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Whole Health in Your PracticeDay 1 Afternoon

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Whole Health in Your PracticeAdvancing Skills in the Delivery of Personalized, Proactive, and

Patient‐Driven Care

Day 1 Afternoon• Me at the Center: Mission, Aspiration, Purpose• Mindful Awareness• Resilience and Clinician Self‐Care• The Personal Health Inventory• Setting the Stage for Implementation: Local Resources

Welcome back to an afternoon of excitement and intrigue...

Reflection

How “Whole Health‐y” is Your Practice?

Based on doing this self‐assessment, what are some specific things you would like to do differently in your daily work?

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Partner Discussion



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Whole Health in Your Practice

4. “Me” at the Center:Mission, Aspiration,

Purpose

Video – Purpose in Life 0‐100

https://www.youtube.com/watch?v=mK66az43EOI


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Video – Dream Rangers

https://www.youtube.com/watch?v=t5RBN97aBNc

Reflection on What Really MattersFind a partner. Each person will take a turn sharing while the other listens.

You will each choose one topic to share about:

JOY: What brings you a sense of joy and happiness?

DREAMS: What is one of your life‐long dreams?

HEALTH: What is your vision of your best possible health?

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Don’t start just yet! More info

on the next slide!

Don’t start just yet! More info

on the next slide!

1. Ask the question to your partner

2. Listen, reflect, and ask clarifying questions. Don’t try to “solve” anything

3. As time allows, take it deeper:

– “How would your life or health change if you focused more on this part of your life?”

o“What would you be doing?”

o“What would be different?”

o“How would you feel?”

Some Suggestions for the Listener

OK, now you can start!OK, now you can start!

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Group Discussion:

What did you notice?

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The Healing Power of Purpose

• Lowers mortality

• It decreases risk of death as much as it is increased by tobacco use, poor diet, inactivity, or high stress levels

• Reduces stroke, heart attack, Alzheimer’s

• Improves sleep, mood, sex life, mental health

• Increases success of staying substance free, seeking prevention

• ↑ HDL, ↓ inflamma on

• Ramps up DNA repair

Almujiang et al, JAMA Network Open, 2019;2(5)e194270. Strecher V, Life on Purpose, New York: Harper Collins, 2016.Burrow et al, Pers Individ Diff, 2016;90:187-9.

Mapping to the “MAP”() • Mission, Aspiration, Purpose

(MAP)

• “The Game Changer”

• Focusing there gets you “buy in” right away

• Even if time is short, still try

to do this part for a moment

• Foundational to the Personal Health Planning Process

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“What do you want your health for?”

People’s answers may surprise you!

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Think About Your Own Mission

• Why are you here in the VA?

• Why are you here on the planet?

• What REALLY matters to you?

• What do you want your health for?

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List ideas on page 37

Map to the “MAP”: Examples of ?’s

• It would really help me partner with you in your care, if I understood what is important to you in your life.

• What really matters to you in your life? What do you want your health for?

• What brings you a sense of joy and happiness?

• How does your current health impact what is most important to you?

• What is your vision of your best possible health?


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Demo: Mapping to the MAP

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Large Group Discussion:

Any experiences using MAP in your practice?

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Explore the “MAP”: Your Turn

• Find a new partner. Decide who will ask questions first.

• Ask about Mission, Aspirations, and Purpose.

• Practice generous listening. Fine to paraphrase or reflect back what they are saying.

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Reflection:

Could you use this with your Veterans?

What does that look like?


Group Discussion:

Could you use this with your Veterans?

What does that look like?



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CASE STUDY – Dave Page 17

• 68 year old Army Veteran (Vietnam)

• Married, one son (47) and one daughter (45)

• Retired mechanic

Current concerns:

• Difficulty falling asleep, ‐ has flashbacks and nightmares

• Poorly‐controlled type 2 diabetes for 25 years

• Right below‐the‐knee amputation 4 years ago

• Chronic pain in left leg; poor circulation and leg ulcers

• Left foot removed 3 days ago. Admitted to have left lower leg removed tomorrow

DiscussionChanging the Conversation

Imagine you are about to meet with Dave…

• What feelings come up about working with Dave, when you hear about this case?

