Dr David Reilly Consultant Physician & Scottish Government’s National Clinical Lead Human Caring for Integrative Care Views through a window In the Age of Science
Slides from the Keynote talk by David Reilly ICCMR 2010 Conference, Tromso, Norway. Centre for Integrative Care Linked audio file on dialogue page Glasgow Homoeopathic Hospital www.davidreilly.net Scotland
Human Caring In the Age of Science
Lost the will Is There Hardening of the Heart During Medical School?
Newton BW, Barber L, Clardy J, Clevelanes E, O'SullivanP. Ac. Med. 2008;83(3):244-249 link
First 3 yrs medical education significantly decreased students'
vicarious empathy… Vs Norm M< F During first basic science Map? Current Our & initial clinical years ENTRY * > = A coping or survival mechanism where empathic feelings are EXIT = * < suppressed?
..proposed empathy be constantly M&F < non-core reinforced cynicism may increase, and ethical and moral development can be stunted
2050 Three broad idea waves, four broad Public Health policy waves
2000
1950 Diminishing Returns from the Previous Wave/Old Map 1900 are the Call for Change In Our Systems
Hunter Gatherer Agriculture Industrial Knowledge ? And in Ourselves ? ? 1800 Modernism Materialism
Enlightenment
2050
1800 1750 1900 1950 2000
Nothing fails like success
I’m Glad Efficiency Yes/No/Later Is General Practice Delivering Holistic Holistic Approach? Care? The Views of Scotland’s GPs.
• Essential to providing good health care? • 2311 (62%) returns – 9 out of 10 GPs (87.3%) • from 3727 GP’s in Scotland’s. • Primary Care currently delivering it? – 1 in 5 (21%) Haratuma Hasagawa, David Reilly, • Current organisation of primary care made it Stewart Mercer possible? Annemieke Bikker – 1 in 15 (6.8%)
BMJ 2002 Nov 23;325(7374). Primary Health Care Research & Development, 2005; 6(4):320-328.
Your Consultations? Constraints on Holism Contributing Significantly to Increased?: Drug £ !120% • Average Length: 9.2 minutes 00-08 £11bn • PRESCRIBING? " Not Taken • How often do you feel rushed by the end – Yes 73% No 18% Neutral 7% BMJ08: 995 of your consultations? • REFERRALS TO 2nd CARE? Quite-Very Often 60% – Yes 63% No24% Neutral 12% • How often do you feel that you rush the • DEMAND FOR CAM? patient in your consultations? – Yes 57% No 10% Neutral 31% USA $287bn Adverse Drug Reactions ADRs: Quite-Very Often 45% GLOBAL $712bn 1/4M Admission UK’08 5yr !30% BMJ 2002 Nov 23;325(7374). BMJ 26April08 p908 th BMJ 2002 Nov 23;325(7374). Hosp ADR >100K † USA 4 th Primary Health Care Research & Development, 2005; 6(4):320-328. Primary Health Care Research & -6 cause death JAMA 98 Development, 2005; 6(4):320-328.
Possibilities?Imagine?
What Shall We Create Now? Imagination is more important than knowledge… Einstein
What is now proven was once only imagined… William Blake Nothing Fails Like Success. Arnold Toynbee, historian.
Hunter Gatherer Agriculture Industrial Knowledge ? ?
?
Nothing fails like success
1983 - Young doctors' views on alternative medicine. ImaginePossibilities? for you? I00 trainees at the National Conference: • Over 80% wanted training • 1 in 3 had received treatment • 1 in 10 treated by alternative practitioner. It is impossible to create a world that differs from your inner map of the world
Reilly DT.BMJ 1983 Jul 30;287(6388):337-9
Anti 1983 - Young doctors' views The Age of Intervention on alternative medicine. The Four Waves: I00 trainees at the National Conference: “… Instead of taking your headache to a neurologist, your First Great Question anxiety• Over to a 80% psychiatrist, wanted and your training search for a tonic to the chemist, you now knock on the door of the acupuncturist, hypnotherapist,• 1 in 3 had and received health food storetreatment in your quest for health. What can we (the expert) The whole person deserves a whole doctor who can assess his whole• 1 inproblem 10 treated and who can by refer alternative him to a specialist, practitioner. orthodox or do to help alternative, if required”. this situation?
