A Healthcare Educational System

Coping gets short shrift in our healthcare system. We don’t spend a lot of time or money on it. Instead, we devote the vast majority of our healthcare resources to various procedures and medications that attempt to cure conditions, or at the very least attempt to get rid of the symptoms that on-going health conditions cause. We hardly spend any time or money on what patients themselves can do to keep the conditions from disrupting their lives.

At the Institute for Chronic Pain, we believe this lack of attention to coping is a mistake. It’s a mistake because it leads to poorer health and greater costs. Let’s explain how a significant lack of attention to coping leads to these unfortunate outcomes and then review what we might do about it.

A healthcare delivery system

For the most part, we have a healthcare delivery system. I mean this statement quite literally. The predominant way in which we provide healthcare in our society is that when something ails us we seek a healthcare expert who provides or delivers to us a procedure or therapy or medication that makes us well. The standard name for this type of healthcare is the ‘acute medical model’ of care. In such care, health is brought about by the healthcare provider. The provider has a certain expertise in what ails us. As patients, we lack this expertise and so rely on the provider to use his or her expertise in order to do something therapeutic to us. As such, healthcare providers do things to us to make us well, as long as we do what they recommend. Patients don’t have much role in the acute medical model, besides being compliant and patient with the recommended therapies and procedures and medications. The real power lies in the provider who provides healthcare. In this way, we come to healthcare providers in a state of ill-health and health gets delivered to us. As stated, we have a healthcare delivery system.

The acute medical model is all well and good, especially if we have cures for what ails us, or at least the ability to keep us alive in a medical emergency. When having an acute appendicitis or a heart attack, it usually pays to be compliant with the emergency room provider’s recommendations. In such situations, we become the passive recipient of the intellectual and technical expertise of a healthcare team that delivers us from a state of poor health and danger to a state of relative better health and safety. We can think of any number of acute health conditions for which this model of care is well suited and can produce dramatic, life-changing, indeed life-saving, results.

Perhaps it’s because the acute medical model can produce such results that it has become the predominant model of providing healthcare in our society. Whatever the reason, it has become the paradigm by which we conceptualize healthcare. By it’s terms, we understand the roles of providers and patients – those who provide healthcare and those who receive it. We use it to understand what we are supposed to do when being unwell – we rely on our healthcare providers to make us well. We use it to understand the healthcare system itself – we have a healthcare delivery system.

The practical consequences of the predominance of this way of understanding healthcare are numerous. Because the procedures, therapies, and medications of the acute medical model are valued in our society, they are typically reimbursed well. They are also reimbursed readily – they tend to have few obstacles to payments. As such, it’s largely how hospitals and clinics make money to pay salaries and other expenses and to make a profit. It’s largely how healthcare providers earn their living. It’s how the pharmaceutical and medical technology industries pay employee salaries and create value for shareholders. It’s also largely what patients want. Who doesn’t want a cure?

The predominance of the acute medical model can also lead to some unfortunate consequences, particularly when it comes to the role of the patient. As patients, we tend to believe that the acute medical model can deliver on its promise of making us well more often than it can in actuality. We might acknowledge that it can’t cure us of everything, but surely, we tend to think, it can keep us well enough. As such, the focus on healthcare in our society tends to remain on what healthcare providers and their technical expertise can do for us. Power and responsibility remain with the healthcare providers, even in cases where their power to make us well is not so great. This subtle form of dependency on the healthcare system to deliver wellness can therefore become increasingly problematic: it’s fine in the cases of acute appendicitis or acute heart attack, but not so fine in conditions where there is no cure.

Chronic health conditions are the bane of our society, generally, and of our healthcare delivery system, specifically. Conditions such as chronic pain, heart disease, type II diabetes, obesity, asthma, and others have become ubiquitous in our society. Whereas our grandparents, we might say, lived in an age of infectious illness (think influenza at the beginning of the twentieth century or polio in the early to mid-twentieth century), we live now in an age of chronic illness. Such chronic health conditions are what now burden us. Despite the magnitude of this problem, the healthcare delivery system isn’t particularly well-suited for this challenge even though, as a society, both as patients and healthcare providers, we tend to look to it for the solutions. It has no cures, to be sure. However, it can’t even keep us all that well. At best, it maintains the status quo of the current less-than-healthy state of the patient. Management and stability of pain, blood pressure, cholesterol, and blood sugars become the goal. Patients, in this model, are to remain compliant with the medication and other therapy regimens in order to keep their numbers within some acceptable range of poor health. Notice how patients remain subtly dependent on the delivery of healthcare in this system and yet the healthcare that is delivered is not so great.