• Any assumptions you find yourself making about him?

• Do you feel connected to him, based on this information?

• What would you guess is Dave’s MAP?

DAVE

The story from the Veteran’s perspective(Page 18)

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DiscussionChanging the ConversationImagine (again) you are about to meet with

Dave…

• How do you feel about working with Dave now?

• What did you learn from his story that will affect how you interact with Dave?

• Would you document differently to share his information with other staff?

• Is the information from the narrative useful/helpful? What provides MAP for Dave?

My Life, My Story

• Narratives

– Veterans interviewed their life stories. Narrative is transcribed and reviewed by the Veteran.

• Personal Health Inventories

- Team helps Veterans complete a PHI and identify wellness goals

- Data passed on to outpatient team and recorded in CPRS

• Writing Workshops

– VA staff can write their own stories, focusing on their experiences as care providers

My Life, My Story

There are Narrative Medicine Tools available in the Whole Health Library at www.wholehealth.wisc.edu


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Video: My Life, My Story:

VA’s healthcare improvements through sharing stories

https://youtu.be/fpzgVlExS20

To Sum Up

• Focus on a person’s values – stay attuned to the “why”

• We’ll see that a Personal Health Inventory can help capture MAP even before the visit begins

• Knowing someone’s story allows for a richer connection and better care, along with better outcomes

• If you explore the MAP, you are well on your way to offering Whole Health in your practice

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5. Mindful Awareness


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You are probably….

A Dog!!

Mindful Awareness is Everywhere Now

Images: content.time.commindful.org Scientificamerican.com Nationalgeographic.com


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A Core Concept

Photo: Explore.va.gov

Paying more attention to my body and mind helps me make better decisions in

my self care

With practice, I can change my focus and my thinking and my responses to benefit my

health

Definition of Mindful Awareness

• Way of being

• In the present moment

• On purpose

• Non‐judgmentally

• With kindnessPhoto: dailywildlifephoto.nathab.com

Other Ways to Define it…

• Jack Kornfield: Loving awareness

• Sharon Salzberg: a special kind of awareness characterized by openness, curiosity and acceptance

• Ron Epstein: Remembering who you are and what is important, every moment of every day.

• Paying extraordinary attention to ordinary experiences…as if your life depended on it!


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Some Clarifications Passport, Ch. 4

• Mindful awareness is a general concept. You can cultivate it informally, or through formal practice.

• Mindfulness is often used as a synonym for Mindfulness Based Stress Reduction, a course that focuses on teaching approaches that can help enhance mindful awareness.

• Meditation comes in many forms. Some forms support mindful awareness; others focus on other goals.

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Mindful Awareness

We all have it...the natural

capacity to pay attention with curiosity and openness.

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Mindful Awareness

We also have the capacity for

mindlessness, inattention, or

going on autopilot.

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Mindful Awareness Experience

Mindful Awareness Research

Photo: Nationalgeographic.com

What research

findings have you seen?

For More Information...Passport, Chapter 4

(See the resource list at the end of that chapter)

Also....Whole Health Library

https://wholehealth.wisc.edu/overviews/mindful‐awareness/


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A Call for More Rigorous Research

Attention is more focused on:• Clearer definitions – what is being

studied?• Stricter study methods• Being clear on what we really know• Clinical relevance

Attention is more focused on:• Clearer definitions – what is being

studied?• Stricter study methods• Being clear on what we really know• Clinical relevance

An Early Study: Promega

• Showed even an 8-week course led to changes in EEG– Meditators had ↑ activity of the left prefrontal cortex

• Vigor

• Optimism

• Enthusiasm

– ↓ activity of the right prefrontal cortex

• Anger

• Fear and anxiety

• Depression

• We now know multiple areas are affectedDavidson, et al. Psychosom Med. 2003;65(4):564-70.

