How Healing Works

by Wayne Jonas

  But implementing these aspirational principles has been a challenge. Medicine still largely follows individual treatment processes and pays for doing things to a patient rather than supporting healing with a patient. We still spend most of our money and time looking for treatment agents that only incrementally add to overall health, rather than optimizing our own agency for transformational healing. The will is there, but the ways are weak, and the economic drivers are against this when it comes to healing. Recently, the Peterson Foundation funded Stanford’s Center for Excellence in Primary Care to find the top 5% of primary care practices that meet the Triple Aim and the patient-centered medical home model, and to describe the characteristics of their success. Not surprisingly, those characteristics were almost identical to those listed in Crossing the Quality Chasm. The most effective health care went beyond simply doling out treatments. These practices spent time probing the other dimensions of healing. They addressed the whole person, organized care to make the patient the driver of their own healing, and created teams of caregivers—all processes addressing the behavioral and the social and emotional dimensions of healing. They provide integrative health care at its best.

  A NEW WAY TO HEAL

  The two missing spheres of integrative health—complementary and alternative practices and lifestyle medicine or self-care—have been growing in research and practice in parallel with the mainstream calls for more person-centered and holistic care. If your physician is interested in learning more about these areas, he or she (and you) can learn more from my description in the next chapter. Many of these resources bring lifestyle and behavioral change into treatment, beyond using them just for the prevention of chronic diseases. Physician pioneer Dr. Dean Ornish has emphasized this point and demonstrated it in rigorous research for decades. In his most recent best-selling book, The Spectrum, he brings together the elements of lifestyle medicine to show that we can reverse chronic disease and turn on disease-preventing genes. This is indeed a new way to heal, compared to what most doctors have been learning.

  As Trevor and many of my other patients have taught me, behavior is only one dimension needed to tap into the 80% of healing. Almost all patients that I see in my practice know that behavior is important for health. But, as was tragically true for Trevor, having that knowledge is not enough. A recent study published by the Mayo Clinic concluded that only 2.7% of the population engages in the four main behaviors that keep people healthy—not smoking, eating a high vegetable diet, engaging in regular activity, and undertaking adequate stress management. Nor does simply engaging in healthy behaviors address the deeper levels of a person—the social/emotional and mind/spirit dimensions—that are so essential to finding the permanent path to healing. Maria changed her behavior, but wasn’t healed until she found a group to teach cooking to. Sergeant Martin was using a treatment—hyperbaric oxygen—proven not to work. Yet by engaging in it with a group of other service members, he improved and healed himself. Had Norma not been enrolled in the clinical study I was running on arthritis, she might never have been motivated enough to move through her pain and return to her volunteer job. For Mabel, as for many seriously ill people and elderly or frail patients, social relationships were the central dimension to her healing and well-being.

  We saw in chapter 7 that at least one health care system—the Nuka System of Care in Alaska—could shift their delivery of health care to a relationship and patient-centered paradigm. The success of this system is partially based on anchoring it in Alaskan Native traditions. But the world is increasingly mobile and made up of diverse traditions with multiple cultures and languages. Is it possible to build an integrative healing system flexible enough for our increasingly mobile and multicultural world? To find out, I visited one system that is attempting to do just that.

  Dr. Rushika Fernandopulle was born in Sri Lanka, where he found, as I did in Vietnam, that much care still comes from traditional practitioners who use natural substances and conduct ancient rituals—just as Aadi did in the Ayurvedic hospital in nearby India. Infectious disease, lack of sanitation, trauma, and malnutrition were common in Sri Lanka. But Dr. Fernandopulle noticed one thing about people with chronic disease and mental health issues: if they could get clean water and food and had access to the basics of modern medicine, they were happy and generally did well. Their lifestyle and social relationships supported lifelong health. As in the five places in the world identified by author Dan Buettner in his book Blue Zones, where people live the longest, healthiest lives, the Sri Lankans had less medicine and less illness than many in Western countries. Traditional practitioners and grandmothers coached people on how to live. There was no gap between the medical space and the life space. The only gap was science.

  Then Dr. Fernandopulle came to America and got arguably the best scientific and medical training available at Harvard. Like me, he saw the miracles that modern science could bring to curing. Like me, he had been exposed to both the advantages and the limitations of ancient traditional healing systems. And like me, he saw that for chronic disease, people in the West were not doing better—yet they were paying more. So he set out to try to fill the gaps in the health care system he worked in here. But he found it extremely difficult to change a system that paid for and reinforced only treatment and cure. Like me, he found that the nature of the medical encounter, the payment system, the electronic medical record, and the SOAP note was not designed for healing the whole person. Finally, he gave up trying to change the systems and set out to design and build a new system that could change the nature of health care and fill the gap between curing and healing. He called it Iora, after a small bird in Sri Lanka.

