by Wayne Jonas
Trevor left his visits with physicians both alarmed and skeptical. He had felt fine before. Now he felt terrible. How had he gone from “healthy as a horse” to an impotent invalid in a matter of weeks? Plus, his insurance did not cover the entire cost of drugs. Some were expensive. Wasn’t there a better way? He had read that high blood pressure could be controlled by diet and exercise. He had been an athlete. Why couldn’t he use this approach? He inquired around in his community for alternative options to drugs. Several of his friends said they had gotten off medications and felt great by exercising and eating better food. They recommended a local practitioner who used “natural” approaches for treatment of disease. She provided the hope Trevor was looking for. Not only was it possible to treat blood pressure naturally, she said, but diet and supplements could actually replace drugs. The side effects of medications could be avoided. She knew of the DASH diet but said that was just a start. She pointed to a “more effective” diet called the “Rice Diet for Hypertension” that would get people totally off drugs. The diet was developed at a clinic only a few hours from where Trevor lived—at Duke University—and had been “proven” to work for more than seventy-five years. He could go to a private center that delivered this diet or—for less cost—she could help him get on a “cleansing” diet and supplements that would do the same thing. She would help him to make it work with his life.
Trevor, optimistic as always, thought this sounded good and began to work with her. He stopped the medications and started the diet and supplements. He immediately felt better. After three weeks on the diet and supplements he went into a drugstore and had his blood pressure checked. It was almost normal. He was back to his old self—or so he thought.
He didn’t see another doctor for ten years—until after his feet began to swell.
THE INTEGRATION GAP
The gap in health care between curing the body and the dimensions of healing is not confined to blood pressure. It is a general gap in health care—one that needs closing. In a recent comprehensive review I took of family medicine, I counted the number of recommendations for the use of drugs and other disease treatments compared to other dimensions described in this book—environmental, behavioral, social/emotional, and mind/spirit. Of the 361 health care management recommendations made during the review, 226 referred to drug management, 87 for behavior and lifestyle, 20 concerned complementary and alternative healing methods (mostly to avoid them), 19 addressed social and emotional counseling, and 9 were for mind-body or spiritual practices. In several lectures on chronic pain, for example, nondrug approaches were recommended as a first-line management in all patients. After one lecture on chronic pain that recommended use of complementary and integrative approaches to pain management, questions from the physicians were focused not on evidence for the effectiveness of these approaches, which ones were covered by insurance, and on how to implement the recommendations. The physicians pointed out that they were not well trained in the delivery of nondrug approaches for pain, that patients did not seek out these practices, and that the health care system did not pay for them. While evidence and a number of recommendations to use these healing dimensions is an improvement over review courses I took a decade ago, there is a lack of integration between curing and healing in our delivery systems. This gap between evidence and practice is difficult to bridge.
Trevor’s doctors treated his numbers but failed to engage him in the lifestyle and social and emotional dimensions required for healing. The alternative practitioner used a diet that can rapidly lower blood pressure in the short run, but has not been shown to be effective in the long run. People cannot stick to it, yet they may think they have eliminated their problem. The herbs and supplements she recommended are not proven to work for high blood pressure. Yet she and Trevor believed in them. The two practitioners—the conventional doctor who addressed Trevor’s biology and the alternative practitioner who provided Trevor with what he hoped for—never communicated with each other. Both knew about an effective and proven long-term dietary treatment for high blood pressure—the DASH diet—yet neither could deliver it. Had he followed that diet, Trevor would still have needed drugs, but likely in reduced numbers or doses—and he would have felt better. Despite increasing evidence and recommendations by national organizations to use more behavioral and lifestyle changes, doctors get very little training in nutritional therapy and even less in dealing with the social, emotional, and cultural dimensions of healing. Complementary and alternative practitioners are rarely trained in how to work with serious diseases and have even less training on how to coordinate what they do with physicians. Trevor fell into the gap between evidence-based medicine and person-centered care. The result was fifteen years of “silent” and poorly treated high blood pressure. When he went back to the doctor to see why his legs were swelling, they discovered he had kidney failure produced by poorly controlled high blood pressure. This led to years of kidney dialysis and the abortive attempts to get a transplant.
Trevor needed an integrative health care approach—one that bridged and coordinated the treatments between his biology and the rest of him; between drugs and self-care; between medical treatment and the social and personal determinants of health; between the treatment “agents” and his own “agency”—his inner capacity to heal.
The miracles of modern molecular medicine, with all its success over the last hundred years, have reached a limit when it comes to managing most chronic disease. Extensive research has repeatedly shown that even full access to medical treatments produces only about 15% to 20% of a population’s health; the rest depends on lifestyle, environment, and social and personal determinants. This failure to focus on the whole person and delivery systems that address health determinants comes from how medical care is delivered—in silos and directed at discrete parts of people—without empowering them to heal. Modern medicine, so powerful in making miracles around acute disease, is now missing 80% of what’s needed for healing chronic disease.
