policy say the pilot, although promising, will likely place too much stress on small doctors' offices as they adapt to increased paperwork and time demands.  

Outmoded institutional narratives may prevent this model from working widely on a sustainable scale:  

1. Our healthcare system is not even a system, it's a hodgepodge pasted together by competing private insurers, erratic record management, and the varying financial means of the employers offering insurance.  Pharma ads and the internet compound the chaos, so patients see themselves as consumers not patients.   And I am afraid that individual outcomes will always reflect the unpredictable "system" enveloping doctor and patient alike.
2. Medical records should all be computerized to make case management affordable.  We'll need to conquer our paranoia about insurers invading privacy and find ways to secure the system. Doctors require quick access to notes from EVERYONE involved in their patients' care.  Alternative practitioners like me should be allowed to enter data on individuals because I spend more time with them than most doctors can.  That way, docs will learn more about complementary/alternative medicine.  Presumably they'll be able to make referrals to CAM with more confidence. As for MY reimbursement issues, that's material for a later blog!
3. Overuse of high technology will continue to inflate costs.  And high-tech doesn't always equate better diagnosis and care.  Hands-on doctoring and communication with patients (which takes time) may still go relatively unrewarded by insurance because it just doesn't seem as snazzy as MRIs, nor is it easy to assess in a controlled, randomized study.

Having said that, if all the findings about placebos are true (and the literature on placebo efficacy keeps growing), a health care model offering slightly more hands-on care, with a few extra physician phone calls, could make a significant difference to patients.  Trust and connection are essential ingredients in healing, and we need more of both.

(the reporting on the Arizona program is taken from Reed Abelson's story in NYT 2/7/09, B3 "For IBM Insurer Reopens Test of Rewarding Doctors for Healthy Patients")

Tara Pope Parker & the health revolution

When the health revolution comes, let's remember to thank intrepid editor Tara Parker Pope of the Well blog and her fellow online editors at the Times.  

Parker Pope's selects studies that matter to us.  And she deftly places in perspective those studies that should matter to us, because they concern the insane complexities of modern healthcare.   A recent refreshing look at the economic costs to patients for their office wait time proves her point.  We're all paying for a system that has unrealistic expectations of how much can be done in a 15 minute clinical visit.  The result? chronic logjams in physician offices.

Other NYT Health articles online reveal the ways patients are abandoned by the system once surgery and other reimbursable services end.  The article "Health scares reduce smoking not waistlines, study finds," reaches broadly into issues of insurance reimbursement and its typically grotesque outcomes.  

In our system, there's this nutty bias toward more surgery over cheaper, behavioral therapy (like yoga therapy or psychotherapy).  

Exercise-based weight loss programs seem expensive, at least upfront.  The programs require clinical supervision,  stress reduction techniques, counseling, nutrition education, blood tests for thyroid etc, and ongoing coaching/counseling.  In contrast, smoking cessation groups are ridiculously common and usually free.  

According to the article, the study's cardiac patients, who desperately need to lose weight and to quit smoking, only gave up ciggies, and maintained the same weight that helped lead to their heart attacks.  Or the most overweight cardiac patients opted for costly bariatric surgery -- that's stomach-stapling to you and me. A bariatric procedure is ineffective when performed without vital but unreimbursed coaching and counseling afterwards.  But what do we reimburse?  Surgery without counseling ... and tragically, the ER costs from the (now, more likely) second heart "event".  Crazy!

Hospitals like Martha Jeff are so committed to patient care that they try to retain at least some of their patient education programs in the current climate.  But they deserve to be reimbursed by Medicare/Medicaid, no question.

Cancer survivor students participate in the Yoga for Life program, offered free at the studio thanks to the Martha Jeff Cancer Care Center.   Students tell me one of the reasons why the class means so much is that it provides individual guidance and caring from someone trained to understand their needs beyond the treatment stage. 

Parker Pope is not only a great editor, but from her choices we see she has a public health agenda. Her blog regularly includes research on the scarcity of good, old-fashioned, hands-on, low-tech healthcare.  Check out a recent piece on  insurance mandates that FORCE physicians to be "unethical" in their care.  Then ... let's all think about how we change this.  Viva la revolucion!

early days at the hospital

The studio where I teach is directly above the physical therapy (PT) department at Martha Jefferson' Outpatient Care Center (OCC).  At first the PTs approached me warily thinking I'd set out a shingle as new-age, rehab therapist.  