  Superficially, the job of an Iora practice is the same as any medical clinic—to prevent and treat illness and disease; to help people get and stay well. However, the second you dig even a little bit deeper, you realize it is indeed very different from typical care. The clinic is filled with specially trained professionals called “health coaches,” who work hand in hand with the nurses and doctors to address any area that might impact your health or interfere with your healing. It provides standard treatments like vaccines, medications, minor surgery, and counseling. But it can also provide information on nutrition and behavioral change, stress and social services, and access to financial or legal help, if needed. And it can link you to responsible complementary and alternative practices and integrate that care into the other services. Every member of the health care team and the patient have full access to all information in the health record—which is structured around the patient rather than the payments—and is fully accessible to the patient at all times. The need to worry about the cost of treatment is eliminated, as all care in Iora practices is provided for a flat fee per patient per month (paid for by what Iora calls a sponsor, which could be an insurance health plan or self-insured employer, for instance). Hospital or specialty care is additional, but the Iora team works closely to provide a broader range of care than traditional primary care, improve access, and eliminate unnecessary care (which makes up one-third of medicine), and to facilitate recovery after specialty treatment. Healing and recovery are ever present. Group classes and individual assistance in nutrition and behavioral change are available, and the staff are tuned in to the social/emotional and mental/spiritual lives of the patients. The space is warm and welcoming, without the usual barriers or industrial feel of typical clinics. The health care team knows you. Employees are selected for and trained in listening and empathy. Unlike most clinics in health care, you will not be interrupted within the first sixteen seconds of the encounter. The feel of caring is palpable.

  And it heals better. Like the top 5% of primary care practices identified by Stanford, Iora’s outcomes are stellar. Data on ten of the clinics open for two years or more shows remarkable results. This includes engagement rates of 85% per year; retention rates of 90% (94% of those engaged); a total medical expense decrease of 14% per year; in-patient admissions and emergency room visits more tha
n 40% below the Medicare fee-for-service average; and a 21% improvement in hypertension outcomes. In addition, Iora has a 90 Net Promoter Score across Medicare markets (this means patients recommend them to others). One hundred percent of patients needing urgent care get a visit within twenty-four hours. Iora’s STAR ratings (the Medicare system of quality in five different categories) increase yearly up to 30%.

  By the standards of the Triple Aim, the patient-centered medical home, and even the Stanford assessments, Iora meets and exceeds those measures. Equally important, the patients, practitioners, health coaches, and communities enjoy the practice more. Practitioners suffer less burnout, and nurses and physicians feel their skills are well used.

  But can this approach be applied in diverse settings with a variety of average people? The answer is that it can. Iora clinics are now up and functioning with good results in areas as diverse as college towns, the Las Vegas strip, and poverty-stricken areas of Queens in New York. “What is needed now,” says Dr. Fernandopulle, “is a health care system that truly wants and will pay for this type of integrated care.”

  HEALING THROUGH PURPOSE

  No matter where we start or how we navigate the elements of healing, it is when we can link them to our purpose in life that deep healing happens. This happens more often when the dimensions of healing are aligned. It also happens more often when good science is brought into the process to enhance it. It can happen dramatically when a person finds those elements that induce their greatest meaning response. Then we go beyond the 20% improvement found in cure-based medicine and tap into the 80% of healing potential that lies dormant in everyone.

  In his book Life on Purpose, Dr. Victor Strecher, professor of public health at the University of Michigan, has summarized the extensive and startling research showing how a life of meaning and purpose prevents and treats chronic disease, reduces suffering, and even prolongs life. When a person feels that they have an important purpose in life, when their values and actions align—especially when that purpose gives back to others—they simply do and are better in all ways. Purpose has been correlated with reduced weight, better sleep, more friends, better sex, faster recovery, less relapse from addictions, less risk of Alzheimer’s disease and dementia, less heart disease, lower health care needs, and lower death rates.

  We even know the biology of purpose. It increases growth in the ventriculo-medial prefrontal cortex of the brain—the brain location of one’s “sense of self”—and it can even maintain and elongate telomeres—the genes that predict your length of life. That individual sense of purpose, when aligned with our family, community, and work, will enhance the health of others in those areas, too. Companies whose employees feel cared for and are aligned with company goals and mission deliver more profits and last longer than companies that don’t. Families and communities with purpose have more vibrancy and happiness, less violence and poverty, better health and well-being. Thus the goal in engaging in the HOPE process is to link your healing dimensions to why you are here in the world—your meaning and purpose in life—and to create a meaning response in mind and body.

  Once we understand the dimensions of healing and the individual elements of meaning and purpose in creating health and well-being, it changes our perspective on health care and illuminates the path out of the current health care dilemma of higher costs, less satisfaction, and poorer health. My patients who use this approach find that they are no longer victims of a system not designed for them. This understanding becomes the foundation for true health (not just health care) reform.

