WHOLE HEALTH: CHANGE THE CONVERSATIONprojects.hsl.wisc.edu/SERVICE/modules/3/M3_EO_Taking_Action.pdf · WHOLE HEALTH: CHANGE THE CONVERSATION Advancing Skills in the Delivery of Personalized,

WHOLE HEALTH: CHANGE THE CONVERSATION

Advancing Skills in the Delivery of Personalized, Proactive, Patient-Driven Care

This document has been written for clinicians. The content was developed by the Integrative Medicine

Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public

Health in cooperation with Pacific Institute for Research and Evaluation, under contract to the Office of

Patient Centered Care and Cultural Transformation, Veterans Health Administration.

Information is organized according to the diagram above, the Components of Proactive Health and Well-Being.

While conventional treatments may be covered to some degree, the focus is on other areas of Whole Health

that are less likely to be covered elsewhere and may be less familiar to most readers. There is no intention to

dismiss what conventional care has to offer. Rather, you are encouraged to learn more about other

approaches and how they may be used to complement conventional care. The ultimate decision to use a

given approach should be based on many factors, including patient preferences, clinician comfort level,

efficacy data, safety, and accessibility. No one approach is right for everyone; personalizing care is of

fundamental importance.

Taking Action: How to Write a Personal Health Plan Educational Overview

VHA Office of Patient Centered Care and Cultural Transformation Page 1 of 28

WHOLE HEALTH: CHANGE THE CONVERSATION Taking Action: How to Write a Personal Health Plan

Educational Overview The real voyage of discovery consists not in seeking new landscapes but in having new eyes.

—Marcel Proust

The Personal Health Plan is a dynamic document, developed jointly between the Veteran and their health care team. The provider, another member of the health care team, or the integrative health coach may be the primary person that drives this process. Information from the intake form and personal assessment tool forms the basis for developing a proactive, focused plan for the Veteran’s path forward. Not only are the traditional health issues reviewed, but the Veteran’s values and personal vision of living life fully are discussed. The plan may include elements from all areas of the Circle of Health, and notes which are the highest priorities. The prioritization is accomplished through an honest, open dialogue between the Veteran, the provider, and the health care team.1

In the Gathering Information module, you learned how to collect information about the many different components of Whole Health. Now it is time to explore how you can use that information to create a Personal Health Plan (PHP).* To illustrate this process, recall Bob’s vignette. Bob is a taciturn 68-year-old Veteran with multiple chronic health problems, whose mission is to be able to fully participate in his granddaughter’s wedding and to do more nature photography. In the last module, you reviewed Bob’s Personal Health Inventory (PHI) in depth. Now imagine you are having your in-person visit with him—your Whole Health conversation. You have asked him a number of questions built on what you read in his PHI, including many of the Whole Health–focused questions listed in the Gathering Information module.

* Unlike the PHI, the VA does not have a set PHP at this time. Offered in this curriculum is an example of a PHP for our vignette patient, Bob, as well as a draft PHP template for consideration, editing, and use.

WHOLE HEALTH: CHANGE THE CONVERSATION Educational Overview: Taking Action

VHA Office of Patient Centered Care and Cultural Transformation

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Now it is time to make good use of all that information. The following steps can guide this process: 1. Synthesize all of the data you have collected. This data also includes what you have

learned about Bob through the PHI as well as other means, including: Medical records The physical exam Your observations of body language Communications with other members of his team, including any family members or

friends who accompany him to the visit Your instincts about him; your intuitive sense of him as a person (This is where the

“art of medicine” comes in.) 2. Prioritize next steps. This can be tricky when someone has a long list of chronic

illnesses like Bob does, but Bob has already helped with that to some degree through his answers on the PHI.

3. Collaborate with Bob on developing the plan. Whole Health care is patient-driven. It is

important to be certain that you have Bob’s buy-in. If you make suggestions that Bob is not interested in following, you will be wasting your time.

4. Arrange follow-up. Who else needs to see Bob? Who else will be on his team along

with you? How should follow-up visits be timed? Remember, this is not easy based on the way many of us are used to practicing.

Learning Objectives The rest of this module is essentially an online guide for writing Personal Health Plans. It is organized around nine general guidelines that will help you through the plan-writing process. Review these guidelines in any order you like. There are more specific guidelines highlighted in bold text within each of the sections. Several of the guidelines contain links to additional clinical tools designed to take the process even farther for you, if you want. Suggestions from people who have been writing health plans for years are scattered throughout this guide as well.

You don’t write a health plan alone. Patients will help you. The PHI is designed to encourage people to spell out what they believe they need to complete their health mission. The professional team (be it a PACT, a PAC teamlet, or the group of other clinicians who see Bob) can also be helpful. Health plans are always in evolution, and they involve multiple people. They are the product of a group effort.



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The central importance of the PHP is underscored by the fact that the vast majority of this course’s content was developed to provide you with tools, skills, and suggestions to help you to create personalized, meaningful, and useful PHPs. After completing this module, you will be able to:

Write a PHP for a patient List four steps to implementing a PHP List nine key guidelines that can help you with creating PHPs Define how belief systems—both the patient’s and the clinician’s—inform Whole

Health care Identify three essential conditions that must be present for a health behavior to

occur Provide an overview of how practical concerns, including cost, health literacy,

time, accessibility of certain treatments, and the Maslow Hierarchy of Needs influence care

Recognize ways to work effectively with time constraints during a patient visit Recognize that accentuating the positive can lead to better outcomes Develop your own template for writing PHPs Strategize about how to choose and appropriately utilize additional clinical

tools to promote Whole Health As always, you must discern for yourself how relevant these guidelines are for you and your practice. No doubt you already use some of the tricks and tips that are discussed. How can you push yourself a little more? The intent is to make it easy, interesting, and enjoyable for you to create PHPs for patients like Bob and, should you so choose, for yourself as well. Ideally (and many of us creating PHPs find this to be the case), writing a PHP will begin to feel more like a creative pursuit—an artistic undertaking—than another task on the to-do list.

