By Craig Weiner, DC
Having been a health care provider for nearly thirty years, the question of how to encourage patients to be more active on behalf of their own health and well-being has always both challenged and inspired me. I’ve had the blessing of having a relationship with my patients that is unique and heartfelt. For me, the patient/doctor experience has been a collaborative one. But not all patients have had that relationship with their healthcare providers. We come out of a generation and a long period of time in which health professionals, and especially medical doctors, were put on a pedestal. The doctor told you what to do, and you did it; or you didn’t. It was a one-sided conversation in many ways, and it didn’t always empower patients. Patients didn’t necessarily learn how to make healthcare decisions themselves. It was a paradigm in which the doctor knew best. The patient was not generally seen as the healer; the doctor was.
We’ve been emerging slowly out of that paradigm with the growth of complementary and alternative healthcare, and now even integrative healthcare. With the birth of the internet and self-empowerment movements, a lot of different factors have started to shift how people perceive their relationship with their bodies and with their healthcare providers. The word “empowerment” is a fitting term for the process by which people gain mastery over their own affairs. Right? Simple. In other words, they’re empowered to make their own decisions; to be able to get their own information; to be a part of their own healing process.
I like that word, “empowerment”; but there are other words or phrases that are starting to be accepted and that aptly describe this shifting doctor/patient relationship. One concept that describes this empowering doctor-patient relationship is “patient-centered”; the idea that a patient sits in the middle of his or her own healing circle of providers. In indigenous cultures this concept can be viewed in terms of a medicine wheel. A Western paradigm may view it as a hub. The critical aspect is that the patient sits at the center of the decision-making process, and in a sense, she is the boss. She hires various practitioners via financial agreement. She may have her doctor, chiropractor, and massage therapist all within her healing circle, working for her best interest. But she sits at the center.
With this patient-centric paradigm, the patient and her healing practitioners can better recognize and honor that she has primary responsibility for her own healing; and she can see herself as a source of her own healing. We manufacture many of our own medicines internally, so it behooves us to explore what circumstances outside ourselves, and even more importantly inside ourselves, serve to create a greater supply of these “locally-grown” internal healing chemicals. The healing that comes from within is made larger and more visible when a patient feels fully supported by such a healing team circle. And science continues to show us that such support increases the strength of our immune systems and amplifies our ability heal ourselves.
Healthcare Provider’s View
I also am passionate about seeing this growing attitudinal shift through the lens of the healthcare provider; many times, it’s as much of a learning curve for the doctor as it is for the patient. As a doctor, my intent is always to support the greatest and highest actions I can take to support the health of my patient. I may be clear on my vision of what is best for my patient. But how do I know exactly what that is? Certainly deep listening is always the best starting place. The question however, is how do we as practitioners empower patients to make the life changes that may be required for them to achieve the level of health they desire?
When we explore this client-centered approach looking at this patient-empowerment model, as physicians and therapists we have to examine a variety of things. Most important, often by oath, is to do no harm. In addition to offering a safe and efficacious form of treatment, “do no harm” also means taking whatever steps we can to reduce stress and anxiety, which can work in opposition to healing. That means asking how can I offer a patient a diagnosis in a way that reveals the truth as we know it, yet minimizes the effect of hearing it, especially when it is a frightening diagnosis? Over the years, a number of patients have told me of crisis experiences with their physicians; these patients swear that they will never forget the day the doctor spoke to them in a way that scared them to death, and they left the office shaking. There is an art to being present with patients when offering them difficult news. In my opinion, there is plenty of room for improvement in our health care system with this practice. This is where the personal practices of a physician are so important. I am a practitioner who incorporates energy medicine modalities into my practice (that is, EFT tapping, see previous LILIPOH article, “The Next Wave of Health, Where Brains and Energy Converge: Emergence of Energy Psychology,” Issue 69, Fall 2012). As a student of trauma, I have witnessed far too often the lingering stressful effects of such experiences, and the adverse effect they can have on patients’ health and well-being.
The patient empowerment process treats the individual as a whole person and recognizes that the tone and focus of the doctor-patient relationship has a direct effect on the patient’s healing. Most doctor visits narrowly focus on the problem; what is wrong and what the patient needs to do to fix it. This model resembles this kind of parental relationship where most communications revolve around the problem and what the child is doing wrong, rather than reinforcing what he or she is doing right. Acknowledgment of right behaviors, taking a moment to verbalize the things that they’re doing well, goes a long way.