Because of these factors, chronic conditions are also the main financial drain on our healthcare system. Chronic health conditions constitute 86% of the cost of our healthcare delivery system and are the leading cause of disability (CDC, 2015). Acute medical emergencies notwithstanding, for this devotion of healthcare dollars, our system of delivering healthcare fosters a subtle form of dependency in exchange for chronic, mediocre states of health and outright disability. Obviously, we don’t get a lot of bang for our buck.

The role of the patient in coping with health problems

So, what’s missing in this picture? It’s the lack of emphasis on what patients can do for themselves in responding to their own chronic health conditions. In the predominance of the acute medical model of delivering care, both patients and providers forget that patients themselves have a role to play in their health. We call it coping.

We might define coping as our cognitive, emotional and behavioral responses to a problem, such as a health condition. In acute health conditions, the typical coping response is the following: cognitively, we don’t know what’s going on and we need answers in the form of a diagnosis and treatment plan; emotionally, we’re concerned, if not alarmed and frightened; this emotional alarm is helpful because it motivates us to act and seek the help of those who do know what to do; and so, behaviorally, we seek healthcare providers who have the requisite expertise to do something to make us well again. This is what good coping looks like in acute medical model healthcare. If, however, as we do in our society, we continue to apply this model of healthcare to chronic conditions we don’t fair so well: cognitively, as patients, we remain lacking the requisite expertise to adequately respond to our condition; emotionally, we remain concerned, if not alarmed, by our on-going state of health and so remain motivated to continue seeking help from those who are supposed to deliver us out of our state of poor health; behaviorally, then, we continue to seek acute medical care – its procedures, therapies, and medications, which simply maintain the status quo. Lack of knowledge or expertise, emotionally alarmed, and dependent – these are not the characteristics of good coping, at least not in the context of chronic health conditions.

What’s lacking when we allow the acute medical model to predominate in our healthcare system is the capacity to:

  1. Cognitively, teach patients what they have, how it develops and why it continues on a chronic course; how to tolerate an understanding of the patient’s own role in these causal factors; and how they can respond to it.
  2. Emotionally, empower them so that they remain both confident in their own expertise of how to self-manage the condition and motivated to do so over the long-term.
  3. Behaviorally,  coach patients on how to make meaningful, productive and sustained changes in their lifestyle so as to improve their state of health and well-being.

The acute medical model simply fails to provide these kinds of help, as it’s not designed to provide it.

Nonetheless, outside the acute medical model, in what’s called the ‘rehabilitation model of care,’ we have healthcare providers who assume this role of using their expertise to teach, empower, and motivate patients to cope well with chronic health conditions. They are health psychologists and other rehabilitation providers. You find them in chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and, increasingly, cutting-edge interdisciplinary primary care clinics where you can see both a primary care physician and a primary care health psychologist.

Notice that the number of such providers and programs pale in comparison to the procedures, therapies, and medications of the acute medical model. As a society and as a healthcare delivery system, we continue to value external, technological procedures and pills over internal coping and lifestyle change, even though the latter is oftentimes more effective. Healthcare providers continue to refer patients to acute medical model care despite the option to refer them to rehabilitation, or coping-based, care. Patients continue to seek the former more than the latter. Insurance companies too continue to reimburse procedural- and pharmaceutical-based care at exponentially higher rates than education and counseling-based care.

It seems our priorities are out of whack when it comes to the greatest health needs of our society. In the case of chronic care, we don’t need more acute medical care, but more educational-based care.