And like everyone else they wondered how a yoga studio landed in a hospital, plopped down like Dorothy's house in Oz.

Becoming a competent PT takes somewhere between 5 to 7 years of pre-med and graduate medical education.  A PT's knowledge of anatomy and physiology often exceeds a doctor's.   Even as an experienced yoga teacher, I can't touch their level of bio-mechanical and clinical experience. I visit the PT clinic, and related PT/orthopedic websites ... and marvel at their amazing work.  

The head of the PT department, a svelte, smart blonde who is not easily gulled,  was especially skeptical at first.  I appreciated that she at least took me seriously.  Everyone else seemed mildly amused I was there.

We were in the notoriously slow OCC elevator and this was part of the chat:

Her: You do .. yoga here? (politely baffled)

Me: Yeah.  Very breathed-based.  Gentle movement.  Meditative.  Like that. (defensive)

Her: Oh yeah, I know all about it.  My sister does it in California.  She can do all this crazy stuff.  Pretty cool ... (looks at me with knowledgeable confidence; then shoots me a quizzical glance asking how that yoga fits into a hospital.  She pauses so I can fill her in:)

Me: Yeah, not that kind of yoga though.  Real simple.  (trying to get my message in a three-second soundbite as the elevator door opens is NOT EASY).  I can give you and the PTs a demonstration.  

Her:  Huh.  OK.  Sure! (still confused but friendly)

She was true to her word.  I came downstairs to give a demonstration, the PTs enjoyed it very much.  Ellen O.  became my PT buddy, the main referral I used for my students with intractable neck pain, a condition that can elude yoga therapy, except with the most patient students.  Many of my seriously impaired students often need to graduate from PT before they work with me.  Now when I walk into the PT department, with its loud rockn'roll and the octogenarians boogying on the treadmills,  I sail past the main desk, say hi to the therapists (some of whom are students, others friends) and ... strange to say ...  I feel pretty much at home.

Versions of the elevator conversation happened often in the early days.  My not-yet colleagues would move off to real work at the breakneck pace of clinical appointments, as set currently by insurance companies (more on alternative-medicine friendly insurance models in a later post).  

While they were hustling to their next patient,  I seemed to be occupying a completely different time/space, as I retreated in a leisurely way down the hall to my spanking-gorgeous but empty studio.  Initially I got sidelong stares for my teaching uniform: long wafty scarf, loose black stretch pants, black jacket, hospital ID.  No low-cut shirts, no middle-aged ass showing, no tatoos or talismans, but definitely sandals.  I have wide, fin-feet and I hate most conventional footwear.

Not all of my students from my hip, downtown studio were willing to follow me into a new, institutional environment that screamed:  "ALLOPATHICS WHO MESSED UP MY HEALTH: A TRIP DOWN MEMORY LANE" or "YOU'RE SICK: NOW PAY UP", or "YOU'RE OLD AND YOU CAN'T DO 'REAL YOGA' IN FUNKY DOWNTOWN STUDIOS".

I knew all these perspectives were wrong but it's hard to explain.  In three seconds or less.

So once again I was in the schitzy position of explaining allopaths to alternative types and alternative practices to allopaths.  

But you know what?  It didn't matter.  I was on fire!!!  This was an assignment I had asked for, and now I had it.  Mike, the OCC developer had handed me the studio space at a ridiculous discount because his wife had cancer, and from their experience, he knew:  Patients need MORE.  

I was so lucky that Ron, a senior VP and Jim, the hospital's president, agreed and wanted yoga in the Outpatient Care building.  At hospital association conferences, Jim actually likes to boast that he has a studio on the top floor. 

We all know it's hard to put a name on what that MORE is, but any of us who have taken care of seriously sick people or been chronically ill ourselves know that this is truth.

Healers and patients both aspire to a truthful, dynamic dialogue about outcomes.  When we're healing we deserve and need that MORE and we should talk about it with our docs and therapists.  

Any effort to bring the two worlds of allopathic and traditional medicine is worthwhile, even when it fails to connect on the first go.   I encourage my students to 'fess up to their docs about their extracurricular  alternative practices (herbs, massage, reiki, acupuncture etc).  Patients need to be heard as individuals, yearning for the MORE.

After the elevator chat, it was clear that the dialogue with my future colleagues wasn't going to be perfect. But at least the dialogue had begun.