Title, Objectives, Test Questions, Outline, Handouts

Title: “Healers at Work”

Objectives:

  1. Describe a study designed to identify and interview “skilled healers”
  2. Identify what these practitioners believe are essential practice skills
  3. To see the importance of the practitioner-patient relationship to the healing

process

  1. To learn from healers what may help us improve what we teach about healing

TEST QUESTIONS: True – False

  1. If you don’t know how to relate well to patients, we can’t teach you.

True______False_____

Answer: False

  1. Courteous gestures and actions may be more important that reassuring words.

Answer: True

  1. Real listening lets the patient explain why they are there with little or no

interruption

Answer: True

  1. Willingness to guide a frightened patient is less important than accurate

diagnosis

Answer: False

“Healers at Work”

INTRODUCTION:

This presentation is essentially an expanded review of a study conceived and completed by Larry Churchill and David Schenck of theCenter for Biomedical Ethics and Society at the Vanderbilt University Medical Center. It was published this year. Its purpose was to focus on physician-patient relationships, as the basis for “interviewing practitioners, identified by their peers as ‘healers’”. The authors then “synthesized the results of interviews with 50 of these practitioners”. Their book “explores in depth the things the best clinicians do.” They made a deliberate choice not to discuss the “many theories of healing, but to focus on the specific actions that exceptional clinicians perform with their patients, [actions]that subsequently [served] to improve their patients’ overall health.” Osteopathic physicians were not included in their study, but as I have reviewed what they heard, learned, and concluded, other implications came to mind.I was drawn to can be clearly considered. One, this study sustains osteopathic medicine’s emphatic insistence that the substantial and fully human nature of the physician-patient relationship is essential to the practice of exemplary medicine. Two, I believe it is equally clear that we should engage in a subsequent, related study that focuses on osteopathic healers and how their emphasis on the primacy of a substantial physician-patient relationship impacts the quality of care—especially in primary care practice. Beyond these two conclusions, I believe we at TCOM, together with other osteopathic medical schools should provide leadership and participate in such a study—one that might well focus on “healers in primary care practice.” I’ll say more about that near this presentation’s end.

The handouts are taken from the book, and offer some resources that might become part of what and how we teach medical professionalism to undergraduate medical students I think there may also be instructive insights and examples of teaching strategies here for preceptors and attendings, as they model medical professionalism in actual practice for clerkshipand graduate medical residency education.

I.THIS STUDY DESCRIBES HEALING RELATIONSHIPS WITH PATIENTS AND WHAT WAS LEARNED ABOUT THEM FROM THE 50 PRACTITONERS WHO WERE INTERVIEWED.

______HEALING RELATIONSHIPS INTERVIEW GUIDE ______

  1. How do you go about establishing and developing relationships with your patients? What concrete things do you do to bring this about?
  2. In your experience, when and how does healing occur? Is healing something you explicitly try to do—or is it something that just seems to happen along the way?
  3. Have you had experiences as a patient that taught you important things about healing? About relationships in health care?
  4. What activities that promote wellness, wholeness and healing do you personally engage in?

______A. EIGHT THINGS THE BEST CLINICIANS DO:

1.DO THE LITTLE THINGS: Introduce yourself; Greet everybody in the room; Shake hands; Smile, Sit down, Make eye contact( as appropriate); Give undivided attention; Be human, be personable: “There are just certain obvious social gestures. . .common in any new relationships, that I try to establish right away.”“If someone feels connected, you’re miles ahead . . .in being able to effect some sort of positive results and impact on the patient.”

2. TAKE TIME: Be still, Be quiet, Be interested, Be present: “ I may have a thousand things going, but I need to. . .sit down and try to look relaxed. . .give body language that says I have time for you.” I start teaching in the first encounter, I spend time listening to the answers to [my]questions. .I try to let some silence take place. . so they can tell me their concerns.” Time: chromos and kairos

3. BE OPEN AND LISTEN: Be human; Be vulnerable; Be brave; Face the pain; Look for the unspoken: “ Patients bring not just their ailments, but their whole wounded selves to physicians” “Listen to his story—let them know you have wounds. .are not perfect. . .Let them tell their own story without too many interruptions.” “Fear [may come out] as anger. . .they’re afraid a loved one is going to die and it will masquerade as anger. . .I need to be prepared for what comes out and not run from it.”