The value of experience is not in seeing much but in seeing wisely. —William Osler, MD



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The following guidelines will help you learn more about writing PHPs.

Key Guidelines for Creating Personalized Health Plans

1. Listen! 2. Understand others’ perspectives… and your own 3. Minimize “nonadherence” 4. Work with time constraints effectively 5. Accentuate the positive 6. Develop and follow a template 7. Fill your toolbox, and choose the best tools for the job 8. Compare notes with your colleagues 9. Create your own Personal Health Plan along the way

1. Listen! Part of personalizing care involves gaining a real sense of a person. Often patients will comment during a Whole Health visit that, “Gosh, I have never had a doctor (or nurse, or counselor, etc.) listen to me like this before.” That, in and of itself, may contribute significantly to Whole Health. That, in and of itself, is a conversation changer. The importance of listening may seem self-evident, but studies indicate that clinicians have room for improvement. For example, an often-cited 1984 study by Beckman and Frankel found that the average doctor interrupts a patient at the beginning of a visit within 18 seconds of the time the patient first starts talking.2 A follow-up study 18 years later found that family physicians redirected their patients 23 seconds after they began to explain the reason for their visit.3 This may sound simple, or even trite, but you will find, if you mindfully observe yourself during a Whole Health visit, that it is very tempting to start talking about the plan early in the visit. Be strong! You might set a timeframe for yourself, such as waiting until the last 25% of the visit before you discuss specific recommendations from your end. Within reason, of course, and if things become repetitive, it is time to shift gears. When clinicians hear about the study findings related to doctors interrupting patients, they often (justifiably) point out that, due to time constraints, interruptions are often a necessary evil. However, this may not be as much of a problem as we tend to assume. In a Swiss study by Langewitz et al., a group of internists were asked not to interrupt after

The first step to allow healing to unfold is to listen.

The longer you let patients share, the easier it will be to write the Personal Health Plan.



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asking the question, “What brings you to the clinic today?” during 335 patient encounters.3 The study indicated that the average length of time that patients spoke was 92 seconds, and the median was 59 seconds. Seventy-seven percent finished their statement in 2 minutes, and only 2% (we know who they are!) spoke more than 5 uninterrupted minutes. In every single situation, the physicians reported that the information they collected was relevant. One of the first things to remember, as you construct a PHP, is that doing so does not require you to be overly directive. Do not overdo it with driving the conversation. As Epictetus put it, “We have two ears and one mouth so we can listen twice as much as we speak.” The Chinese character for “listen” captures this nicely. It includes five symbols—ear, eye, heart, king, and undivided attention.

The true leader—the “kingly one”—listens through the senses and from the heart as well, with undivided attention. Return to the list of key guidelines. 2. Understand others’ perspectives … and your own

The best doctors have mastered the skill of bringing several different attributes together. Whenever possible, the doctor must know the scientific details related to the understanding, recognition, and treatment of disease. When adequate information is not available, the good physician, who is always a good observer, will make appropriate decisions with inadequate information (the art of medicine).4

There are many different sources of knowledge, and there is great variation from person to person as far as how they determine if something is true or not. We become very attached to our truths, and it is human nature to experience strong emotions (even fight or flight), if

Ear

Eye

Undivided Attention

Heart King



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those truths are questioned. Think of all the conflicts that have arisen throughout human history over differences related to belief systems. Let’s take a mindful awareness moment. Mindful Awareness Moment

How Do You Know?

Take a moment and think of a statement you know to be true. Some examples:

The sky is blue. Beethoven is a great composer. Avoid touching the pancreas during surgery if at all possible.

Now take a moment and ask yourself a series of questions:

1. How do you know this statement is true? Where does that information come from? Did someone else tell you? Did you read it somewhere? Did you learn it through your senses?

2. Suppose someone walked up to you and told you they disagreed. What would your response be? Would you feel any emotions? Would you want to argue with them? Why would you have that particular response?

The next time you have a conversation with a patient, try to note moments where the person expresses a belief that you do or do not agree with. What do you notice? Do you feel an urge to correct them? How do you respond if they question your authority or knowledge?

When we ponder these issues, we are entering the realm of epistemology. Unlike the many other ‘–ologies’ we normally encounter in health care, like neur-ology, gynec-ology, otolaryng-ology, etc., it is a branch of philosophy. (There are no “epistems” to study in the human body, at least that we know of.) Epistemology involves questioning what knowledge is and how we decide if something is true or not. And when it comes to patient-clinician encounters, thinking about this issue is fundamental. Let’s use Bob’s meeting with you, his clinician, as an example. As noted in the description of Bob in the introductory module:

You are not looking forward to seeing Bob. Even though he does not talk much, he seems to radiate a sense of disapproval of you and your team. You feel like you have reached the limits of what you can offer him as far as medications. He does not usually follow through with what you suggest anyway. In fact, he often does research on the Internet or reads mailings from dietary supplement companies and then tries treatments that you don’t know much about.



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This brings up another important tip:

Patients have more access to information than ever before. We, as clinicians, are no longer the keepers of “secret wisdom.” As of 2013, 81% of U.S. adults were using the Internet. Of those using the internet, 59% of American adults reported searching for health information online within the past year, and 35% say they have gone online to try to make a diagnosis for themselves or someone else.5 Beyond the Internet, there are many other sources of information out there. We can learn by reading facts, making observations, having direct experiences, and being taught by others. We can also learn through being part of a culture or religious group and through stories and narratives. Many people also trust in the knowing that comes through instinct, intuition, or flashes of insight. If a clinician derives truth through one perspective, and the patient derives it from another, there is the potential for a clash between the two. An important part of writing PHPs is being able to collaborate so that neither one has to compromise too much in terms of what he or she believes. An effective PHP is one that respects Bob’s belief system and sources of truth and yours as well. Say Bob has been trying a local chiropractor for his back pain. Perhaps he is a strong believer in its benefits for his back pain, but you are uncertain. How do you handle this discrepancy?