outside in
Reilly DT.BMJ 1983 Jul 30;287(6388):337-9 The Statue+self-healingThe Age of Enablement Our - Evidence Based Science & Art of Our - Selves Medicine Chisels Intention Remedies Attention Drugs Compassion CARING TOOLS Herbs The Fifth Wave Empathy Needles Kindness Art Science Scanners 2nd Great Question Honesty Integrity Scalpels Listening Lasers What can be done Time Cuts to help release Touch Qualitative Quantitative Massage self-healing Silence Oils capacity? Atmosphere conditions Manipulations Motivation meaning Trances inside out Expectation relationship Awareness Words Perspective Foundations of Healing
Our - Evidence Based Art & Science of Our - Selves Medicine Chisels Intention Remedies Attention Drugs Compassion CARING TOOLS Herbs Empathy Needles Kindness Art Science Scanners Honesty Integrity Scalpels Listening Lasers Time Cuts Touch Qualitative Quantitative Massage Silence Oils Atmosphere Manipulations Motivation Trances Expectation Words Awareness Perspective Healing and Creativity
Human Caring In the Age of Science
The Healing Enquiry – creating a shift in health care Inspiration… Emerging Maps?
What Does The Rise & Impact of CAM Mirror?
!78% of (40) Doctors were still using Homoeopathy integrated in Too fucked up their NHS General Practice 2 years after introductory training.
SO WHAT WAS HAPPENING BEFORE? “Listen more/less dismissive” “Re-learned history taking” “Now finding expectations for antibiotics etc difficult” “More aware of natural healing” “More broad-minded” “Now see patients as a whole, not cellular biochem levels” “Rekindled my interest in clinical medicine” “Find practice richer and more fascinating” “I marvel at my lack Afterof homoeopathy knowledge” GPs feedback “How did I manage without it?”
Reilly D. Taylor M. Developing Integrated Medicine. Comp Ther in Med October 1993;suppl 1:1-50.
1988 Patients As Our Teachers
“See a different doctor at each visit” “I feel rushed.. unlistened to” “Only seem to prescribe drugs” “Ignore me as a person, more interested in my disease” Vision for 21st Century Health Care Care is based on continuous Care is based primarily on healing relationships visits
Care is customised Professional autonomy according to patients’ drives variability needs and values
The patient is the source of Professionals control care control
Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine 2001
take account, too, of people’s inherent ability for self-healing and recovery. support people to have more control Integrative Care of their conditions and their lives and promote their efforts to enhance their !Fragmentation health and wellbeing " Coherence in a person and/or the adoption of a holistic approach their care * focuses on the person, not the disease, and Community applies a holistic approach to meeting the Care physical, practical, functional, social, emotional A good GP was one who and spiritual needs of patients and carers listened to them, believed them, supported them and Self-Care CAM empathised with their situation, Orthodox Integrated pain and distress. an approach to care which is person centred and based on neither Therapies Care diagnosis nor prognosis but on patient and carer needs * Reilly D. Enhancing human healing. BMJ 2001;322(7279):120-1 LTC Action Plan. Living & Dying Well. Getting to GRIPS With Chronic Pain
the feeling being that quality of life/suffering issues are not given sufficient priority. The negative comments outweighed the positive experiences and observation by a rate of about 5:1 drawing on the power of people’s stories;
no emphasis on self- management or dedicated input, were common experiences.
the increasing importance which we expect NHS Boards to place on issues relating to the quality of people’s experience of services.
equip staff for new roles and action is taken to create the conditions approaches to care that support a productive partnership between informed and empowered Developing structures to allow people more time for consultations and promote continuity of care based upon a structured, systematic and ‘bounced from pillar to post’, integrated approach to the provision of care. trying drug after drug
LTC Action Plan. Living & Dying Well. Getting to GRIPS With Chronic Pain Inspiration… Emerging Maps?