A healthcare educational system

So, what if in addition to a healthcare delivery system we also had a healthcare educational system? What would it look like? Beginning with primary care, it would involve clinics that have not only primary care medical providers, but also primary care health psychologists. So, for example, type II diabetes patients would obtain medication management and nutritional counseling, as they do now, but also meet with a health psychologist to focus on the following:

  • Tolerating and accepting greater degrees of ownership and responsibility for their diabetes and overall health
  • Understanding the role that patients play in the development and maintenance of the condition
  • How to make incremental lifestyle changes to improve their diabetes and overall health
  • How to sustain these changes over time

In the limited number of primary care clinics that operate in this manner, the focus of such care is not to deliver well-being to patients, but to educate them, empower them, and motivate them to improve their well-being themselves. As a result, patients no longer remain in the afore-mentioned subtle dependency on the expertise of their healthcare providers. Through a healthcare educational system, patients become experts themselves.

Health psychologists, thus, operate under the principle that knowledge is often insufficient
for sustained meaningful change. In our current acute medical model, the education and counseling that medical providers engage in typically ends with the provision of information: information, such as that smoking is bad for you; that you should lose weight; that you should exercise more; that you should learn to manage your stress; and so on. However, who doesn’t know these things? Simply knowing these things isn’t typically enough to successfully quit smoking, lose weight, start exercising or manage stress. Information is therefore insufficient for successful lifestyle change.

As such, we typically need someone to sit down and go over how to apply this information in ways that lead to long-term successful lifestyle change. However, no one, in our current healthcare delivery system, sits down with patients and actually goes over how to cognitively tolerate and accept such information or how to understand the individual’s role in achieving these goals; no one sits down with them and shows how to become empowered, confident and motivated to pursue and maintain these health goals; no one sits down and clarifies how to actually make incremental behavior changes that can successfully meet these lifestyle goals; no one develops a trusting relationship over time in which these often sensitive discussions can be had, as a coach has with the athlete that he or she trains; and no one can meet with patients on a periodic basis over time, with extended appointment times that last anywhere from fifteen minutes to an hour. No expert healthcare provider performs this role, except for the health psychologist.

What would it be like to have a trusting relationship with someone in your primary care clinic in which you can have up to an hour appointment, without the sense of being rushed, to discuss sensitive issues about how your health affects your life, but also how your life affects your health, to learn and grow, and to become a healthier and happier person, despite having some chronic condition? You’d become an expert at coping with your chronic condition and as such you’d know how to manage it so well that it would no longer disrupt your life in any significant way: what occupies your time, attention and energy would be your job, family and other life pursuits – not your chronic pain, diabetes, or heart disease.

Outside the primary care office, a healthcare educational system would also have specialty clinics. They would be interdisciplinary in nature, such as chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and the like. Patients would seek care in these clinics in order to obtain advanced education and training in the self-management of their respective conditions. The function of these programs is typically two-fold. First, their intensity allows patients to take the next step in developing their expertise, which is to actually start reducing their dependency on the healthcare delivery system. By participating in these programs, patients get so good at self-managing their condition that they are able to reduce the amount of medications they take. Coping, in the form of healthy cognitive, emotional and lifestyle behavior changes, comes to be able to substitute for some of the medications that patients have heretofore relied on to manage their condition for them. Second, the intensity of these programs allow patients to learn and regain the confidence that they can return to some type of meaningful work.

Of course, a healthcare educational system wouldn’t replace a healthcare delivery system. There is a time and place for acute medical model care. Medical emergencies occur and the acute medical model is best suited to respond to such cases. Even in the acute phases of what might turn out to be a chronic condition, there can be a role for the acute medical model. So, for example, patients can often benefit from acute medical model pain or cardiac management in the early phases of these conditions, even when the conditions subsequently later become chronic.

However, the vision we are entertaining involves a re-setting of priorities or emphasis when it comes to the roles of both the healthcare delivery system and a healthcare educational system. Patients and healthcare providers wouldn’t continue to repetitively seek acute medical model procedures and therapies long after a condition has clearly become chronic. Rather, everyone involved would see the point of switching the emphasis away from vainly attempting to deliver well-being to patients and towards educating, empowering and motivating patients to successfully improve their own well-being. In so doing, as a society, we would have to modify the value we place on the acute medical model, seeing that it has high levels of value in only certain contexts, and we would have to increase the value we place on rehabilitation-based care.