Consider the following whenever a difference in opinion (epistemological clash) like this arises.

Be clear on why the other person has made a particular choice. What informed Bob’s choice to see a chiropractor? Did one help him or a loved one in the past? Does he know other people who have had success with them? Did he read about the benefits of chiropractic somewhere?

Know your own thoughts and feelings about a particular issue. If you are feeling strong emotions around differences in beliefs between yourself and your patient, it is important to explore why. Some ways of knowing are based on logic and rationality, but how we feel about them may not be. We have all seen discussions of appropriate treatments become heated.

Share what you know about the therapy, test, etc. Educating and offering your experience is a main reason why most people come to see you, after all.

Always find out where your patients are getting their information.

Remember that the scientific method, evidence-based medicine, and your experience, which may be very important sources of information for you, might not be as important to patients as other ways of knowing.



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Consider whether you would suggest alternatives to what your patient is doing or may want to do, and think about how you would bring up those other options in the conversation.

Of course, being understanding of a person’s beliefs and why he or she has them does not mean that you compromise your own. Share your beliefs, but recognize that personalized care is also about respecting where a person is coming from, as well as recommending the treatments you think are best.

The ordinary patient goes to his doctor because he is in pain or some other discomfort and wants to be comfortable again; he is not in pursuit of the ideal of health in any direct sense. The doctor on the other hand wants to discover the pathological condition and control it if he can. The two are thus to some degree at cross purposes from the first, and unless the affair is brought to an early and happy conclusion, this divergence of aims is likely to become more and more serious as the case goes on.

—Wilfred Batten Lewis Trotter For more information, see the How Do You Know That? Epistemology and Health clinical tool.

Return to the list of key guidelines.

3. Minimize “nonadherence” It is a rookie mistake. A clinician writes one of his or her first health plans, and it is a work of beauty. It recommends anything and everything that might be helpful for each of the circles within the Components of Proactive Health and Well-Being diagram. It expertly draws in all the available evidence. In fact, it is so well-meaning that it brings tears to one’s eyes. And the patient ends up not following it. We all know this happens. Let us talk about some of the main reasons why. According to Michie and colleagues, there are three essential conditions that must be present for a health behavior to occur.6 Most of the research in the area of patient nonadherence centers around nonadherence to taking medications or nonadherence to following a treatment after a given diagnosis has been made. (By the way, nonadherence is preferred over the word “noncompliance,” which has negative—and paternalistic—implications.) It is disturbing to note that rates of

Motivation, opportunity, and capability must be considered when you are making recommendations to patients.



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nonadherence to medication recommendations are as high as 20%-50%.7,8 Fortunately, an important way to improve adherence is to individualize care, which is a fundamental piece of any Whole Health visit.9 However, just as is the case for medications, nonadherence to recommendations made in Whole Health PHPs is a potential challenge. Here are some of the most common reasons why people don’t adhere to the recommendations in their health plans:10

Cost While times are changing and coverage is broadening to include some therapies and approaches that were not covered before, cost remains an issue. That is especially true for people who want to use certain complementary/integrative modalities (CIM). Even if you think “Therapy X” is ideal, many Veterans will not follow through with said therapy if the VA does not pay for it. In terms of Bob, the patient in our vignette, we may have more luck because he has shown a history of paying out-of-pocket to try less conventional approaches.

Accessibility

Even if something is covered, it has to be accessible. It makes no sense to recommend a specific form of cognitive behavioral therapy for sleep, for instance, if there is no therapist in the area who can offer it to a patient, or if the wait time to see someone would be months. Similarly, you can’t suggest a mindfulness class if there is no one around who can teach it. A person must also have transportation to visits arranged, and if this is a challenge, or if they already must make many health visits in a given week, they may not follow through.

Health conditions

Certain health conditions can limit adherence as well. There are many of these, but the biggest challenges are the “3 D’s”:

o Depression11 o Drug and alcohol abuse12 o Dementia13

Being in denial, while not a formal diagnosis per se, can also limit adherence to a plan.9

Culture Focusing on personalized care will help you and your teammates to learn what these issues might be and how best to pursue them with cultural humility. For more on cultural humility, see Georgetown’s National Center for Cultural Competence website. Their clinician self-assessment tool can be found at http://nccc.georgetown.edu/resources/assessments.html.

http://nccc.georgetown.edu/resources/assessments.html



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Health literacy

Health literacy is a complex concept, which has been defined as “...the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”14 A study of 502 Veterans, ranging in age from 22 to 82, found low, marginal, and adequate health literacy in 29%, 26%, and 45% of the Veterans, respectively.15 When you make a recommendation, ensure that it is understood. Ask your patients to explain the elements of their health plans in their own words.

Hierarchy of needs

Maslow presented his Hierarchy of Needs in 1943.16 The needs at the bottom of the pyramid are more basic and more necessary for survival in the short term than the items at the top.

In writing a PHP, keep the hierarchy in mind. If Bob is homeless or unable to get food, it will be quite difficult for him focus on healthy relationships, personal development, or meaning and purpose.

Everybody gets so much information all day long that they lose their common sense.

—Gertrude Stein Return to the list of key guidelines.



