politics and practice based on mindfulness

Saturday, February 14, 2009

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.   

Friday, February 13, 2009

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.

Thursday, February 12, 2009

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")

Wednesday, February 11, 2009

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!

Sunday, February 8, 2009

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.