The parent-child model of health care delivery is one that has long been cultivated. I have witnessed many on-line forums where physicians report that if they don’t take that tone, and then if a patient is not “compliant” with their recommendations, then the condition worsens. The illness can become lethal, and then fears of physician liability come into play. So it is important that patients value themselves enough to demand mutually respectful relationships with their physicians. I frequently ask people what their relationship with their doctor is like, and whether it is a respectful and supportive one. Sometimes I get “Eh, it’s alright, you know, he writes the prescription, he does this, he does that. Yeah, he’s fine.” That really is a bare minimum—a pretty mediocre response. So my question to that person is, “What’s stopping you from finding someone better? Do you care enough about yourself? Do you hold yourself with enough esteem to say you deserve better?”
In the empowerment relationship, there needs to be decision-making, not only by the doctor (or insert whoever the healthcare provider is, whether doctor, therapist, or clinician). If you have a problem and the doctor tells you to do a certain thing, and you don’t want to follow his or her suggestion, how comfortable are you with saying “I’m not comfortable with that. What other options do I have?”
In response to your query, you may be given a perturbed glance that suggests the practitioner is thinking, “Are you questioning my skills? I know what’s best for you.” If you get that kind of response, that’s a pretty good sign that this practitioner might not be someone you want to continue to have a relationship with. Either you find a way to transform and change that relationship, or you use the “law of two feet,” and head somewhere else.
In my practice, I often have new patients come to me who just moved to the area. I’ll ask them if they have found a primary care physician yet. Unless they have a serious health condition, the response is often that they “have not gotten around to it.” That means that they will likely wait to initiate a relationship with a new doctor until they are in a lot of pain or scared of something being really wrong. Then they get whatever physician is on call, establish a beginning relationship, and then continue out of obligation or not wanting to hurt the doctor’s feelings.
I always encourage people to establish a relationship for the first time with a new practitioner when they’re not in a lot of pain, not scared, and not seeking help for an emergency situation.
How does one go about establishing this initial doctor-patient relationship? I encourage talking in person to the physician’s staff and saying, “This is going to be my first time with the doctor. I’d like to do a consultation. I’d like to be able to just talk to him or her before the exam. What would it take to do that?” The receptionist or nurse may give you a good answer, or she may say that on one has ever asked for that before. I suggest asking the receptionist what might be the best way to tell the doctor your concerns, understanding that time will surely be limited. You could ask if it would it be helpful to put some of your concerns in writing before the visit, and send them via email. That might be a more efficient use of the doctor’s time, given a typical schedule that runs on ten or fifteen minute intervals.
These suggestions should stir up the way we think about establishing a more healing type of patient-practitioner relationship. There are several elements that I think are important in bringing about this empowered patient-centered relationship; and here are some perspectives for you to consider, and some questions to ask yourself.
Emphasizing the Whole Person
Do I feel as if my doctor is treating me as if I’m a whole person, and not just my condition? Is he or she seeing me as more than my diagnosis with a significant family history? Does he understand that I am not just my physical body; am I ever asked about the other equally important parts of my life that are relevant to my health, such as the state of my family life, my spiritual beliefs, and even the emotional history of my early life, that may have set things into a pattern that if not resolved, may contribute to the ongoing nature of my illness? (In the Fall 2012 issue of LILIPOH referenced above, I also discuss adverse childhood experiences and their effect on adult health.)
Trust and Safety
I believe that patients should feel safe telling the doctor anything. They should feel secure in sharing whether they have followed the doctor’s recommendations, or not. It is critical to be able to trust your provider; to be able to tell them your habits and activities that affect your health and not feel like you will be judged or reprimanded. If that kind of safety and trust do not exist, I recommend seeking a different provider, because feeling safe is an essential element of the healing process.
The Placebo and Nocebo Effect
Most people have heard of the placebo effect. It is what happens when we believe something we do, or a medicine we take is going to help our bodies heal; and it happens, even when there is no inherent active component in the treatment. There are many famous examples, but one of my favorites is the arthroscopic knee study performed by Dr. Bruce Mosely. In essence, the study followed patients who received a sham knee surgery, and believed they had the real thing (they watched a surgical procedure video of someone else’s surgery and believed it was their own), as well as having a small surgical scar. The results for the sham patients were just as favorable as for those who had the actual surgery. Now there is a lot of debate regarding the ethical use of placebos, and for good reason. What is far easier to incorporate, however, is the efficacious use of the “nocebo effect.”