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4. Work with time constraints effectively Inevitably (and understandably), one of the first questions clinicians ask when they take the in-person Whole Health course is, “How much more time will this take me?” This is understandable because it is difficult to see patients, serve on committees, deal with reminders and metrics, and still manage to find a good balance between work and other aspects of life, including self-care. In the scenario for Bob, you have had a busy day and are already behind. It would be naïve to think that under those circumstances, a clinician could review a PHI in depth or create an elaborate PHP. Clinicians who are rushed are less likely to offer personalized, proactive, and patient-driven care.17 It is known that physicians with high-volume practices and shorter visit lengths prescribe more drugs. Shorter interviews contain less prevention and health-promotion activity as well. That said, physicians with high-volume practices schedule more follow-up visits. There is a mindful awareness piece to this. You must be able to pause and recognize when you are reaching for a prescription pad or relying on a “quick fix” because of the time pressures you are under. What if there were other, equally efficient actions you could take that allowed you to bring Whole Health more into the equation? How much time one can give to a Whole Health visit will vary from clinician to clinician. Of course, it would be ideal to have an hour or more for a Whole Health visit. However, even in 5-10 minutes in the emergency department or during an acute care visit, it is possible to offer a few quick suggestions. And if a patient is a part of a team with members who communicate well with each other, Whole Health care can be a group effort, and that saves time for any given individual clinician as well. Imagine if Bob had a health coach you could turn him over to, to work out the details of his plan and help him follow through with action steps and goals.

Here are some suggestions (based on hard-won experience) that we recommend you keep in mind:

Set the agenda Set the agenda right from the start of the visit. The average patient has three concerns to address during a primary care visit, despite the fact that he or she is often asked to identify just one when the visit begins. It is worth it to check early on—not when your hand is on the door—what your patient’s concerns are for the day. Some clinicians will set a three-concern limit with their questions. As a 2007 study explored in detail,18 by simply asking the question, “Is there something else?”

Whole Health is much more a matter of perspective than a matter of how much time is available. “Changing the conversation” need not be synonymous with “changing the length of the conversation.” Simply shifting the focus of the visit—what you choose to talk about—can change everything.



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versus “Is there anything else?” unmet concerns were decreased by 78%, which no doubt correlated with greater patient satisfaction with the visit.

Although we all dread long written lists, they do have a number of advantages. First, they are testimony that the patient is engaged in his or her health care and in the visit, since the patient has taken some time to think ahead and write down his or her concerns. Second, a list makes it easier to negotiate what is reasonable to cover at this particular visit. You don’t have to spend time uncovering the patient’s agenda because the patient has penned it out for you. In my personal experience, people with written lists rarely fail to identify otherwise hidden concerns. Finally, the list provides an opportunity to compliment the patient on his or her efforts, which helps to build your relationship. The conversation could start this way: “I see you have a list today. I am pleased you have thought ahead about what we might cover at our appointment. Let’s take a minute to look at the list together and make sure we cover the most important items today.19

Prioritize Come up with just a few priorities to focus on first in the health plan. Yes, you want patients to achieve their missions, and yes, there are likely at least 10 things you could suggest right now to help them do it, but it is okay to introduce these gradually. People often do better if you change one variable at a time in their treatment. Which of those 10 things rise to the top of your list of priorities? You can even choose just that “one thing” that strikes you and the patient as most important. For Bob, it may be nutrition or physical activity.

Take small steps

Research tells us that even small steps can bring about significant health improvements. For example:

o A 2%-5% weight loss can significantly reduce cardiovascular risk and risk of developing diabetes. 20

o A 5 mmHg drop in blood pressure makes a significant difference in outcomes.18

o 15-30 minutes of brisk walking can lower heart disease risk by 10%.18 o When the major health protective behaviors are evaluated, few Americans

are ever found to be following them. Only 3% of American adults meet the four key goals of being a nonsmoker, being physically active, being at a healthy weight, and eating five-plus servings of fruits and vegetables a day.21 Picking one of those four items alone can make a big difference in overall health.

It is okay to keep the plan simple. Set people up for success. It is also okay to make it very elaborate, if you think that is what someone needs; again, it is about



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personalizing the scope of the health plan as much as you personalize the recommendations it contains. Research suggests that changing just one behavior may have a positive influence on many others,22 so don’t underestimate the power of even the shortest PHPs.

Use SMART goals “SMART” stands for specific, measurable, action oriented, realistic, and timed. SMART goals are featured heavily in many VA programs. For a quick overview, see the SMART Goals section of the El Paso VA Health Care System website: http://www.elpaso.va.gov/ELPASO/features/SMART_Goals.asp.

Make good use of follow-up visits

Consider choosing a different component of Whole Health each time. It can even become a routine part of a physical examination. Continuity makes a significant contribution to a therapeutic relationship,23 as was noted in the module Gathering Information.

Make use of shortcuts

Clinical tools, patient handouts, and insertable text for electronic, medical record–generated patient information can all help save time.

Take advantage of the team approach

You are right; you cannot and should not try to cover every area of the Components of Proactive Health and Well-Being in one visit, unless you have a lot of time. One person’s Whole Health care is not a solo endeavor for any one clinician, even if you happen to be the person who knows the patient best and sees her or him most often. Outline the main parts of the PHP, then have others on your team teach the patient more about tools that can be used. For example, you could tell Bob you would like him to learn some breathing exercises, but then you can have your medical assistant teach him how to do them and provide handouts or other readings to support his learning.

http://www.elpaso.va.gov/ELPASO/features/SMART_Goals.asp



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Speaking from experience, we can tell you that it is entirely possible to complete a 15-minute visit and feel that Whole Health was addressed well. Knowing the patient well streamlines things, as does having great communication with the rest of the patient’s team.


The 5-Minute Health Plan

1. Take one minute to review Bob’s Personal Health Inventory. What is most salient to you? What does he seem to care about most?