The most recent description of this dilemma was published by leaders at the U.S. National Academy of Medicine in a report called Vital Directions for Health and Health Care, edited by Drs. Victor Dzau, Mark McClellan, and Michael McGinnis. They describe how the money spent each year on health care in the United States (the most recent figure then was $3.2 trillion) is no longer providing the value it once did. They find that “an estimated 30% is related to waste, inefficiencies, and excessive price; health disparities are persistent and worsening; and the health and financial burden of chronic illness and disabilities are straining families and communities.” They collated expert input in nineteen papers and made four main recommendations: pay for value, empower people, activate communities, and connect care. Had Trevor’s physicians been paid to get him better, not to just give him drugs (that is, pay for value); had he been empowered to take responsibility for his health (empower people); had the community he lived in trusted the medical system (activate communities); and had there been an integrated approach between his medical treatment and his more natural approaches (connect care), Trevor would not have been lying in a hospital bed pleading for more time and praying for a donor kidney to appear.
Soon after the publication of Vital Directions, Samueli Institute and the Institute for Healthcare Improvement released the Wellbeing in the Nation (WIN) plan, which described how the United States could build an infrastructure to enhance healing in communities across the globe. The report recommends establishing a national well-being index and a community well-being extension service network to facilitate local integration of community well-being efforts. By addressing prevention, health promotion, and well-being, any community and its members can flourish. Both these reports point to local examples. Many communities already have sufficient resources to do this. The integration gap can be filled if we have the will to change our approach and rebalance curing with healing.
FROM SOAP TO HOPE
In the history of medicine, the use of a chemical, cellula
r science is very new. Our understanding of cell function and the chemistry of cure is only about two centuries old. Oxygen, for example, that essential molecule for survival, was discovered by Joseph Priestley in 1774. The establishment of reductionist science as a basis for medicine is only about a century old—being solidified as the gold standard after the Flexner Report on medical education was published in 1910. The application of this science for human testing in the form of randomized controlled trials (RCTs) is a little more than sixty years old—the first one was done in 1948. The solid establishment of RCTs as the gold standard for what is called evidence-based medicine today is more recent, with a concerted push from academics in Canada and England in the 1970s. The application of technology to further refine and manipulate the body is still more recent. By any metric, the science of medicine is young. So young, in fact, that the downsides and limitations for the prevention and treatment of chronic disease are only now beginning to emerge. As these limitations are more understood, there has been a parallel resurgence of interest in holistic approaches that were dismissed in the last hundred years. As I discovered in my practice, an integrative approach to health was needed—one that merges and coordinates curing and healing. To do that, I had to make a shift from the way I had been taught in medical school and practiced for decades—an approach exclusively focused on finding the disease—to a way of working with patients that enhanced their healing capacity. I had to widen the lens of my practice to reach out of the regular clinic visit to one that touched people in their life-space. I do this by going from what traditional medicine calls a SOAP visit to what I call a HOPE visit. Let me explain.
Most patients don’t realize it, but when they visit their physician, he or she already has a specific plan to structure and report on the visit. In almost every visit, a physician will summarize the encounter with something called a SOAP note. SOAP stands for subjective, objective, assessment, and plan; it’s designed to label the patient with a disease or illness diagnosis and its corresponding treatment.
SOAP is the way that every medical student, resident, and nurse and many other medical care practitioners learn how to organize their thinking around an encounter with a patient. Electronic medical records are built around the SOAP.
Subjective starts with the patient’s chief complaint—what he came in for and what he says is bothering him. This complaint is filled in with further questions looking for additional subjective information reported by the patient.
Objective is what the practitioner observes; it includes observations of the body itself and laboratory test results and imaging. While there’s no explicit ranking of subjective and objective, most practitioners have a bias toward the objective, giving it more value in the assessment than the subjective or what the patient says.
Assessment is meant to be a succinct summary of what the clinician thinks is the problem and is essentially the diagnosis. This diagnosis is usually attached to a code or a set of terminologies that form the lexicon of all medicine. The assessment is not only how we categorize patients to research them and get new knowledge; it also forms the categories around which we pay the practitioner, and track outcomes for the health care system. Thus it is essential to the livelihood of the health care system and the practitioner.
Finally, the plan is what we intend to do about the diagnosis, whether that be the execution of a treatment, the providing of advice, or further assessment and testing. Physicians are taught that the plan needs to align with the assessment and, under ideal circumstances, with at least with the objective part and hopefully, with the subjective part as well. The SOAP note is how we organize the entire experience of the patient visit and follow-up. In most medical encounters, no matter what the patient presents with, they will go out of the office framed in a SOAP. That SOAP is rarely shared with patients; if it is, we rarely ask them whether it makes sense. We don’t expect them to know what the diagnostic codes, descriptions, and plans should be or what they mean. Good communication in a clinical encounter entails explaining the assessment and plan in nontechnical terms and the research evidence, with the goal of engaging the patient in clinical decisions. This process is called shared decision making, and it is almost universally espoused as important for every chronic disease decision—yet it is rarely done. Physicians vary considerably in their skill at communicating the assessment and plan to patients, and usually any SOAP discussion remains technical.