Mindful Awareness and Biology

• Longer telomeres = longer life and less chronic illness

• Various types of mindfulness meditation lengthen telomeres (11-500+ hours)

• Brains spend more time in a relaxed state

• Brains are more attentive, too

• Inflammation decreases

• Stress hormones decrease

• Immune function improvesSchutte, Psychoneuroendorinol, 2014;42:45‐8. https://wholehealth.wisc.edu/overviews/mindful-awareness/


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Research Highlights: Mindful Awareness Helps Healthy People

• Reduces– Stress and anxiety– Depression, rumination– Anger and distress

• Improves– Quality of life

– Emotional intelligence, creativity

– Concentration

• And (per another study)– Enhances spirituality and values– Increases empathy– Fosters self‐compassion

Photo: Adam Rindfleisch

Khoury, J Psychosom Res 2015;78:519–528. / Chiesa, J Altern Complement Med, 2009;15(5):593-600.

Research Highlights: Mindful Awareness Helps Sick People

Remember, mindfulness is not merely a ‘therapy,’ but it has shown benefit with some conditions

• Especially responsive:– Chronic stress

– Depression

– Somatization

– Various types of pain

– Anxiety disorder

– Psychosis

– Substance use

– Binge eating

– Insomnia

http://www.hsrd.research.va.gov/publications/esp/cam_mindfulness‐REPORT.pdf

Mindful Awareness:How do you cultivate it?

“The key to meditation is learning to stay.”


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Mindful awareness is an opportunity to be in the wholeness of life… including suffering, joy, peace, unrest, creativity,

fullness, emptiness – everything…It is not merely a technique for coping with a specific problem.

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More Than A Tool

Discussion

When are you at your most:Aware Present Centered Focused Calm

Formal and Informal Practices

• Breath Awareness

• Seated Meditation

• Moving/ Walking Meditation

• Scripture Study

• Mindful Eating

• Contemplative Prayer

• Compassion Practice

• Body Scans

• Mantram Repetition Photo: Dailyheal.com


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1. Beginner’s Mind

2. Non-judging

3. Patience

4. Non-striving

5. Acceptance

6. Letting go

7. Trust

Seven Attitudes of Mindful Awareness

Drop Beneath and ... Observe

ThoughtsJudgment

Emotions

Awareness

MoreMindful Awareness

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Breath Awareness Practice1. Find a comfortable position

2. Allow eyes to close if you like

3. Remember the seven attitudes

4. Let go of busy‐ness or life concerns

5. Pay attention to your breath

6. When attention wanders to thought, sensation, emotion etc. simply notice

7. Gently return focus to your breath

8. Practice as long as you wish

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Mindful Awareness and Medicine

Meditation: How much at a time, and is it safe?

–Safety

Very safe, and…

…If risk of psychosis or flashbacks, should be guided by a trained professional


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Discussion:How can your clinical stool or office chair

become your meditation cushion?

That is, how can you integrate mindful awareness in your daily life?

List your ideas on page 38.

Suggestions: Mindful Awareness at Work

• Pause for a moment before every interaction

– Threshold exercise– A few deep breaths– While cleaning your hands

• Use a stethoscope or other object as a reminder

– Sitting in a chair or shaking hands can also remind you

• Join a group to practice

– Some PACTs do mindfulness before they start the day

• Try other daily practices

– You will experience several during this course

• Other ideas?


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Take a Break!

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6. Resilience and Clinician Self‐Care

We start out...

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And Challenges Arise...

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Reflection




Partner Discussion





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Burnout Indicators

Burnout affects half of physicians, and even more nurses.

Key indicators of burnout include:

1. Emotional exhaustion

2. Depersonalization & decreased empathy

3. Lack of personal accomplishment

http://www.headington‐institute.org/Portals/32/Resources/Test_Are_you_burnout.pdf

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Key elements:1. Depersonalization & decreased

empathy2. Reduced performance3. Poor judgement

Compassion Fatigue

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Zhang BM et al, J Nurs Manag, 2018;26:810‐9.