2. Take one minute to think about Bob’s mission. In one sentence, how would you

summarize it? 3. Now, with the mission statement in mind, spend just three minutes, writing out

the top three suggestions you would make for Bob. Notice your thought process as you write those suggestions.

o How did you decide on priorities? o Were your choices based on areas you feel you know the most

about? o Were they based on your knowledge of the research, your

instincts, or some combination of the two? o What other factors came into play?

Consider your beliefs about how you spend time in your practice. Do you assume that the amount of time you spend always correlates with the quality of the visit/conversation?

You have just created a health plan in just five minutes!

4. Consider how you would discuss the plan with Bob.

Recognizing that Bob (and perhaps family and friends) would weigh in on the content of the plan as well, how can you most efficiently discuss the plan you have created?

If you were pressed for time, how might you use handouts, reading materials, referrals, or the assistance of others in your clinic to streamline the planning process?



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5. Accentuate the positive The findings of this investigation show that there is a point in being positive: patients who present with minor illness show greater satisfaction and are more likely to have recovered from their illness within two weeks if they receive a positive rather than a negative consultation.24

We are trained, as mentioned in previous modules, to find the problem and fix it. One important aspect of Whole Health is to be sure to take time to look for what is right as well. Focusing on the positive is an important emphasis of the Personal Health Inventory.

The Aspirations Model In the introduction to the in-person part of the Whole Health: Change the Conversation course, one of the first concepts that is introduced after the Components of Proactive Health and Well-Being and the 3 P’s (personalized, proactive, patient-driven care) is the Aspirations Model. The Aspirations Model was created by the Institute for Alternative Futures (http://altfutures.com/).

Reprinted with permission from Alternative Futures Institute25

The Institute for Alternative Futures encourages various groups to use their vision of the future to change their approach in the present. The right side of the illustration represents an all-too-common way that we might experience some part of our lives, be it our health, our home environment, or our work. We play a defensive game, reacting over and over again to circumstances we are beset by, until we feel trapped like a hamster on a wheel. This can lead to a sense of disempowerment and weariness (the “exhaust cloud”). Bob, our patient, is at a high risk for feeling this, given that he has so many different chronic health issues.

http://altfutures.com/



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Alternatively, it is possible to focus on our aspirations—where we would like to be—and to base our day-to-day choices and actions on those aspirations. We may ask mindfully, at any given moment, how much our actions in the present are leading us to our desired outcomes. This can involve not only responding to circumstances, but also shifting behaviors. With a clear goal in mind, with the freedom to dream and aspire to something more, a person can experience change. It works beyond the patient level too; if we, as clinicians, focus on our aspirations, our experience of our work can change, and the system may even change too.

Collaborating with patients to create their mission statement is one way to focus on aspirations. There is something heart-warming about doing everything one does for Bob’s care because we want to support his being able to escort his granddaughter down the aisle at her wedding.

Appreciative inquiry and positive psychology When we teach integrative medicine fellows to construct health plans, we always ask that they include a section early in their plan that focuses on what a given patient is doing right. Here is how this section might read for Bob: Bob, before we launch into some suggestions of other things you can do to improve your health, I want to take just a moment to acknowledge all that you are already doing. I appreciate that you are exploring different options online, and I look forward to discussing what you find there with you, hopefully giving you some useful advice based on my other patients’ experiences. I am struck by the importance of your relationships with your family and how clearly this shines through in your PHI as you describe helping your widowed daughter raise your grandchildren. Even if there are times where the only positive thing you can say is, “Thanks for taking the time to show up,” that is something. Who knows how much time and energy a person might have invested simply to come in and see you?

Always take a moment to ask… Why are we doing this work in the first place? Why does the conversation matter? What does the patient want his or her healing for?

Always take a moment to voice to patients what they are doing well and what they have working in their favor. This improves patient outcomes.



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Focusing on strengths is the foundation for appreciative inquiry in the world of management theory. Like the Aspirations Model, appreciative inquiry focuses on what is going right, on assets. It draws from what is positive to support Whole Health and has the potential to revolutionize how we care for patients.26-28

This approach is also at the core of positive psychology, which was introduced as an area of psychology in 2000.

The field of positive psychology is about valued subjective experiences: well-being, contentment, and satisfaction (in the past); hope and optimism (for the future); and flow and happiness (in the present). At the individual level, it is about positive individual traits: the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future mindedness, spirituality, high talent, and wisdom. At the group level, it is about the civic virtues and the institutions that move individuals toward better citizenship: responsibility, nurturance, altruism, civility, moderation, tolerance, and work ethic.29

A 2013 meta-analysis of 39 studies with 6,139 participants concluded that positive psychology interventions led to improvements in subjective well-being and psychological well-being that, while small, were both significant and sustainable.30 Specifically, benefit was found in the reduction of depressive symptoms. More studies are needed, but in general, there seems to be no harm associated with positive psychology interventions.

Optimism

Optimism is one important ingredient tied into positive psychology. Optimism reflects the extent to which people expect, in general, that their futures will be positive. Higher levels of optimism correlate with the following:31

o Better subjective well-being in times of adversity o Higher levels of engagement and less avoidance or disengagement o Taking more steps to protect one’s health o Better overall physical health o Better success with relationships o Higher income through persistence with education

In sum, the behavioral patterns of optimists appear to provide models of living for others to learn from, and we know that optimism, in general, improves health outcomes.31

—CS Carver

If you see someone—even just intermittently—it is worth it to celebrate successes before moving onto what else he or she “should do.”



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At its best, the treatment plan becomes a map for healing that the [clinician] and the patient can navigate together… In so doing, we remind our patients that we have heard their story and have a sense of who they are and what is most important to them. Finally, the plan serves the patient as a tangible reminder of our belief that healing is possible.32

Gratitude Gratitude is not only the greatest of virtues, but the parent of all others.

