The Abbott Way: Goal Directed Treatment Plan

Part IV: Goal Directed Treatment Plan

            In the penultimate post for this 4 part series, we will delve into the idea of the Goal-Directed Treatment Plan with regards to healing for our patient. Now, any doctor or medical student will be very aware of the treatment plan, and will certainly attest to the fact that all patients receiving care ultimately receive a treatment plan. I argue, argue, however, does this standard treatment plan actually address the desired goals, the true needs and most importantly the “Nourishing Review” conducted previously in our 4-step medical encounter. Even with my optimistic attitude, I am hard-pressed to believe that this is actually the norm. Now critics may say that the treatment plan implemented by the doctor is perfectly sufficient for the majority of illness and I would reluctantly agree. My hope, however, is that even if you arrive at the same ultimate treatment strategy, regardless of whether one intimately discusses ideas, goals and desires with the patient, the fact remains that in one instance YOU ACTUALLY GARNERED PATIENT INPUT. In this age of health care, empowering the patient and allowing them to dictate his or her course of healing is the PRIMARY GOAL OF CARE, not simply prescribing a drug or implementing a temporary intervention.

            Here is where I may begin to sound a little crazy, but I am not afraid to say, in my mind, if I was able to have a patient choose to spend 30 minutes less each day on his or her cell phone and replace those minutes with family time, yet do absolutely nothing to change diet, exercise, or drinking habits, I would consider that a successful completion of a goal as part of our adopted treatment plan, You see, this is completely independent of any changes or improvements to the individual’s physical health that can be quantifiably determined. If at the end of a visit I have a patient leave without taking any drugs to modify HTN, DM II or HLD, and they are unable to commit to any dietary or lifestyle changes, yet they choose three activities identified from his or her Nourishing Review to implement on a daily basis, I am entirely satisfied. Investment into one’s own health is the first step to positive changes and improved well-being, not drugs that artificially improve blood markers of metabolic health. Patients that improve their happiness and feel satisfied with their lives will ultimately be in the right place to adopt healthier lifestyle habits, this is a simple truth.  I like to tell people all the time, humans are generally only good at attempting one task or changing one habit a time. Add even one additional change or modify up to three habits, and invariably nothing happens, and we simply feel worse for it. So with this in mind, I encourage patients to conduct the Nourishing Review, cultivate happiness in their lives and spend at least 5-10 minutes a day practicing mindful self care- whether that is meditation, gratitude, a body scan, journaling or simply deep breathing, all of these mindful activities can center the mind and put us in a place where we can actually think and act on lifestyle changes.

              Like I say time and time again, my job as a physician is not to make you better or solve all of your problems, my job is to engage in a positive discussion of what may be your current roadblocks to optimal health, and what may be the best strategies for achieving your goals. I can support and prescribe medicines, supplements, or herbals to help you achieve these improvements, however, I cannot live your life or tell you what to expect along the way. A world of empowered patients will ultimately make for healthier patients, regardless of what treatments you actually utilize. The reality is that proper nutrition, adequate sleep, positive social and human connection, spending time outdoors in nourishing sunlight, engaging in regular movement/exercise and practicing routine mindful activities/stress reduction are the cornerstones to optimal health. This will never change and anyone that tells you of a perfect cure that does not involve these principles is downright wrong. The resources, apps, online tools/protocols used to successfully modify behavior and allow one to successfully adopt new habits following these fundamentals will always vary, and this is exactly what a capitalistic economy/society provides. 

              Gary Kraftsow of the Viniyoga Tradition used to say frequently during our RYT training lectures, one method/sequence is never right for everyone, however, one method/sequence is always right for someone. So I encourage everyone to create a nourishing list, use this as your guide for a treatment plan with your physician, and engage in a positive discussion regarding the lifestyle principles outlined above. As doctors we want to believe we are doing right by engaging in shared decision making, however, if the decisions still ultimately revolve around only our understanding of the potential treatment options, what good is it to be considered “shared?” Whether you are a patient or a healer, we can all benefit from the understanding that shared decision making isn’t the perfect answer, but that cultivating an active discussion regarding what nourishes the patient, in addition to following our fundamental lifestyle pillars, all within the context of addressing an individual’s primary presenting complaints, will provide healing and vitality to all willing to invest the time and energy to find it.

The Abbott Way: Healing Touch

Part III Healing Touch

            We all are quite familiar with the physical exam, and what would a doctor’s visit be without a proper physical? The problem comes; however, when 1) we forget entirely about doing any form of physical exam and simply stick to questions regarding history and presenting symptoms 2) we walk through the motions, simply engaging the patient in what we may feel is only a necessity in terms of charting for the EMR or 3) (more relevant to healers in training like myself) in the midst of being so concerned about acquiring and practicing a “skill” we entirely remove ourselves from the reality that we are a human touching another human, whether it is for a specific purpose or not. While these 3 reasons are not exhaustive, they readily come to mind when I think about the pitfalls when approaching a physical exam within the context of the medical encounter.