4. FIND SOMETHING TO LIKE, TO LOVE: Take the risk, Stretch yourself and your world; Think of your family. (Groopman)” Some degree of compassion, interest, emotional investment in patients, offers protection against misdiagnoses. . “I try to show the patient I’m willing to be involved in his life. .start the bonding process at the first meeting. . .” I took a class with a famous psychiatrist who taught techniques of patient conversation—recommending ‘lean forward, sit on the front edge of your chair’. I asked, ‘Wouldn’t it be better to just show you are interested in your patients?”

5. REMOVE BARRIERS: Practice humility; Pay attention to power and its differentials; Create bridges; Be safe and make welcoming spaces: “ I’m not too good to open a door, roll a patient back into a room, wipe snot off a crying mother” “ I want them to understand that I am human, not a god. I am a physician.”

6. LET THE PATIENT EXPLAIN: Listen for what and how they understand; Listen for fear; for the anger for the expectations; for the hopes: “ We focus on explanations— portions of the patient’s stories relating to their current complaint. .Patients need to be heard, know they are being heard” . .” Ask them what they understand about a what’s going on so far; it allows them to ask about tests or it’s an opening about the emotions [that are} important to them at that moment.’ E.g. “What I understand is that in a lot of pain and I’m very scared., because X,Y,Z. It gives them an opportunity to frame their understanding to show you what they need most now.”

7.SHARE AUTHORITY : Offer guidance; Get permission to take the lead; Support patients efforts to heal themselves; Be confident: “ Today’s visit is to find out whether I can help you; [if so] I ‘ll make some recommendations top you. .but you will always dictate what you want to do.” “What’s often not recognized is the patient brings a level of expertise too. Who knows more about them than them? And after all, it is about them and how they are able to get better.” “Lack of confidence has doomed many a therapy—the first step in healing the patient is to be confident. . . “I think a lot of that for them, is a perceived confidence—it has to do with the way you interact, the way you speak about options, your confidence in your own skills.”

8. BE COMMITTED AND TRUSTWORTHY: Do not abandon; Invest in trust; Be faithful; Be thankful: “ One practitioner said he always finds a way to say: ‘ We are going to work through this together.” “Another, often treating chronic, complex illnesses says: “ I may send you to see a specialist, but you will always come back to see me afterward.” “I tell patients that they can always count on leaving with a plan with me.” “Healing is about connections and connections are about listening to people’s stories—doing that is what makes us trustworthy—as as we are found trustworthy, are able to be more effective.”

B. MEDICAL RITUALS:

1. IN-OFFICE RITUALS—Revisit little things in office/treatment room setting

2. RITUAL STRUCTURE OF INTENSIVE CARE—Rituals of care and communication in the ICU—Renew introductions, promise to hear questions, tell the truth, sit down and go over things, prepare them for what may happen and what is happening—p.44 ICU Rite of Passage

C. HOW HEALING HAPPENS—REPORTS FROM THE FIELD: “ Healing is multifaceted and multilayered. I’m more interested in people being whole than being well. I think true wellness is wholeness—where there is an acceptance of life, of each other, being connected.” . .One of the things I believe very strongly is that healing is not equal to the absence of disease. If we think that, think narrowly that only if we can eradicate disease can we achieve healing, then we are once more short-changing our patients.”

1. IN THE BEGINNING: “ IT’S NOT ABOUT THE ASTOUNDING DEPTH OF MEDICAL EXPERTISE—ITS ALL ABOUT RELATIONSHIP”: Read from interview—handout

2. THE ROUTINE EXAM—health maintenance: KEEP IT SIMPLE—3 F’S :FITNESS, FORGIVENES AND FULFILLMENT “Chinese proverb—“If you seek revenge, dig two graves.”