The nocebo effect is a term used to describe the harmful effects of inactive elements. It occurs when a patient expects something unhealthy to happen as a result of an intervention, and so it does. Studies have shown that when patients received a salt solution, and were told that it was a chemotherapy drug, up to thirty percent lost their hair and eighty percent vomited as a result. Although I am not promoting the idea that a physician should be untruthful to patients, there are clearly subtle ways in which we do speak of expectations; in such cases we should be extremely mindful of the manner in which we convey information and expectations. It is our responsibility to know that the words of a healthcare professional can have a profound effect on the outcome of any procedure. I believe we should incorporate the wise use of both placebo and nocebo in our communication styles with patients.
A good tip for someone who has been given a frightening diagnosis is to refrain from racing to the computer, spending hours on internet search engines, and finding the most severe representations, pictures, and statistical outcomes for their prognosis. Ask a loved one who can cull through all the chafe and horror sites to find the most useful information, and offer that to you. You need not expose yourself to sites that can have a powerful nocebo effect, which may very well create more fear and anxiety than you already have.
Collaborative Decision Making
Whether the goal is to lose weight, lower blood pressure, improve bone density, or lower blood glucose levels, the “how to” process should be a collaborative one. The patients have lived in their own bodies, and they have an intimate knowing that the doctor will never have. This needs to be honored, even if the information patients share puzzles the doctor, who has never heard the same thing reported before. Patient know what can motivate them, and the likelihood of their following a recommendation; the doctor has evidence of what alternatives have been shown via research to be most effective. The relationship works best when a doctor and a patient both have mutual respect for the fact that they each have a body of knowledge, and both are equally important. I believe that creating such a mutual relationship depends upon the agreement and practice of both parties. Patients have not typically been given such responsibility in the past; and for a long time physicians were not trained to allow and support it. But I have seen much progress in this direction.
Active patient involvement is a key to empowering a patient, and it plays a large role in healing. How does a care provider support the motivation of a patient to make healthy lifestyle changes?
The first step should always be to ask; ask the patient, “What needs to be in place to support you in making the changes that we come up with together? What will better enable you to succeed? The answers sometimes are simple, and sometimes surprising. Knowing this information in advance can be a key to creating any successful change. I have found that for some patients, having an accountability plan is useful. In other words, giving patients homework, and having them report back via phone or email, can be very helpful for some.
Baby steps. I almost always make my first recommendation for lifestyle changes to be minimal and ridiculously simple to engender confidence and whet their appetite to ask me for further changes. There is nothing more depressing than making a first effort and failing at it from the start. I might offer an exercise that takes one minute per day, or a dietary change that begins with drinking one glass of water to start the day. While the single change may be minimal, it is surprisingly effective in beginning a new regime that can grow in its scope.
For others, more support at home is needed. This is especially true for weight loss, smoking, and alcohol reduction. If you are the only one in the household making these changes and others continue to partake, the results are far less likely to be favorable. In that case the engagement of the family becomes critical; I will ask permission for a discussion to happen with, for instance, the patient’s spouse, to explore ways of family and household support.
The Times, They Are a-Changing
I am encouraged by what I see, both in the mainstream media, as well as in the discussions I have with other health care providers. My interview with Larry Dossey, MD, in the last issue of LILIPOH is an example (Issue 76, Summer 2014). Dr. Dossey is a research journal editor, author, and physician who is a trailblazer in this paradigm shift; he also expresses feeling great encouragement for the turning of the tide. Dr. Lissa Rankin’s New York Times best-selling book, Mind Over Medicine: Scientific Proof that You Can Heal Yourself is an excellent resource. It is enjoyable to read and offers many studies that reinforce the importance of empowered patients taking charge of their own health.
It is important to note that none of my suggestions are specific to any vocation or specialty. The onus of responsibility for being mindful of improving healing relationships with a patient is just as important for a nurse, chiropractor, medical physician, physical therapist, acupuncturist, naturopath, and so forth. My vision continues to be that all patients stand in the center of their own healing circle, feeling the support of their family, their health care providers, and their community support system; that allows them the greatest possibility of self-healing.
Craig Weiner, DC
Dr. Weiner has been a health professional for nearly thirty years and maintains a chiropractic private practice in Langley, Washington on beautiful Whidbey Island. He also travels extensively to train practitioners in EFT Tapping and other healing modalities. www.chirozone.net, www.EFTtappingtraining.com