An important and essential part of this re-evaluation of our healthcare system would be the role of the reimbursement arm of our system – health and disability insurance companies and government institutions. They too would have to modify the value they place on each of the respective types of healthcare. Currently, reimbursement rates for acute medical model procedures and therapies are exponentially higher than rehabilitation, or coping-based, therapies. This system of valuation cannot but influence what type of care gets provided. To be sure, it’s one of the reasons that the acute medical model predominates in our healthcare system.

What if, though, the reimbursement rates for medical providers were the same whether they provided education and counseling or a procedure? What if the health psychologist’s cognitive behavioral therapy was reimbursed at the same rate as medical providers’ education and counseling, or medical providers’ procedures? What if nutritional counseling and physical therapy were reimbursed commensurate to these other therapies as well? If the reimbursement rates of all these therapies were at least within the same ballpark, even if they weren’t exactly identical, we would have a very different healthcare system. Healthcare providers would stop being incentivized to provide acute medical care to conditions that are clearly chronic and they’d be incentivized to take the time to sit down with their patients and have the lengthy, oftentimes sensitive, discussions about how to cope with a long-term health problem.

Specialty care would significantly change too. In the vision we are entertaining, the value that we place on acute medical care would be commensurate with the value of coping-based care. Reimbursement rates for interventional procedures and surgeries would no longer be astronomically higher than interdisciplinary rehabilitation programs. To acknowledge that there may be a time and place for such former procedures, suppose that reimbursement rates declined only as they were repeated over time for the same condition. So, patients and providers might pursue interventions and surgeries, especially in the acute phases of a condition, but their value would decline as they get repeated long after it is clear that the condition is chronic. The reimbursement rates of interdisciplinary rehabilitation care would then start to become commensurate with acute care, especially when it comes to care for chronic conditions. In so doing, we’d stop incentivizing healthcare providers to deliver acute care to chronic conditions. The result would be that as a healthcare system we’d come to start valuing the right treatment for the right condition at the right time. We’d all obtain better care at a lower cost.

Whether you’re a patient, a provider or a representative of an insurance company, maybe it’s time to start demanding a healthcare educational system that focuses on coping-based care.

References

Center for Disease Control. (February 3, 2015). Chronic disease prevention and promotion. Retrieved from http://www.cdc.gov/chronicdisease/.

Author: Murray J. McAllister, Psy.D.

Date of last modification: April 12, 2015

Why See a Psychologist for Pain? (Part 2)


In the last post, we addressed the question, “Why see a psychologist for pain?” The answer is that psychologists are the experts in teaching patients how to self-manage and cope with chronic pain. Patients who see psychologists for chronic pain can learn how to self-manage and cope with pain so well that they can largely come to live a normal life despite having chronic pain.

 

Another way to respond to the question of “Why see a psychologist for pain?” is to look at the role of the nervous system in chronic pain and how psychologists are experts in the treatment of health problems related to the nervous system. Let’s attempt to unpack this statement.

Nervous system & chronic pain

People commonly think of chronic pain as if it is a long-lasting symptom of an injury or illness that has failed to heal. This viewpoint is mistaken. Take, for example, the notion of degenerative disc disease. It is common to think that degenerative changes of the spine are the cause of chronic back pain. However, we know that degenerative changes of the spine are only minimally correlated with pain, which means that most of what makes up the experience of pain cannot be attributed to degenerative changes of the spine (Endean, Palmer, & Coggon, 2011). Such changes of the spine are a minor ingredient, if you will, in the pie that’s chronic pain.

A more accurate understanding of chronic pain is that it is a disorder of the nervous system called “central sensitization.” An orthopedic injury, for example, might have initially caused a case of back pain, but now, after many months or years, the whole nervous system is involved, including the brain and spinal cord. Changes to the whole nervous system have now made the nerves at the original site of the injury highly sensitive and reactive. They are stuck, as it were, in a “hair trigger” mode that makes any little movement painful.