          

          In the spirit of adapting language to modify our intentions and overcome cognitive biases, this is where I suggest replacing  “Physical Exam” with “Healing Touch.” Simply taking a moment to pause, breath and re-center myself with the intention of not only eliciting a potential sign towards pathology, but providing a healing human connection through touch has been critical for me during my medical school training. If anything, I realize that my actual physical exam technique is certainly not of the caliber of a family doctor with 30 years experience listening to hearts and lungs, so why not take the opportunity to truly provide a soothing touch? With both a resident and attending physician also conducting a physical exam on nearly all patients that I see in the hospital, I am not overly concerned that the patient is being inadequately cared for in terms of the physical examination.  Now, while I have specifically pointed out encounters from the medical student perspective, the truth is that all healers, those training and who have practiced for numerous years can stand to benefit from reframing their intentions when it comes to patient contact.

            Danielle Ofri of NYU School of Medicine and Bellevue Hospital has become one of my favorite authors and speakers within the medical field and it is no surprise that in July 2014 she wrote an article for the NY Times entitled “The Physical Exam as Refuge” that got more than a few gears churning in my head when it came to changing my approach to the physical exam. To put it succinctly, her article is pure magic, and I suggest to anyone willing to change his or her perspective on the physical exam to follow the link below to read her piece.

Ofri “The Physical Exam as Refuge”

http://well.blogs.nytimes.com//2014/07/10/the-physical-exam-as-refuge/

            Her primary point in the conclusion sums it up perfectly, “So while the utility of the physical exam for diagnosing illness may not be quite as refined as it once was (though certainly still quite useful), it has become a tool of a different sort, a refuge from the intrusion of technology, a moment of only touching and talking.” Ask anyone in medicine today and the first thing that most will complain about are EMR’s and the amount of time spent dictating notes or typing and sitting in front of a computer monster. Just this past week, during Pediatric Grand Rounds at UVa, our speaker spent the entire 60 minute lecture discussing how to go about tackling the monster that is EMR and modify our hospital workflows such that we can actually be more efficient and improve patient care. While this post is not focused on the technological modifications that we could implement to allow us to operate outside of the “monolithic EMR system,” we must realize and take any opportunity to engage our patients without involving a computer screen.

            To wrap up and bring this post to a hopefully cheery and more practical ending, I will share with you a recent patient encounter of mine that was precisely what I think of when it comes to “Healing Touch”. I was seeing a young 7 year old boy with Type 1 Diabetes in our Pediatric Endocrine/Diabetes clinic. The boy had some serious energy, yet was polite beyond imagination. It became quite clear as I started talking to this young boy that his enthusiasm for life was certainly not restrained by his chronic illness. From baseball to swimming, to playing adventure games outdoors, this little guy was living life to the fullest. In addition, he told me in the most genuine manner I have heard to date- including adolescents and young adults, that he wanted to be a doctor and go the UVa School of Medicine. So I said, “Well, if you want to be a doctor, how about we start your training right now?” I had already seen him playing with the otoscope and ophthalmoscope on the wall and clearly he wanted to have these tools of the trade in his hands. So I started with him and said, “We are going to do a head to toe exam and after I do each of my parts of the exam on you, you will get a chance to do some of the same things on me, how does that sound? Eager beyond belief, he was already lying upright on the table ready for me to look at his eyes, feel his neck and listen to his heart. Step by step, I went from looking at his pupils to shining a light up his nose and in his mouth to listening to his heart and lungs, and finally gently pressing to feel the pulses in his arms and legs. While I explained to him that he would have to have more training to look at someone’s ears and at the back of the eye, he was overjoyed to listen to my heart beat, feel my pulses and watch my pupils dilate with a shining light. It was by the far the most enjoyable “Physical Exam” I have performed during my training up to this point, and amazingly enough, likely the most accurate and effective. My heart had be stolen by this one little boy, and through the course of the visit, with the attending speaking with the mother and I engaging with the 7 year old patient, we had broken down, together, the barriers of EMR and the temptation to simply go through the motions of a physical or type endlessly into the computer aka: the pit of despair. “Healing Touch” is not just an optimistic expression for an approach to human contact, it is truly a manner of providing therapeutic relief to our patients that goes far beyond diagnostic relevance. And in the end, we all might find that, as doctors and medical students, we might just benefit from a little “Healing Touch” ourselves.