  What is needed now is a willingness to bring healing back into health care. The most effective way to do that is to bring it deliberately and intentionally into your life. You may not have access to integrative health care in a Nuka- or Iora-like system or get your care from one of the top 5% of patient-centered medical facilities. But this should not matter. Remember, only 20% of health comes from the treatments you get by walking into a doctor’s office or visiting a medical clinic. The rest—the 80%—comes from you, from using the dimensions of healing already embedded in your life. By engaging in a HOPE-like process, you can unleash that 80%.

  In the next, and final, chapter, I provide a simple set of instructions and accompanying tools for doing a HOPE visit. You and your physician can use those tools to access your healing dimensions. In the appendices, I provide a process that you—even without your physician—can use for your own journey to healing. Take this journey into your life; work through the questions yourself; take what you discover to your physician if she is willing to partner with you on that journey. If your doctor is hesitant, give her this book; when she has finished it, ask for impressions. It is my hope that doctors find these principles and tools useful in their own lives. I have. They might even help to ease their burnout and be more patient-centered in their practices. You can be your doctor’s healer!

  HOPE AND HEALING

  The oncologist had unintentionally set my wife up to make The Cake, which was so effective in advancing her recovery. We had tried many other treatments to help her with fatigue, anemia, hair loss, and the risk of heart and nerve damage from chemotherapy. These included both conventional medications and alternative supplements of various types. For most of the alternative treatments, there was little evidence. For a few, there was evidence of harm. The oncologist offered several drugs for dealing with the side effects of therapy. Some worked well, especially for nausea and severe white blood count drops, but again, the evidence for many of them was slim, and nothing helped much for her extreme fatigue.

  Then, during one oncologist visit just before the July Fourth holiday, Susan described again her tiredness and shortness of breath. The doctor was headed for the door when I asked about Susan’s anemia—low red blood counts. She looked at the labs: “Oh, yes, they are low,” she said. “You have anemia.” She paused for a bit and then said, “You know, that is most likely what is causing your fatigue. But it is nothing to worry about, Susan. It’s expected with chemotherapy. It’s not in a dangerous range, so we’ll keep an eye on it. It’s normal for what you are going through. You will start getting better soon—after the chemotherapy.”

  Susan told me later that on hearing this, a light went on in her mind. This was “normal,” and it was up to her to get through it. After that visit, she said to me, “As I understood it, the doctor basically said to just tough it out. That’s what I thought. That is what I am doing and will keep doing. Let’s really celebrate the Fourth. It’s time to be normal.”

  It was a few days after that Susan mustered the energy to make The Cake. The oncologist, of course, never knew about The Cake or most of the other factors that sustained Susan’s healing during the onslaught of the treatment. She didn’t have time to. But without The Cake and the hope it engendered in Susan, the healing transformation she had during her cancer treatment might not have occurred. It was a hope the oncologist had given almost as a side comment, thrown out as she put her hand on the door to leave for the next patient. I thought of all the times I had done the same thing with patients. I thought now that it doesn’t have to be this way in health care—to focus so much on the treatment and cure that we often miss what induces the healing.

  SPIRIT MATTERS

  This was the fifth trip to the hospital for Trevor to see if he could get a kidney. When he arrived around midnight, the doctor said that if the possible kidney did not match for him that night, they would discharge him in the morning and start again later in the year. Trevor’s wife stayed with him and went to sleep in the chair in his hospital room. In the quiet of the early morning, Trevor reflected on what his wife had said; how his “incorrigible optimism” had gotten him into this mess; how he had not trusted the doctors and believed too much in natural treatments; how he had focused so much on giving back to his community—following his one passion and purpose—that he had neglected himself and his own health. Had there been a system of integrative health to fill the gaps between drugs, diet, and self-ca
re; had the care he received been more person-centered; and had it been better linked to his purpose, he might have avoided years of suffering and expense, prevented the injury his wife endured when she donated her own kidney unsuccessfully, and not had to endure his current almost total dependency on the medical system. Perhaps, he thought quietly to himself, his optimism, his passion, his purpose, his prayer had all been misplaced. He was in a deep despair—hopeless. All he wanted was to be well so he could go back and help his people—young people especially who had been like him. He wanted them to have the opportunity for a full and successful life.

  Then he did something he was not supposed to do. He got out of bed without assistance and kneeled to pray. His knees hurt. The IV pole pulled at his arm. He felt dizzy. At the side of the bed he prayed his favorite Bible passage from Isaiah 6:8: “Then I heard the voice of the Lord saying, ‘Whom shall I send? And who will go for us?’ And I said, ‘Here am I. Send me!’ ” He then got back into bed and thought of the hymn “I Am Here Lord.” A deep peace suddenly came over him. At that moment “I knew I was going to get a kidney,” said Trevor. He described feeling much more than his usual optimism. It was an overwhelming feeling of release—of giving himself up to whatever God wanted of him and that he was being held in the Lord’s loving hands. He fell into a deep sleep—better than he had for weeks.