I first met Mr. J when I was a newly minted doctor at Boston Medical Center (BMC). He walked into my office with an air of confidence, his head high, but his eyes rested warily upon me. He had been a member of the Black Panthers and now was a strong member in the organized labor movement.
His gaze quickly softened and crumbled though as I sat with him and asked him gently what brought him in. He was in a broken place — his body ravaged by years of pain that now interfered with his everyday activities: his blood pressure was high and contributing to daily headaches, his once strong body had grown corpulent with inactivity, his partner of many years was falling deeper into renal failure and undergoing regular dialysis, and he felt deeply alone in the world and depressed.
Together, we started discussing each element of his medical conditions, trying to disentangle them from the knot of concerns so that in addressing each one separately, we could perhaps fix the whole. At least that is what I told myself in those initial days of practicing medicine.
A decade of practice has taught me that it is not possible to disentangle illnesses like Mr. J’s. Each element was interconnected—not a knot but rather a woven tapestry—each of them a strand in his story and none of them there by accident. For real movement towards health to occur for Mr. J (and for any of us) all of these pieces of the medical chart had to be addressed together.
This is not a new idea. The founders of medicine were expert at looking at the whole person. Hippocrates is believed to have said: “It is more important to know what sort of person has a disease than to know what sort of disease that person has.” However, the practice of medicine today has traveled lands away from the wisdom of our founders.
Young doctors today are increasingly encouraged to train in specialized medicine, becoming more and more expert on a particular part of the body and its associated conditions and diseases. The lure of these specialties includes a sense of prestige and larger amounts of pay — certainly not something to be ignored by those who have gone through large amounts of financial strain to get through long years of medical training.
According to the National Resident Matching Program, 7,871 US medical students matched in 2015 in primary care — internal medicine, family medicine, and pediatrics. While this number is up from prior recent years, it still only comprises 26 percent of the 30,212 positions available in residency trainings.
Compartmentalized thinking about illnesses and body systems is further supported by the increasingly common 15-minute office visit, as well as today’s coding and reimbursement system. This is particularly true of the new International Classification of Diseases (ICD)-10 coding system. Replacing its sister ICD-9, the ICD-10 code breaks a patient’s health conditions into incredible granularity. Up to seven digits in length, the ICD-10 code can capture up to 68,000 medical diagnoses (up from 13,000 in the ICD-9 classification).
And while the expertise of these specialty fields and the specificity of our coding system have an undeniably important place in the advancement of medicine, where does this leave our patients — patients, who though they may certainly feel fractured, are living with all of these bits together in one body and in one life?
This is the question that plagued me and a handful of my colleagues at Boston Medical Center, where 70 percent of patients come from underserved populations. To offer some sort of healing to this fractured system of approaching patients, we have developed a model of care that brings together three tools — medical group visits, the principles of mindfulness-based stress reduction (MBSR), and evidenced-based complementary medicine.
We named our new model Integrative Medicine Group Visits (IMGV).
The focus of the model is chronic pain, which often lies at the center of many of our patients’ stories. The Institute of Medicine (IOM) recently estimated that chronic pain affects 100 million Americans, deeply impacting their lives and costing the health care system up to $635 billion a year. Furthermore, research shows (and our experience supports) that pain is consistently undertreated in patients of low socioeconomic and minority status.
Three Components Of The Model
Much of the medical literature on treatment of chronic pain and its associated chronic conditions deals with group medical visits, mindfulness-based stress reduction, and evidenced-based complementary medicine. These three tools are key components of the IMGV model.
Group Medical Visits
Group medical visits are a model of care whereby up to 12 patients who have a shared condition such as diabetes, high blood pressure, or even pregnancy are seen together for an extended medical visit, allowing time for individual medical attention, teaching time, self-management, and socializing. These kinds of groups have been shown to be effective for some patients in improving their health-related quality of life, satisfaction, chronic pain trust in their physicians, coordination of care, and diminishing disability days.