—Cicero

Gratitude, which is associated with habitually “…focusing on and appreciating the positive aspects of life,” is also worth considering in a PHP when one is attempting to focus on the positive aspects of a person’s life. Gratitude is also associated with a number of benefits, including:33,34

o Higher levels of alertness, determination, attentiveness, vitality, and enthusiasm

o Increased time spent exercising o More sleep that is of better quality o Fewer physical symptoms, including headaches, coughing, and pain o Better immunity

For more information on these different areas, see the module on Personal Development and its related clinical tools.

Return to the list of key guidelines. 6. Develop and follow a template Personal Health Plans come in many forms. When integrative medicine fellows first learn to write PHPs, they are very elaborate. The fellow may make a few initial suggestions during the visit for the patient to try right away, but most of the plan is created after the visit. Each patient receives a detailed, personalized document that is organized around a template similar to the Components of Proactive Health and Well-Being. Of course writing such a plan takes time. As fellows gain more experience, the health plan writing process becomes faster. Experienced clinicians write the health plan “on the fly” as the visit unfolds, so that they can give a completed plan to the patient by the end of the visit. Doing so requires a clinician to rely on various resources that can accompany the different suggestions—handouts, websites, and other suggested reading. In the University of Wisconsin Integrative Primary Care and Consultation Clinics, we have a number of shortcut phrases we can type into our electronic medical record to call up handouts or other information that can be printed out for patients at the end of their visit.

A reasonable amount of optimism can improve the quality of care we offer. Simply saying, “I am optimistic that you will get better” in a PHP may have a significant impact.



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During their training, fellows generate their own health plan templates. The template allows them to organize their thinking and recommendations during the course of a patient visit. You are encouraged to create your own template, using the Components of Proactive Health and Well-Being. Remember, for many visits, especially with experience, you may find the outline for a PHP can be as simple as

Mission: XXXXX Recommendation 1. XXXXX Recommendation 2. XXXXX Recommendation 3. XXXXX

Several resources exist to guide you. To support you in this process, we offer a walkthrough of the process of creating a PHP for our patient, Bob. We are using the same template for writing a PHP that is provided in the in-person part of this course, so it may look familiar.

Access Draft Template for a Personal Health Plan. Refresh your memory about what Bob wrote in his PHI. Finally, see Bob’s health plan, with comments about how and why it was written as

it was.

TIPS FROM YOUR COLLEAGUES

I encourage you to create a template for health plans you write. You may not always write about every item that it contains, but it helps you keep your thinking organized during visits with patients. It is a lot like having a format to follow when you take a history and do a physical on someone. I run through the various areas of the Circle of Health:

1. Mission 2. Me at the center (I ask what makes the person unique—how will I remember him

or her?) 3. The eight self-care approaches 4. Conventional and complementary approaches. I actually break this down into

preventive care needs, testing, medications, and other conventional treatments, and then complementary approaches. I even break down the complementary approaches, just so I can make sure I think about as many possibilities as I can. I use the five classifications of complementary and alternative medicine created by the National Institutes of Health (NIH): (1) Whole Systems Therapies, (2) Dietary Supplements, (3) Body-Based Therapies, (4) Energy Medicine, and (5) Mind-Body Approaches. Usually, I do not spend much time on mind-body approaches because they are already covered under “Power of the Mind” in the eight self-care approaches.

5. Community (I also think about the person’s care team within this category.) 6. Follow-up and referrals

—Adam, Integrative Medicine MD and Fellowship Director



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Of course, the Circle of Health is itself a template one can follow. You might simply want to keep it somewhere you can see during a visit. Do not forget about the “circle equation” beneath the larger circle, which is just as important as the rest of the diagram:

Return to the list of key guidelines. 7. Fill your toolbox, and choose the best tools for the job

We can “change the conversation” with patients in many different ways. Identifying someone’s health mission, organizing the conversation around the Circle of Health, helping to ensure good self-care, and invoking mindful awareness can all be important conversation changers. Philosophical shifts—shifts in the way we think about various health issues—are fundamental to the adoption of the Whole Health approach, and what we choose to incorporate into health plans are informed by those changes in perspectives. As William James said, “Genius, in truth, means little more than the faculty of perceiving in an unhabitual way.” When tailored appropriately for a given patient, health plans truly can be works of genius. Of course some of what is added into a Personal Health Plan is going to be similar to what goes into any other plan of care. Conventional therapies are an important part of the Circle of Health, and most clinicians are very attuned to methods for preventing illness and promoting health. That said, there are options—options that might be classified as “integrative medicine tools”—that also can prove helpful and may be less familiar to many clinicians. A significant proportion of the materials offered in this curriculum are clinical tools, skill sets, and therapeutic approaches that are intended to give you practical suggestions and


I have to remind myself often that the most valuable thing I bring to patients is my time and concern for their health. The rest seems to fall into place. Certainly with time, growing familiarity with supplements and herbs and other healing modalities helps. This speeds up the process, with less time spent on reviewing literature and exploring integrative medicine alternatives. It all comes back to having more time to spend with patients and greater attention to detail and the uniqueness each person brings to the table.

—Rob, Integrative Medicine MD



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techniques you can pass along to patients. Try them out. Modify them to suit the needs of your work environment and your patients. Develop additional tools of your own. One important resource to help you create plans is the clinical tool, Resources for Personalized Health Planning. This provides a number of suggestions, websites, and tools and is organized based on the Components of Proactive Health and Well-Being diagram.

How do I decide what to recommend in a plan? People who are first learning about Whole Health, integrative medicine, and complementary approaches often ask how to know what tools to use or recommendations to make in any given circumstances.