© Centre Painting Alex Gray, Images David Reilly
Dopamine placebo Changes in brain function of depressed subjects during treatment with placebo Fuente-Fernandez, R. et al. Expectation and Leuchter et al dopamine release: QEEG American Journal of Psychiatry, 159 mechanism of the (1):122-129, January, 2002 placebo effect in Parkinson's disease. Quantitative EEG Science, 293, 1164 - 1166, (2001). Response to antidepressant showed objective change in the Dopamine - brain chemical lacking in Parkinson's prefrontal cortex. BUT so did response to placebo Placebo injection - released comparable amounts to real drug of the brain chemical Jon Stoessl -leader- brain-imaging study. "The
magnitude of the response is striking," “suggests in some patients most of the benefit obtained from an active drug might derive from placebo effect” “Expectation can be an effective drug”.
Reilly DT, Taylor MA. Developing Single Blind: Integrated Medicine. Compl Ther. in Med 1993;1 Suppl 1:1-50. Placebo - Team knew, OPICS explained patient did Better not) 1 month later Baseline Double Blind: The thick black pen line (Team & is the Patient’s View of Patient don’t Worse their Overall Progress - know if:) filled in interactively Active with the Doctor - who Treatment clarifies not judges OR a 2nd Placebo Lancet 1994;344: 1601-1606. A B A B Placebo
Placebo Placebo Placebo
C D C D Placebo ACTIVE
Placebo Placebo
OPIC solution Reilly DT, Taylor MA. Developing Integrated Medicine.Compl Ther in Med1993;1 Suppl 1:1-50. OPICS p 26-28 Reilly DT, Taylor MA. Developing Integrated Medicine.Compl Ther in Med1993;1 Suppl 1:1-50. OPICS p 26-28
Is this experimental? Views through a window
SEEING the cinema IMAGINING & Psychoneuroimmunology? movies of
SEEING the mind
IMAGINING
TIME 12/2/07 White cell Goebel MG et al Behavioral conditioning of immunosuppression is possible in humans. The FASEB Journal. 2002;16:1869-1873. ! DB x4 in 3 days Next Week 90! FRUSTRATION! Placebo Gap IL-2 and IFN- 80! mRNA expression, Control 70! intracellular production, and in HEARTRATE 60!
vitro release of ! IL-2 and IFN-, as 90 ! well as ! APPRECIATION lymphocyte 80! proliferation. 70! 60! HEARTRATE And get subsequent immunosuppression 1! 50! 100! 150! 200! www.heartmath.com just from TIME (SECONDS)! Immunosuppress with the Drink+Placebo. ! Psychophysiological© Copyright 1997 Institute of HeartMath! coherence - Effects? Flavoured Drink + Cyclosporin A
Changes in brain function of depressed subjects during treatment with placebo Leuchter et al QEEG American Journal of Psychiatry, 159 (1):122-129, January, 2002 Quantitative EEG
Response to antidepressant showed objective change in the prefrontal cortex. BUT so did response to placebo Monk meditating: dramatic increase gamma electrical activity in prefrontal cortex (middle frontal gyrus) – the area of positive emotions -striking changes especially meditation on compassion. From ‘Destructive Emotions’ (Link ..Empathy Research) narrated by Daniel Goldman
Alterations in Brain and Immune Function Produced by Mindfulness Meditation Davidson R, Kabat-Zinn J, Schumacher J, et al. Psychosomatic QEEG Medicine 65:564-570 (2003) Automatic EEG pre/post & 4/12 RCT of widely used 8-week training program in mindfulness meditation applied in a work environment with healthy employees. N=25 , Choice wait-list control group (N = 16) End of 8-week period all Aware vaccinated with influenza Meditators vs Controls vaccine. " left-sided anterior activation - better mood, MINDFULNESS Being aware of what’s going on when it’s going on & correlated With non- judgmental friendly awareness " antibody to flu vaccine Patient Enablement Instrument Changes in patient enablement
7.00 Predicated on creating a self-sustaining change in self-care 6.00
5.00
Built on a change in the self-relationship – e.g. Mean 4.00 self-compassion. 3.00 www.thewel.org 2.00 47 patients with full data set up to 9 months. POST CORE 1 POST MBCT 3 MONTHS 9 MONTHS
Error bars: 95% CI Centre for Integrative Care Previous Work at GHH: Mean Enablement Score was 4.7 (SEM Glasgow Homoeopathic Hospital 0.26) 50% higher than the average in primary care. BMJ 1999; 319: 738-743.
