Establishing an Optimal Healing Environment

An optimal healing environment (OHE) involves the delivery and context of medical treatment rather than the specific treatment itself. It focuses on creating healing in the process of disease treatment. This means optimizing the "meaning and context" effects of the care process rather than ignoring or dismissing them as "placebo" effects. An OHE involves attending to three primary domains of care delivery: (1) the "inner," personal environment of the team and patient; (2) the "inter," personal or relationship environment of care delivery; and (3) the "external" behavioral and physical environment of the medical home (Jonas et al., 2003).

Often, a "medicine" itself is given the most credit in medicine. A prescribed medication is valued for its "specific" medical influence, as deemed beneficial by randomized (placebo-)controlled trials (RCTs). This research focuses on the effects of the drug and attempts to control the context in order to reduce "nonspecific" (placebo) effects that may compromise the results. This helps physicians understand the specific effects of the drugs they prescribe, but it does not value those nonspecific effects that surround the prescribing of a medication. It is impossible, even undesirable, to remove all nonspecific effects from the patient encounter.

"Meaning" and "context" effects are rooted in relationship-centered care, including empathy, trust, empowerment, and hope. Research on one of the most frequently prescribed drugs in primary care, selective serotonin reuptake inhibitors (SSRIs), shows that these work only about 6% to 9% better than placebo (Kirsch et al., 2002; Turner et al., 2008). Both placebo and drug work well and are often almost 60%

1. Access to care based on an ongoing relationship with a personal physician who is able to provide first-contact, continuous, and comprehensive care.

2. Care provided by a physician-led team of individuals within the practice who collectively take responsibility for the ongoing needs of patients.

3. Care based on a whole-person (holistic) orientation in which the practice team takes responsibility for either providing care that encompasses all patient needs or arranges for the care to be done by other qualified professionals.

4. Care coordinated and integrated across all elements of the complex health care system and the patient's community.

5. Care facilitated by the use of office practice systems (e.g., registries, information technology, health information exchange) to ensure that patients receive the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

6. Reimbursement structure that supports and encourages this model of care.

Modified from American College of Physicians. Joint principles of the patient-centered medical home, March 2007.

http://www.acponline.org/advocacy/where_we_stand/medical_home/approve_jp.pdf.

Table 2-2 Optimal Healing Environments

Inner Environment to the Outer Environment

Healing Intention

Personal Wholeness

Healing Relationships

Healing Organizations

Healthy Lifestyles

Integrative

Collaborative

Medicine

Healing Spaces

Expectation Hope

Body

Spirit

Family

Community

Compassion Empathy Social support Communication

Leadership Mission Culture Teamwork

Diet

Movement Relaxation Addictions

Person oriented Conventional Complementary Culturally appropriate

Nature

Light

Color

Architecture

Enhance awareness expectancy.

Enhance personal integration.

Enhance caring communication.

Enhance delivery process.

Enhance healthy habits.

Enhance medical care.

Enhance healing structure.

Modified from Jonas WB, Chez RA. Toward optima

healing environments in

health care. J Altern Complement Med 2004;10 Suppl

1:S1-S6.

effective. Therefore, if the drug only accounts for 9% of this effect, which factor accounts for the majority of the healing influence? Maybe researchers are not giving enough credit to the clinician and the nonspecific variables that surround the prescribing of the pill. Maybe it is simply the act of listening to people who are suffering and giving them a sense of understanding that there is something they can do to overcome the suffering. Maybe it is the interaction between two people before the medicine is prescribed that has the greatest healing effect. Psychiatrists gifted at developing a trusting relationship were found to have better effects with placebo in treating depression than their colleagues less talented at developing relationships who used active drug (McKay et al., 2006). Acupuncture delivered with a greater ritual produces better effects than the same points treated with less ritual (Kaptchuk et al., 2008; Kelley et al., 2009). Maybe it is the cost. Drugs that cost more (up to a certain point) work better in pain treatment than the same drugs that cost less (Waber et al., 2008).

Family physicians do not need to wait for further research to create an OHE for patient care. Physicians already know that the factors summarized in Table 2-2 will help encourage the healthy unfolding of complex systems. The most important part in influencing healing in others is focused on the left side of the table and starts with a self-reflective, internal process. Family physicians first need to understand the importance of continuously exploring their own health, so that they are prepared to do the same for their patients.

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