The process of deciding what to put into a PHP can be influenced by many factors. These include:

o Evidence-based medicine—in context. It is always a good policy to let

information be evidence-informed, but that is not to say that presence of conclusive research findings is the only reason to put something in a PHP. In a recent editorial in the Journal of the American Medical Association,35 Braithwaite describes how six dangerous words, “There is no evidence to suggest,” if used without care, can discount the potential benefits of many therapies and not only devalue patient preferences and a clinician’s past experiences, but also undermine the shared decision-making process. Choosing the most effective intervention requires both weighing the evidence and practically determining, through firsthand knowledge about the patient, what is most likely to be of benefit.

o Other ways of knowing, such as intuition. As noted in Guideline 2 above, there

are many ways to discern what is truth. In addition to scientific understanding, clinicians also contribute items to health plans based on past experiences, instinct, and an intuitive sense of what someone needs.


If you honor the healing space, often the patient will tell you what’s wrong and how to treat it. Oftentimes I am just repeating that back to them. The magic there is the ceremony between two people that allows what is needed for healing to unfold and gives both of you insight. Once you have that information, it is up to both people to create the plan. That is where that partnership comes in. You just need to confirm what the person already knows, and in that regard, it is the easiest thing ever. You explore strategies of how to bring about healing together, and you help him in that process.

—Dave, Integrative Medicine MD



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Interesting work on the relationship between intuition and expertise has arisen in the nursing literature. Numerous studies support the link between intuition and nursing expertise.36 Benner has proposed a theory of nursing expertise that addresses multiple ways of knowing.37 Five stages are described in transition from a novice to an expert nurse: In the novice stage, learning comes through instruction. Rules learned are

context free; that is, they are not based on the nuances of a given situation. Advanced beginners begin to make use of situational elements. They tailor

their responses more carefully to the situation. In the competence stage, actions are organized in terms of long-range plans

that are broader in scale. Those who are proficient, view each situation as a whole. There is more

synthesis. Analytical thinking and intuitive understanding combine to guide decision-making.

For experts, understanding of tasks and situations is more intuitive and fluid. Experts act naturally, almost without needing to analyze, particularly in more familiar situations. Decisions are informed not by anxiety (as is true for novices) but by a broader array of emotions.

Intuitive processes are so fast that one just knows or acts without being aware where the thought or action comes from. The knowledge on which it is based is not directly accessible and in any case not explicitly used… It is tied to the practices from which it is acquired and often results from informal and implicit learning… ‘Not feeling right,’ for example, is regarded as the outcome of an implicit monitoring process that may trigger immediate intervention, further thinking or even deliberate learning, depending on the situation. Intuition can thus be explained as the outcome of highly personalized, knowledge-based, non-analytical processes that may help physicians deal with the complexity of the tasks they face.38

o The ECHO mnemonic. Using the ECHO mnemonic (Efficacy and evidence, Cost,

Harm, Opinions) is one way to empower decision-making. The components of ECHO are in no particular order of importance. No matter what the therapy or intervention, it is important for a clinician to take into account the following variables when considering what to recommend as part of a health plan:

Efficacy and evidence. What does the research tell us about how well the intervention works? Are research findings significant enough to be clinically meaningful? This ties in the bulleted item above, about using evidence-based medicine.

Cost. Is the therapy cost effective? How much would a patient have to pay out of pocket for this therapy? Would services be covered at all by insurance or other social programs? How available is the therapy?



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Harm. What does the research tell us about the potential for harm? How well can a given therapy mesh with other therapies a patient is currently receiving? Potential dietary supplement–drug interactions are of particular importance.

Opinions. Does the therapy match the personal opinions, beliefs, and culture of the person who will be using it? Where are they getting the information that is informing their opinions?

This is described in greater detail in the module Introduction to Complementary Approaches.

o Searching for root causes. Try to ascertain whether there are any seminal events of

physical problems that are linked to a multitude of problems and concerns. Here are some examples that frequently arise:

A poor diet can be linked to obesity, hypertension, diabetes, depression, and any number of other clinical problems. The same can be true for insufficient physical activity, substance use, and depression. Never underestimate how poor gut function and inflammation might contribute to ill health.

Past traumas can be worth discussing. In addition to the physical and other traumas sustained during combat, others may also play a role. It is striking, for example, how often people with myofascial pain/fibromyalgia find improvement after discussing and working through trauma of a physical, emotional, or sexual nature.

Sometimes it can help to take a step back and apply a completely different perspective. For instance, looking at someone from the perspective of Chinese versus Western medicine may afford a new perspective.

o Asking the patient. As noted earlier in this guideline, sometimes it is as simple as

asking the patient, “What do you think would help you the most right now?” This is a question on the PHI, and the response can be a nice starting place for collaborating with the patient on writing a plan.

o Your personal experience. As discussed in the Introduction to Complementary

Approaches module, you can teach more if you have direct experience with various tools. Try them out as part of your self-care approaches. We know that patients view their clinicians as much more believable if the clinicians seem to be following their own advice. For example, a group of patients who watched a video of a physician recommending diet and exercise found her much more convincing if she had a bike helmet and an apple on her desk.39




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8. Compare notes with your colleagues An educational approach that learners working with the Whole Health models rate as being particularly useful is reviewing other clinicians’ health plans. Doing so allows one to see how much PHPs vary in terms of length, tools recommended, and overall template/organization. Many of these online Whole Health modules include learning plans for the patients presented in the introductory vignettes. You may want to look closely at the suggestions offered. Look at samples, including the health plan that was created for Bob. Interspersed throughout this module are several light green boxes with recommendations from Whole Health clinicians with experience in creating health plans. Below are some additional bits of advice from two experienced Whole Health clinicians.


These would be my reflections, if at all helpful. 1. Having time and space to hear a patient’s story without interrupting is such a gift, and

can be so therapeutic. 2. Learn to protect your own energy—put one foot in their circle, but not both 3. Start with a few, concrete goals—one diet, one exercise, one breathing/meditation,

maybe a supplement. I tended to throw too many suggestions at folks, and it seemed to overwhelm them. Save others for a follow-up visit, which allows a chance to read and learn more about a particular question or condition.