SF12 Physical Functioning Fatigue Impact Scale Changes in FIS
Changes in SF-12 Physical 130.00
120.00 32.50
110.00 30.00
Mean 100.00 27.50 Mean
90.00 25.00
80.00 22.50
70.00 20.00 BASELINE POST CORE 1 POST MBCT 3 MONTHS 9 MONTHS BASELINE POST CORE 1 POST MBCT 3 MONTHS 9 MONTHS Error bars: 95% CI Error bars: 95% CI Statistical significance improvement (i.e. decline) across all time points. SF-12Physical statistical significance from 3rd time point. Note, SF12-Mental rated as fine and no-change –Qualitative results revealed why.
ORIDL MAIN COMPLAINT Overall patients (33) The Crucible of Change
Relationship What is the difference between illness and wellness? I and WE
I Illness The Encounter
WeWellness
Tich Naht Hahn (Link ..Empathy Research)
Corridor Corridor
Creating GHH
Moth ! 90! FRUSTRATION! 80! 70!
HEARTRATE 60! ! 90! APPRECIATION! 80! 70! 60! HEARTRATE 1! 50! 100! 150! 200! TIME (SECONDS)!
! © Copyright 1997 Institute of HeartMath! Open Presence
! brain activity in area that normally assigns When The Room Disappears emotional value [judgement?]
! reaction in ‘emotional stress tests’
Richard Davidson, Prof Psychology & Psychiatry, University Wisconsin Averaged in 6 Buddhist monks. Investigating the Mind Dialogues.
Heart ECG EEG
The Role of Physiological Coherence in the Detection and Measurement of Cardiac Energy Exchange Between People R. McCraty, M. Atkinson and W. Tiller. Proceedings of the Tenth International Montreux Congress on Stress, Montreux, Relationship – Join-Up Switzerland, 1999.
!“..heart generates the strongest electromagnetic field produced by body, …. ! when two people touch or are in proximity, one´s electrocardiogram (ECG - heart) signal is registered in the other person´s electroencephalogram (EEG -brain).”
www.heartmath.org
Integrative: less fragmentation, more coherence. Empathy and Compassion EMPATHY – to imagine and seek to understand The Dance what it is like in another's situation – in their shoes. It is the fuel, the wood, from which the flame of compassion grows
COMPASSION – a quality of mercy, of wishing the other is released from their suffering, and its creative relationship - moving together causes creating change Investigating the Mind Dialogues. Empathy Study GHH NEW Maps Stories, Poems & Journeys
metaphor & new meaning and story …if you were a plant?... What?
& …outside of story…
Ask Why Do You?
Feed a pet? Evidence Based Water a plant? Poetry? Care for a child?
Why? Why is it not optional?
You can already do this – How?