The SOAP process happens tens of thousands of time every day around the world; it structures the medical encounter and drives the medical treatment engine. The SOAP note is formulated around a set of basic assumptions that organize all modern medical education, research, and practice. SOAP uses a pathogenic framing: it is about disease and illness, not healing. It is the way modern medicine diagnoses diseases and aligns them with treatment. How much evidence connects the assessment part to the plan part of SOAP determines whether a treatment is judged to be evidence-based or not. This, in turn, structures the way research is done, such as how patients are selected for clinical studies. This then restricts what is allowed in health care. It keeps modern medicine focused on seeking cures. This constant search for cures creates multiple treatments that are “done to” the patient. Because SOAP uses the biomedical, biochemical paradigm, it often misses the dimensions of healing found by and in other parts of patients. The concept of salutogenesis—the process of healing—is a concept I and others have expanded on from Aaron Antonovsky, who first coined this term in the 1970s. Salutogenesis rarely comes up explicitly in a clinical encounter. Doctors focus on pathogenesis—the process of how disease is produced—and how to counteract it. No wonder most clinical encounters are not person-centered or holistic and miss most of healing. We doctors always must fit them into a SOAP! In the medical profession is it called the “tyranny of the chief complaint”—and we are stuck on it.
Doing a SOAP process with each patient visit is important for disease diagnosis and treatment, but if we are to balance curing with whole person healing, we need more than SOAP. We need an encounter focused specifically on healing. So, to balance the standard medical encounter with healing, I follow up the SOAP process with a HOPE note. HOPE stands for healing-oriented practices and environments, and it addresses dimensions of physical, behavioral, social/emotional, and mind/spirit—and so tap into the 80% of how healing works. It involves a set of questions designed to help the person identify and navigate a unique pathway to healing. The HOPE questions probe how the person is already engaged in healing, and then seeks to match that with good evidence to enhance those activities. It highlights what the person has intuitively discovered and adds the rational elements derived from rigorous research. Since both intuition and science are uncertain by themselves, pairing these different ways of knowing maximizes the benefit for both curative treatments and the person’s healing capacity. It optimizes the meaning response. By doing a HOPE, I help patients avoid the gap that Trevor had fallen into.
The story of another patient, Mandy, illustrates how SOAP and HOPE together create integrative health and healing.
MANDY
At forty-five years old, Mandy should have been able to maintain a household—but now she could not. Even before the accident, she had struggled to care for two teenaged boys and a nine-year-old daughter, a husband who worked a lot, and a part-time job. Her life consisted of juggling schedules, meals, household chores, phone calls, and social media. There was no time for self-care. She had worked full-time until fifteen years ago. Then, in what she thought was a relatively minor car accident, she sustained a neck whiplash and shoulder ligament tear on her right side. She gave it time to heal and followed all instructions, including physical therapy and taking anti-inflammatories. But the pain never went away. It became chronic. Soon she had major neck stiffness and intractable pain down her shoulder and right arm. A fifteen-year journey with neuropathic pain had begun.
Over that fifteen-year period, she was diagnosed with multiple other conditions, fr
om depression to anxiety to PTSD to neurosis. She continued to try and maintain as healthy a life as possible: exercising as she could, doing physical therapy, eating well, and cultivating relationships with friends and family. As with many patients in chronic pain, these were challenging activities. Most of her encounters with medical professionals resulted in being prescribed more medications. At one point, she was on more than five medications, including the opioid OxyContin, from which she had difficulty freeing herself. The pain would flare up when she tried to taper off of it. Eventually, with the help of an inpatient pain treatment group, she got off the OxyContin and began taking other, less addictive drugs, such as Neurontin and Lyrica, which partially improved both her neuropathic pain and crying episodes. “Let me warn you, Doc—I cry,” she said on her first visit with me, tears already welling up in her eyes. “Sometimes I just cry for no reason—sorry.” I waited until she stopped.
Her pain was significant. She rated it between five to seven out of ten on a daily basis. It was accompanied by spasms and stiffness in her neck and right shoulder. Over the fifteen years, she had had many other treatments besides drugs: regular physical therapy, steroid injections, and electrical stimulators and psychotherapy, all from conventional pain clinics or her primary care doctor. Like Trevor, she entered into the parallel world of complementary and alternative medicine, seeing chiropractors, acupuncturists, herbalists, homeopaths, and mind-body practitioners. They all seemed to help a bit, some more than others—temporarily. She found that hot baths and meditation helped the most—when she had the time to do them. Sleep was never in the cards, both because of her busy family—the boys were up late doing homework—and because the pain did not ease at night. She woke frequently and never felt rested. Sometimes she would just go into the bathroom and cry.