4. Having a detailed questionnaire that a patient completes prior to the appointment is super useful—it gives me much of the information I need, allowing more time in the visit to focus on areas that require more detail and discussion.

5. Build a library of material. Create handouts, blurbs, spiels on things you recommend frequently so it will save you time in the future.

6. Walking the line is difficult, between wanting to provide hope and compassion, serve as an advocate on a patient’s journey toward wellness and yet wanting to call them out on maladaptive, irresponsible behaviors. Sometimes it works, sometimes it backfires.

—Anne, Integrative Medicine MD




As for the health plans, my advice would be: 1. Balance getting the work done with learning new things. Use pre-fab material (that you

created) for items that are routine, such as advice about vitamin D and fish oilsupplementation, so you have more time to research unique topics (e.g., evidence formedicinal mushrooms in cancer) .

2. Reflect on the story the patient told you during the consult. What do they really need?Why did they come to see you? Sometimes it is easy to get into the mindset of what youneed to do for a patient with “X,” which doesn't always lead to what the patient reallyneeds to heal.

3. Know your resources. What we know about these topics is constantly changing, butwhere can you go to find up-to-date information?

4. Put effort and time into the health plans, but not so much effort that your own healthsuffers! If you find yourself recommending healthy lifestyle interventions such asmeditation and exercise but not having time to do it yourself, it might be time for acheck-in and some self-care.

—Jackie, Integrative Medicine MD


9. Create your own personalized health plan along the wayOne of the best ways to learn about writing PHPs is to complete the Personal Health Inventory and then write one for yourself. The process of applying Whole Health approaches to our own lives as clinicians (and as patients, a category to which all humans, including clinicians, belong) can be one of the most instructive you can have. Follow all the other guidelines offered in the module, and see what you come up with. If you feel comfortable doing so, it can be helpful to share your thoughts with a friend or family member.

For more information, see the module Clinician Self-Care.



Taking Action: A Guide to Creating Personal Health Plans Clinical Tools

Example of a Personal Health Plan for Bob Draft Template for a Personal Health Plan There Is Enough Time to Write Health Plans Aspiration, Appreciation, Gratitude, and Optimism: Focusing on What’s Going Right The PLISSIT Model

This educational overview was written by J. Adam Rindfleisch, MPhil, MD, Associate Professor and Director of the Academic Integrative Medicine Fellowship Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public Health, and Assistant Director and faculty for the VHA Whole Health: Change the Conversation clinical program.

References

1. Office of Patient Centered Care and Cultural Transformation. Personalized healthplan staff guide [draft]. Veterans Health Association; October 2012.

2. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data.Ann Intern Med. 1984;101(5):692-696.

3. Langewitz W, Denz M, Keller A, Kiss A, Ruttimann S, Wossmer B. Spontaneoustalking time at start of consultation in outpatient clinic: cohort study. BMJ.2002;325(7366):682-683.

4. Hurst JW. What do good doctors try to do? Arch Intern Med. 2003;163(22):2681-2686.

5. Fox S, Duggan M. Health Online 2013. Published January 15, 2013; PEW ResearchCenter website. Available at: http://www.pewinternet.org/2013/01/15/health-online-2013/. Accessed December 7, 2013.

6. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method forcharacterising and designing behaviour change interventions. Implement Sci.2011;6:42.

Whole Health: Change the Conversation Website

Interested in learning more about Whole Health? Browse our website for information on personal and professional care.

http://projects.hsl.wisc.edu/SERVICE/index.php

http://www.pewinternet.org/2013/01/15/health-online-2013/

http://www.pewinternet.org/2013/01/15/health-online-2013/

http://projects.hsl.wisc.edu/SERVICE/index.php



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7. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200-209.

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10. Kleinsinger F. Working with the noncompliant patient. Perm J. 2010;14(1):54-60. 11. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance

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16. Maslow AH. A theory of human motivation. Psychol Rev. 1943;50(4):370-396. 17. Wilson A, Childs S. The relationship between consultation length, process and

outcomes in general practice: a systematic review. Br J Gen Pract. 2002;52(485):1012-1020.

18. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med. 2007;22(10):1429-1433.

19. Olson KP. "Oh, by the way...": agenda setting in office visits. Fam Pract Manag. 2002;9(10):63-64.

20. Golay A, Brock E, Gabriel R, et al. Taking small steps towards targets - perspectives for clinical practice in diabetes, cardiometabolic disorders and beyond. Int J Clin Pract. 2013;67(4):322-332.

21. Reeves MJ, Rafferty AP. Healthy lifestyle characteristics among adults in the United States, 2000. Arch Intern Med. 2005;165(8):854-857.

22. Prochaska JJ, Spring B, Nigg CR. Multiple health behavior change research: an introduction and overview. Prev Med. 2008;46(3):181-188.

23. Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004;53(12):974-980.

24. Thomas KB. General practice consultations: is there any point in being positive? Br Med J (Clin Res Ed). 1987;294(6581):1200-1202.

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26. Bushe G. The Appreciative inquiry model. In: Kessler E, ed. The Encyclopedia of Management Theory. Thousand Oaks, CA: Sage Publications; 2013.

http://altfutures.org/



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27. Trajkovski S, Schmied V, Vickers M, Jackson D. Using appreciative inquiry to transform health care. Contemp Nurse. 2013;45(1):95-100.

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39. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med. 2000;9(3):287-290.

Documents

WHOLE HEALTH: CHANGE THE CONVERSATIONprojects.hsl.wisc.edu/SERVICE/modules/3/M3_EO_Taking_Action.pdf · WHOLE HEALTH: CHANGE THE CONVERSATION Advancing Skills in the Delivery of Personalized,