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• Studied most in nurses• Can come on faster

than burnout

The solution?PAUSE. REST.BE KIND TO YOURSELF.

The solution?PAUSE. REST.BE KIND TO YOURSELF.

1. Acknowledgement of the suffering. What are you feeling? Where in your body? What do you need to be comforted?

1. Acknowledgement of the suffering. What are you feeling? Where in your body? What do you need to be comforted?

Maybe It’s Really Empathy Fatigue

2. Self‐talk. What might you say to yourself to offer comfort? Serenity prayer? A mantra? Quote scripture?

2. Self‐talk. What might you say to yourself to offer comfort? Serenity prayer? A mantra? Quote scripture?

https://pro.psychcentral.com/self‐compassion‐as‐an‐antidote‐to‐empathy‐fatigue/

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You can’t have too much compassion, but you can totally have too much of feeling the suffering of others...

3. Soothing touch – heart, abdomen, face, self‐hug 3. Soothing touch – heart, abdomen, face, self‐hug

Best to do these right in the moment, when you can...Best to do these right in the moment, when you can...


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Burnout in General Population vsPhysicians, 2011 to 2014

Shanafelt TD, et al. Mayo Clinic Proceedings, 2015;90:1600‐13.

Also in the 30-50% prevalence

for nurses, psychologists, social workers,

and others

Also in the 30-50% prevalence

for nurses, psychologists, social workers,

and others

2015 VISN 1 All Primary Care Staff Burnout Survey

62% of primary care staff respondents are experiencing burnout

•Highest in Health Technicians and LPNs at 73% vs. other PACT members.

Primary care staff show moderate‐to‐high levels of engagement. Nurses have the highest levels.

•Nures have higher levels of ‘Dedication’ and ‘Absorption’ in the work; lower ‘Vigor’

There is a moderate‐to‐high level of mismatch between workers’ and the workplace’s assessments

•Mismatch is most pronounced in Control & Workload

Why Does it Matter?Burnout’s Effects

• Relationship problems– Marital discord– Conflicts with colleagues– Poor patient relationships

• Accidents• Poor decision making• Less empathy• Medical errors• Poor communication• Health problems• Quitting, early retirement

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Your Own Self‐Care and Patients

• Your well‐being matters in its own right, AND...

• You preach what you practice

–That is, you mention behaviors to patients if you do them yourself

• They practice what you preach

–Patients engage more with you if they know you are doing self‐care

–E.g., the ‘apple and helmet’ studyFrank E, et al. CMAJ 2013;185(8):649‐53.Frank E, et al. Arch Fam Med 2000;9(4):359‐67.Frank E, et al. Arch Fam Med 2000;9(3):287‐90. Images: Road.cc and techflourish.com

Patients follow your example

Patients follow your example

Impact of Professional Fulfillment

• Clinicians who have higher job satisfaction receive higher patient satisfaction ratings

• Higher professional fulfillment for a clinician is linked to more patient adherence

– Includes taking medications, exercise, and food choices

DiMatteo et al. Health Psychol. 1993;12(2):93‐102.Haas et al. J Gen Intern Med 2000;15(2):122‐8.

Photo: Familycircle.com

What Leads to Burnout?

1. Lack of control over office processes

2. Lack of control over schedule

3. Excessive paperwork4. Difficult and

complicated patients5. Not enough time in

the day; not enough for for self care

6. Lack of coping skills for stress

7. Personal bad habits (smoking, drug use)

8. Not enough time in the day

9. Regret over chosen career

10. Perfectionism*

Eckleberry‐Hunt et al, Acad Med 2009; 84:269‐277.

IndividualInstitutional

*Perfectionism and other traits need not be a liability. And we can’t blame the victim!

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Drivers of Resilience & Burnout

Shanafelt et al, Mayo Clin Proc. 2017;92(1)129‐146.