Empathy and Enablement
Therapeutic Empathy Scale * Patient Enablement Instrument Enablement, Empathy and the • 1) I felt I could trust the doctor • 2)The doctor really understood • 1) Able to cope with life Therapeutic Relationship what I said • 2) Able to understand your A study of consultations at • 3)The doctor was sympathetic illness and concerned • 3) Able to cope with your illness The Centre for Integrative Care • 4)Sometimes the doctor did not • 4) Able to keep yourself healthy seem to be genuine • 5)Confident about your health • 5)The doctor did not understand Glasgow Homoeopathic Hospital • 6) Able to help yourself the way I felt • 6)The doctor talked down to me Stewart Mercer, David Reilly, Graham
Watt • Burns 1996; minor modification, PEI: Howie et al Later modified as CARE score BMJ 1999;319(7212):738-43. BMJ 2001; 322:865 Br J Gen Pract 2002 Nov;52(484):901-5. www.adhom.com Factors Correlated to Enablement Empathy & Enablement 3 key factors account 41% variation 1. Patient’s Expectation (0.37), • Empathy did not necessarily result in enablement 2. Doctor’s Confidence in Therapeutic Relationship (0.41), • But – it was a necessary pre-condition 3. Perceiving the Doctor as Empathetic (0.37). ( p<0.001) • There were no cases (i.e. not 1 in 200) of high EMPATHY explained 66% of variation in enablement. enablement with low empathy. x2.5 more important that doctor’s confidence • Since confirmed in >8000 cases. x9 more important than patient’s expectations.
BMJ 2001; 322:865. Br J Gen Pract 2002 Nov;52(484):901-5. davidreilly.net. BMJ 2001; 322:865. Br J Gen Pract 2002 Nov;52(484):901-5. davidreilly.net
ORIDL: Outcome Related To Impact On Daily Living Formerly GHH Outcome Scale 3 Links in Therapeutic Process.
ORIDL has shown concurrent validity when compared to MYMOP and SF12 & Outcome? THE ENCOUNTER THE IMPACT THE OUTCOME ORIDL Scale The patient decides for example Cured/ Back to normal +4 if the outcome/ EMPATHY [CARE] ENABLEMENT [PEI] OUTCOME [ORIDL] Major improvement +3 change is of Moderate improvement, affecting daily living +2 significant value to • Follow-up study of 74 of 200 people @12 months - measured Slight improvement, no effect on daily living +1 them in daily life (≥ Outcome Related to Impact on Daily Living: ORIDL * No change/Unsure 0 2) • Showed Enablement on exit from first encounter was Slight deterioration, no effect on daily living -1 Significantly Correlated with Subsequent Health Outcome Moderate deterioration, affecting daily living -2 12 months later. Major deterioration -3 Disastrous deterioration -4 Later work – also direct link Empathy # Outcome.
A generic tool that can be tuned for the context eg “Overall Result” “Main Complaint” Wellbeing” “Coping” * BMC Health Services Research 2007, 7: – & info on davidreilly.net
“Inside” Therapeutic Encounter Centre for Integrative Care - GHH A QUALITATIVE STUDY • Patients valued the TIME available, the WHOLE-PERSON approach, and being treated as an INDIVIDUAL • They felt their “STORY WAS LISTENED TO” (often for the first time), and all their symptoms taken seriously • They felt the doctors at GHH were TRUSTWORTHY, COMPASSIONATE and positive, often engendering HOPE • EQUALITY of relationship was a major theme, with a strong sense of mutual RESPECT
Mercer & Reilly. Patient Educ Couns 2004; 53(1): 13-8. INTEGRATIVE CARE- GHH
94% of 200 in-patients 3-6 month Cobweded face • 100% previous conventional care, 97% by Consultant
CLINICAL IMPROVEMENT (ORIDL # 2) • 73% “enough to change daily life” & 70% Mood IMPACT ON CONVENTIONAL CARE: • 41% ! consultations with GP. • 41% ! conventional drugs • 53% !admissions to hospital • 39% !outpatient visits
Background FACT 1998;3(4):190 & update on www.adhom.com.