3.ADDRESSING THE LAYERS: YOU KNOW WHAT DOC, THIS HAS BEEN THE BEST 6 WEEKS OF MY LIFE

4. END OF LIFE: WHEN IT COMES TO THE OTHER COMPONENTS OF OUR BEING

5.PRACTICING PRESENCE: “PRESENCE IS BEING WILLING TO BE LED, AND NOT FEELING YOU HAVE TO ORCHESTRATE

6. THE HEALTHY PRACTITIONER: I DON’T BELIEVE THAT ANYBODY IN THIS WORLD IS INDISPENSABLE

D. HEALING TRADITIONS: THE ROLE OF RELIGION AND SPIRITUALITY

E. PATIENTS PERSPECTIVES: HEALING FROM THE OTHER SIDE OF THE BED-RAIL.

1. DISEASES AND ILLNESSES: Cite Patient Comments

2. ENGAGING THE PERSON TO TREAT THE PATIENTS

3. THE TRAUMA OF CARE

4.HEALING OVER THE LONG TERM

F. THE BIOLOGY OF HEALING: NEUROSCIENCE AND THE EDUCATION OF HEALERS “Although many of us think of ourselves as thinking creatures that feel, biologically we are feeling creatures that thinks.” Jill Bolte Taylor G. ETHICS AND MEDICINE: HEALING THE WOUNDS OF FATE

1. MASTERING THE SKILLS OF A PRACTITIONER` a.Skills Must Be Taught “Learning skills involves learning (a) new behaviors, (b) the proper sequence of these behaviors, (c) the ability to recognize what counts as a “desired result”. “:However innate a skill may seem to be, it still requires validation as a skill. Minimally, this validation is teaching.” 2. Skills Entail More Restricted and Simpler Skills for Their Execution: e.g. Driving a car 3. Learning skills entails Developing Habits

4. Skills Are Taught By Mentors, Teachers, Experts: Recognition of an authority is twofold: (1)Masters must be recognized in their field by colleagues as accomplished performers and (2) Masters must be recognized by apprentices as authorities—even if only for a specific domain

Four Key Elements in Learning and Teaching Skills

  1. Observation of a skilled performance
  2. Performance of skills overseen and reviewed by mentors
  3. Trial and error
  4. The use of imperatives
  5. Skills are Practiced in Specific Contexts and Must Be Learned There

ETHICS AS THE PRACTICE OF LIFEHEALING SKILLS AS CHARACTER TRAITS

HANDOUTS:

Table 1.2 SUMMARY : PRACTIONER SKILLS THAT PROMOTE HEALING RELATIONSHIPS

  1. Do the little things
  • Introduce yourself and everyone on the team
  • Greet everybody in the room
  • Shake hands; smile; sit down; make eye contact
  • Give your undivided attention
  • Be human, be personable
  1. Take time
  • Be still
  • Be quiet
  • Be interested
  • Be present
  1. Be open and listen
  • Be vulnerable
  • Be brave
  • Face the pain
  • Look for the unspoken
  1. Find something to like, to love
  • Take the risk
  • Stretch yourself and your world
  • Think of your family
  1. Remove barriers
  • Practice humility
  • Pay attention to power and its differentials
  • Create bridges
  • Be safe and make welcoming spaces
  1. Let the patient explain
  • Listen for what and how they understand
  • Listen for the fear and the anger
  • Listen for the expectations and the hopes
  1. Share authority
  • Offer guidance
  • Get permission to take the lead
  • Support patients’ efforts to heal themselves
  • Be confident
  1. Be committed and trustworthy
  • Do not abandon
  • Invest in trust
  • Be faithful
  • Be thankful

Box 3.8 p.69

Death as healing at the end of life, yes. But where, one may ask, is the healing in the death of a child?

“ I had a child, dying of a brain tumor. I had told him and his parents good-bye that morning, and he died later that afternoon. I had to go over and pronounce the death, but I didn’t rush or hurry, because I knew the parents well, and we had already taken care of all that. We got there maybe a couple of hours later, and everything was out of the room, except the boy’s body, and the bed had been stripped. The male nurse and I stood by the bedside. He shed a few tears, and I said a prayer—and then I remember this incredible, absolutely incredible sense of peace. And I have thought about that so often, but then I realized that the peace came from the realization of the wholeness of that child who died totally and completely unaffected by the great worries of the world. He died totally, totally whole—and that is an awesome thing to realize.”