The Quadruple Aim

Better Outcomes

Lower CostImproved Patient

Experience

Improved Clinician

Experience

Bodenheimer, Ann Fam Med. 2014;12(6): 573-6.

The Quadruple Aim

Better Outcomes

Lower CostImproved Patient

Experience

Improved Clinician

Experience

Bodenheimer, Ann Fam Med. 2014;12(6): 573-6.


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The Opposite of Burnout:Resilience Discussion

• In general, what makes a person more resilient?

• What helps you be/stay resilient?

• What would help your team?

Resilience Can Be Trained!

1. Think flexibly

2. Have a positive attitude

3. Develop “active coping skills”

4. Fine‐tune your moral compass

5. Have role models

Can also do a web search for “The Resilience Prescription”

for a summary

Resilience Can Be Trained!

6. Face your fears

7. Have strong social support

8. Maintain Physical well‐being

9. Train regularly (plan ahead)

10.Recognize and foster your strengths

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Short Mindfulness Intervention:Maslach Burnout Inventory Changes

Fortney, et al., Ann Fam Med, 2013;11(5):412‐20.

Even brief meditation training decreased elements of burnout in clinicians.

Discussion: Resilience Superstars

At your table, each person chooses one of the following to share about for for a minute or two.

1. Who do you admire for their resilience? Why?

2. When have you shown resilience in your own life? How? What helped you succeed?

3. How can you cultivate more resilience in your life?

4. Share an example of when a patient or colleague demonstrated strength and resilience.

5. How can you enhance resilience in your workplace?

Photo: positivepsychologyprogram.com

To Learn More:Whole Health Library

https://wholehealth.wisc.edu/tools/burnout‐part‐1‐origins/

https://wholehealth.wisc.edu/tools/burnout‐part‐2‐solutions/

Photo: positivepsychologyprogram.com


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7. Assessing Whole Health:The Personal Health Inventory

Gathering and Synthesizing Information:The Whole Health Assessment

• We talked about Self‐Reflection and Exploration (right upper quadrant) in the MAP module.

• Next, collecting and consolidating information is key.

• The Personal Health Inventory is one of many ways to assess where someone is.

Whole Health Assessment Tools Come in Many Forms

• Patient Interview• Physical exam• Lab/Diagnostics• Clinical Tools for Risk Assessment


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The Circle is an Assessment Tool

“Look at this Circle.

• The green areas focus on different areas of self-care.

• Where are your strengths?

• Is there an area where you would like to focus today?”

“Look at this Circle.

• The green areas focus on different areas of self-care.

• Where are your strengths?

• Is there an area where you would like to focus today?”

The Key to Whole Health AssessmentPersonal Health Inventories

On a scale of 1 to 5 with 1 being miserable and 5 being great where do you feel you are on the scale for:

1. Physical Well‐Being?

2. Mental/Emotional Well‐being?

3. Life: How is it to live your day to day life?

The Parts of the PHI

These are referred to as “The Vitality

Signs”


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• What do you live for?

• What matters to you?

• Why do you want to be healthy?

PHI: Mapping to their MAP

These questions get them started with exploring

MAP even before a clinic visit.

PHI: Where You Are,Where You Would Like to be

In the MyStoryPHI, there is space to write about your self‐ratings, too.

There is also one question on professional care here.The numbers help with The numbers help with

applying Motivational Interviewing

• Now that you have thought about what matters...

–What is your vision of your best possible self?

–What would your life look like?

–What activities?

• Any areas you want to work on?

Where might you start?

PHI: The Reflection Questions

If they answer

these, you already have a head start on the PHP!


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Homework Activity: Your Own PHI

• Complete the Brief Personal Health Inventory, pages 13‐14

– It is 2 pages, front and back–Takes 5‐10 minutes

–Have loved ones do it too!

• NOTE: You will be discussing the inventory with others throughout the rest of the course

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Pulse Checks, Homework

But don’t leave! We are not done yet!

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8. Setting the Stage for Implementation:Local Resources


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Thank YouAnd see you tomorrow!

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