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.

The Abbott Way: Nourishing Review

Part II: Nourishing Review

            While I have targeted the Review of Systems to be replaced by the Nourishing Review, it is by no means a pure swap in terms of information. A comprehensive Hx/Life Story often can involve taking a ROS, however, I would like to suggest that from a holistic, functional perspective, we are an interconnected human organism and classifying signs and symptoms by individual systems only truly serves the purpose of complete documentation as well as the concern for potential malpractice suits by not addressing an underlying pathology. The fact that at any given time, one may be suffering from an illness that predominantly manifests as symptoms attributable to one system, doesn’t mean we should treat these symptoms in isolation or disregard the entirety of the human body. Our ever increasing understanding of the vast array of illnesses attributable to disrupted intestinal enterocyte integrity along with a disturbed intestinal microbiota reveals that isolating and attributing symptoms to single systems or anatomical locations is downright wrong.

            It is often said that we should treat the patient not the disease, but I think what is more apt is saying we should treat the human being not the pair of kidneys. In order to do this we must individualize our assessment and treatment and change our perspective on what can actually provide healing. To start, we can take 5 minutes to ask the patient a simple, yet incredibly personal question: What nourishes you? Now I’m not talking explicitly about the eggs and bacon you ate for breakfast, but rather about the people, places, events, sensory experiences, and activities that provide the happiness, the joy, the fun in your life. What can sometimes follow this question may be things like: chocolate cake, having a cold beer, laying in bed on a Saturday morning for hours, or gnawing on popcorn while binge-watching a show on Netflix. And while I most certainly can attest that these activities are probably incredibly enjoyable and provide hedonistic pleasure beyond typical day to day happenings: they are not what I would call “nourishing.” When trying to paint a picture of true nourishment I often describe the renewing flames to your internal fire: the energy that keeps your candle burning, the drive moving you to share your light with all those in your life. Hopefully it is very clear from this description that most likely chugging a Big Gulp Slurpee really isn’t nourishing, but spending a morning enjoying a cup of tea with a significant other while watching the sunrise probably is. Over the past month, I have recently embarked on creating my “Nourished By List” and I have been astounded by what I have found. Simply giving yourself the time and space to think about the things that truly bring you happiness and joy is amazing on its own right. And the process is continually evolving, dynamic and never complete. Sometimes we feel so pressured by our daily routine, we do not even get a chance to actually take the time to realize what it is that we love to do, who we love to be with, or where we love to be. Expectations abound in our society and upholding or obliging to these expectations can often lead to a complete loss of who we really are. Making a “Nourished By List” can provide you with the template to live a fulfilled life and stay true to your essential being. This list is your recipe for healing during any illness, regardless of what the drug prescription, chest x-ray or blood chemistry may say. 

            As a physician it is not my job to make you better by external means, it is simply my opportunity to engage in a healing journey that allows you to realize what it is that you should do to heal and return to a vital state of being. I’ll take a patient’s Nourishment List over a complete Family History and ROS any day, and best of all, I don’t have to spend the time asking yes or no questions- I can simply listen and allow the patient to construct this list all on his or her own. To me there is probably nothing more pleasing than engagement in purposeful thought followed by the realization of what it is I can and should be doing to live a happy and meaningful life. Okay, maybe subsequently doing a fulfilling activity or being with someone that nurtures my true happiness is even better, but you can’t get there without the silent contemplation beforehand, so in that case, we can all benefit and enjoy the mindful awareness that allows us to see how we can find our inner bliss.