Box 3.14 p. 85 “Healers need other healers to help with the healing process

“I was holding a lot of stuff, not fully nurturing myself and always out there.. Out, out, out—then there is no time for nurturing and rebuilding. It’s just always out, and then you’re just tired—and then you’re out again, and then you’re tired. During a tired period. . .that is not a good time to be healing with anyone, because you’re just empty.

And my guide helped me understand the necessity of taking time off for rebuilding. And that’s not a failure. That it actually takes love and courage. It’s a very self-loving, caretaking thing to do. But something I never learned how.

So I really appreciate an external person saying, ‘This is a good thing. Try it, even if it’s uncomfortable. Because, one, it’ll be a loving thing to do for yourself—and, two, you’ll be a better healer if you do.’ Right,right. Kicking and screaming I went. Kicking and screaming.

Great Healers need other healers to help with the healing process. We have to have relationships with healers in order to be healers ourselves.

______

For short-term care, DO THIS:

______

  • Greet me as people typically greet each other: look at me, slow down, be polite, listen to me
  • Speak to me, and not about me to others in the room.
  • Recognize that I am in a life crisis when I come to you. Make room for this experience in our interaction—a matter of perception: “I see” Empathy.
  • Acknowledge seriousness when that’s appropriate.
  • Invite me to be a partner in my own healing. Take seriously my account of my illness. Tell me the truth.
  • Acknowledge that I have a life outside the exam room, outside the hospital.
  • Be calm. Make gentle physical contact to reassure my wounded body.
  • Use humor and imagination to open up tight spaces.
  • Be careful how you name or label my condition. That name or label will carry much weight with me and my caregivers. It will follow me all through the medical system.
  • Keep me in your sight. I want to be visible.

For Short-term care, DON’T DO THIS:

  • Be in a hurry or distracted
  • Speak rapidly, in jargon, without pausing.
  • Focus only on my disease
  • Deliver consequential information brusquely, quickly or in public locations.
  • Discredit my statements about my condition.
  • Be rude or callous in dealing with me or my primary caregivers.
  • Insult my capabilities, my intelligence, my race, gender, social class, or religion.
  • Drain my energy. Subject me to exhausting procedures, especially if they are of less than critical importance, and especially when I am still weak from initial trauma.
  • Spend more time at your computer or consulting your formulary than you do looking at me and talking with me.
  • Make me invisible. Drop me or ignore me or look away.

______For long-term care, DO THIS:

  • See me first—not your diagnostic system, or the diagnostic labels you receive from other practitioners.
  • Fidelity. Be faithful. Stay with me and consistently reassure me about this.
  • Tell me the truth.
  • My engagement over the long haul is key: Keep me going. Work with me to overcome discouragement, fear, despair—any blocks that arise in our relationship.
  • Affirm my grasp and stance toward my illness. This is the foundation of all else.
  • My primary caregivers are essential. Keep them engaged over the long haul.
  • In the course of long-term care, your staff and support people (PAs, RNs, therapists, social workers, insurance clerks, and receptionists) will spend more time with me than you will. Make sure they’re attentive, kind, well-trained.
  • Be open to knowing me and my world more fully.
  • Be open to having me know you more fully, as a practitioner and a human being.

______For long term care, DON’T DO THIS:

  • Refuse to recognize me as human as things go on and on and on.
  • Protect me from the truth, by omission or evasion or fabrication.
  • Let my care become routinized.
  • Stop seeing me—especially if I am getting worse, approaching being “incurable”
  • Abandon me.

TABLE 8.1 p 237

Healing SkillsCharacter Traits

  1. Do the little thingsHumility
  1. Take timePatience
  1. Be open and listenCourage
  1. Find something to like, to loveCompassion
  1. Remove barriersJustice
  1. Let the patient explainEmpathy
  1. Share authorityRespect
  1. Be committed and trustworthyIntegrity

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