Mindfulness-based Stress Reduction
Mindfulness-based stress reduction is a model of care that uses mindfulness (defined by the model’s founder Jon Kabat-Zinn as “the practice of purposeful awareness of the present moment with a nonjudgmental attitude”) as its base for an eight-week group curriculum. The course includes didactic discussions and experiential practices such as sitting meditation, body scan, walking meditation, and yoga. A recent review of 17 randomized controlled trials of MBSR showed overall improvement in mental health measures compared to controls, as well as improvement in chronic pain scores.
Integrative medicine, as defined by the Academic Consortium for Integrative Medicine and Health is “the practice of medicine and health that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing.”
At Boston Medical Center, we founded the Program for Integrative Medicine and Health Care Disparities over a decade ago and are one of the few academic centers in the country offering therapies such as acupuncture, yoga, massage, and tai chi to the urban underserved. We have seen, and systematic reviews support, that evidenced-based complementary medicine therapies such as these can all help with chronic pain.
Structure of the Integrative Medicine Group Visit
The Integrative Medicine Group Visit incorporates patient-centered strategies to improve health, coping, and adherence to chronic care management. It is an intensive nine-week series for a group of eight to twelve patients with chronic pain and other chronic conditions, such as depression and obesity, which often accompany pain.
The two-and-a-half-hour weekly session starts with patients taking their own vital signs, rating their own pain and mood, and writing about any health changes they have noted over the prior week. The session is co-facilitated by a physician and a mindfulness-based stress reduction instructor, who use motivational interviewing and shared decision-making techniques.
The visit includes self-care management and patient education on topics such as glycemic index, blood pressure, stress and its effect on the body, omega 3s, and vitamins and minerals. Also included are the principles of mindfulness-based stress reduction and group experiences in evidence-based complementary medicine, such as self-massage, acupressure, yoga, and cooking demonstrations.
The patients always share a healthy meal at the end of the group and have time to practice mindful eating as well as an opportunity to connect to each other more. Additionally, each of the participants meets individually (before or after the group) with the provider to address private or acute concerns and, when needed, for specific medication adjustments, diagnostic test ordering, or referrals. Confidentiality is established within the group by having each of the participants and the providers sign a confidentiality agreement.
Of the initial patients that went through the IMGV program in 2013-2014, the majority had a statistically significant decrease in pain and depression, and clinically significant improvements in sleep quality and perceived stress. Across the board, those who suffered from high blood pressure had a decrease in both their systolic and diastolic blood pressure.
What is more, patients that were in IMGV had far fewer emergency room visits while in the groups than before or after. We conducted interviews with participants at the end of the IMGV, and their words gave us just as much information as the numbers.
One participant said, “Before I started these meetings I pretty much gave up my life because it felt worthless. The pain had taken over my life…when you are overwhelmed, stressed, in pain you forget to breathe and how to de-stress. After the group meetings I have been meditating, breathing, when I feel that my anxiety levels are rising I use my tools. I do my yoga. I am a more positive person I have to say, more happiness.”
The encouraging data and inspiring stories of patients from our pilot program led us to apply for a grant from the Patient Centered Outcomes Research Institute (PCORI). Established as part of the Affordable Care Act in 2010, PCORI’s goal is “to determine which of the many healthcare options available to patients and those who care for them work best in particular circumstances.”
Among thousands of applications for PCORI funding, IMGV was one of the few selected for funding in 2014 and the only one of its kind focusing on health care disparities and integrative medicine. Through this grant, we have been able to expand the IMGV to other community health centers in the Boston area that are affiliated with Boston Medical Center, train more providers in this model of care, develop our curriculum, and speak locally and nationally about the model. Most importantly we have been able to open our doors to more patients suffering from chronic pain and accompanying chronic illnesses.
As for Mr. J, he is now on the patient advisory counsel for the IMGV. He is not on any blood pressure medications, as he has used walking and healthy eating to get his blood pressure down. His partner of many years has since died, and though he misses her terribly, he has reconnected to his own children again and reached out to old friends. He has gone back to school to become an urban gardener. His pain has diminished to such a tolerable level that, he smilingly tells me, he can happily dig the fruits out of his own garden.