The Abbott Way: The Life History

Part I: Life Story

              Rather than begin the conversation with the prodding question: “What brings you in today? or “Can you describe the pain you are having?” why not start with something different like “Tell me a little about yourself,” or if you are well acquainted already “What have you done since we last talked,” or even “What was it like growing up in…? While some people may look at you and simply say my throat hurts and I need some medication, most people when given the open-ended opportunity to share their life story become quite revealing, honest and overall quite happy. Some may even forget about their discomfort altogether during the recollection of playing capture the flag in elementary school, or sharing the wonders of a recent vacation. A History of Present Illness is overrated, if given the chance to hear a person’s life story first, we can much readily come to realize who and why the patient’s current symptoms are imparting suffering. The reality of illness is that it is entirely a subjective experience, yet we are focused only on objectifying symptoms, quantifying pain or categorizing a collection of symptoms into distinct syndromes. If I cannot understand which symptoms are disruptive to the patient, how the patient’s experience of the symptoms is leading to impaired well-being and most importantly, how a patient’s mental and emotional relationship to his or her current malady is ultimately manifesting as his or her experience of the illness, I will never successfully provide healing, This may come as a shock, but just because Sudafed is used as nasal decongestant, doesn’t mean I should prescribe it or suggest its use to someone presenting with such a complaint. What if an individual’s fundamental issue is spending too much time in a crowded, moldy office building with inadequate ventilation, or the individual has food intolerances to dairy products due to underling intestinal permeability, yet they do not experience overt abdominal bloating or pain, but are exhibiting systemic signs of congestion and inflammation? And what if an individual has had chronic joint pain for the last 20 years and only recently developed a common cold; if you decide to solely target treatment to the osteoarthritis, and provide some degree of relief, yet do nothing for the viral illness, you might find that the patient loves you eternally for their newfound ability to exercise in minimal pain even if there sinuses are still as congested as the Hampton Roads Bridge Tunnel. So instead of taking a formal history with a focus on a chief complaint, start with a life history and you may be surprised to find you may find out about grandma Ida’s heart attack and your patient’s past history of alcohol abuse all the same as if you had asked them in as laundry list. Many current physicians can agree that most illness and disease can be diagnosed by a thorough history in lieu of imaging and laboratory tests. I would argue, however, that without establishing a degree of comfort and trust by obtaining a life story from your patient, who is to say what they tell you is truthful, accurate or complete? Gaining trust is essential to practicing effective medicine, and while a thorough history most certainly can diagnose almost any condition, only by connecting to a patient and elucidating a life story can you most certainly provide a means to heal.

The Abbott Way: A Replacement for the Current Patient/Doctor Interaction

            Practicing medicine is rather simple when you break it down into the relevant tasks a physician is expected to perform. There is taking a complete history of the patient’s current complaints, past medical history, social history including alcohol and drugs, past surgical history, pertinent family history, allergies and current medications. After taking a thorough history, one will usually then conduct a Review of Systems asking straightforward questions for all the body systems in order to elucidate possible issues that the patient may have “forgotten about” due to the pressing nature of the chief complaint. This is then often followed by an assessment of vital signs and finally by the ritualistic physical exam. While this may be the end of the formal patient and doctor encounter, it is by no means the end of a physician’s responsibilities. Following this interaction, a doctor may begin documentation into an electronic health record- if not conducted during the interaction itself, verbal documentation of one’s decision making as part of the “work-up” for the patient’s present complaints, a plan for further diagnostic imaging and laboratory studies to help narrow the list of possible diagnoses, and lastly the development of a final assessment and plan for treatment. When conducted in the academic hospital setting, a formal presentation to other team members regarding the course of therapy is often conducted as well. Following all of these formal processes, the doctor can then return to discuss and initiate a treatment plan with the patient, provide education for self-guided therapy and prescribe drugs or additional medicines. There it is, a doctor’s duties in a paragraph, and yet the process of obtaining the skills to complete all of these tasks effectively takes an entire lifetime. And as I will argue, if one simply follows the template above, I don’t think we will ever reach the ultimate goal of practicing medicine: providing vitality and well-being to all patients who seek our help.

            While I have spent the entirety of this post describing the current formal, medical interaction, I have realized through my training that despite that fact that this framework has provided a reasonable means for treating disease within the Western Medicine system,  and the reality that this type of interaction has been performed for years with relative success, doesn’t mean we can’t improve or even more shockingly, that this method may simply be inadequate for relieving most suffering. While at this point in my training as a third year medical student, I by no means can provide the array of care conducted at the hospital by nurses, residents, attendings, or other staff, but what if we changed the rules of the game and redefined what it meant to treat illness. While my years of practicing medicine upon completion of my training are still years off, I feel obligated to share a different method for approaching the patient encounter to all those currently healing the sick, for as I see it, you cannot change a system, you can only provide a different perspective that allows those around you to choose for themselves what is worth the time and effort. Nothing is more precious than an individual’s time so why not use your 15-minute encounter for something meaningful, even if it means disregarding the ROS, eliminating electronic documentation or completely ignoring medication reconciliation.

             So in a four-part blog series to follow, I will provide a potential substitute for the History, ROS, Physical Exam, and Treatment. For the sake of humor I will call it the Abbott Way: A Life Story, A Nourishing Review, A Healing Touch and A Goal-Directed Acton Plan. While each of these practices can be implemented separately as part of a physician-patient interaction, I whole-heartedly believe and plan to utilize all 4 as part of my normal encounters with people everyday. To be honest, I think I would be doing a disservice if my medical care did not involve all four of these practices. After finishing the series, I hope that you may share this same view.