In the notion of central sensitization, we also see one of the central tenets of chronic pain rehabilitation: that when it comes to chronic pain, what initially caused the pain is not now the only thing that maintains pain on a chronic course. The notion captures the complexity of causal factors in chronic pain, as opposed to acute pain, which may have one cause – an injury or illness. Biological, psychological, and environmental factors are known to influence the development of central sensitization (please see the Institute’s content page on central sensitization for more details). The notion of central sensitization also explains other psychosocial aspects of chronic pain – chronic fatigue, insomnia, limited cognitive deficits such as poor concentration and short-term memory, gastrointestinal upset, anxiety, and depression (Meeus & Nijs, 2007; Wieseler-Frank, Maier, & Watkins, 2005; Yunus, 2007)

For many years, psychologists have successfully treated patients with health conditions related to the nervous system: depression, the various anxiety disorders, insomnia, irritable bowel syndrome, as well as chronic pain.

Psychological therapies for chronic pain

The Society for Clinical Psychology, which is a division of the American Psychological Association, developed task forces to compile a list of treatments that have been determined to be effective for a variety of disorders. They defined “effectiveness” as having multiple clinical trials from different researchers showing the effectiveness of a specific treatment. Not surprisingly, they have identified as effective multiple psychological treatments for mental health disorders such as depression, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder, and general anxiety. However, they have also identified as effective multiple psychological therapies for health conditions. There is strong empirical support for cognitive behavioral treatments for chronic low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia, headache, and chronic pain syndromes in general. They have also identified effective psychological therapies for primary insomnia and irritable bowel syndrome. You can find information on these treatments here and here.

These therapies are effective likely because of their impact on the nervous system. Just as cognitive behavioral therapies reduce the reactivity of the nervous system in persons with post-traumatic stress disorder or panic disorder, in terms of their heightened startle response or susceptibility to panic, respectively, cognitive behavioral therapies for chronic pain disorders are likely to reduce the reactivity of the nervous system. By reducing the reactivity of the nervous system, patients come to have less pain and increased abilities to cope with the pain that remains.

References

Endean, A., Palmer, K. T., & Coggon, D. (2011). Potential of MRI findings to refine case definition for mechanical low back pain in epidemiological studies: A systematic review. Spine, 36, 160-169.

Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473.

Wieseler-Frank, J., Maier, S. F., & Watkins, L. R. (2005). Immune-to-brain communication dynamically modulates pain: Physiological and pathological consequences. Brain, Behavior, & Immunity, 19, 104-111.

Yunus, M. B. (2007). The role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Practice Research in Clinical Rheumatology, 21, 481-497.

Published date: 7-29-2013

Date of last modification: 7-29-2013

Author: Murray J. McAllister, PsyD

Why See a Psychologist for Pain?

Patients can sometimes question why their physician wants them to see a psychologist for pain. The concern, of course, is that they are going to get stigmatized. They might wonder, “Doesn’t my doctor not believe me?” or “Do they think it’s all in my head?” This understandable reaction can often prevent patients with chronic pain from seeking the care of a psychologist. It is, however, unfortunate. Among all healthcare providers who specialize in the treatment of chronic pain, psychologists provide some of the most effective therapies. Patients can fail to benefit from them when they fear stigma and fail to follow-up on recommendations to obtain psychological care.

Psychologists have a long tradition of providing chronic pain management. Psychologist were integral to the development of chronic pain rehabilitation programs thirty to forty years ago and have been either running them or working in them ever since. As described in previous posts (such as this one here), chronic pain rehabilitation programs are commonly considered among healthcare providers to be the most effective treatment option for people with chronic pain.

To get such care, though, it’s helpful to know what psychologists do when seeing patients for chronic pain. In this post, and the next, we will explore the answer to the question: Why see a psychologist for chronic pain? We will answer this question from two broad perspectives.

First, in this post, we will look at the answer from the perspective of the role of coping and self-management. Second, in the next post, we will explore the issue from another perspective. Namely, we will look at the answer from the perspective of the bodily organ system that is most responsible for chronic pain – the nervous system.

So, the quick answer to the question of why you should see a psychologist for chronic pain is the following:

  • Among all healthcare providers who treat chronic pain, psychologists are the experts in teaching patients how to cope with and self-manage pain.
  • Psychologists are experts in the treatment of nervous system problems and chronic pain is largely the result of nervous system disorders.

Let’s now look at the first answer in a little more detail. We’ll look at the second one in the next post.

Self-management of pain

All experts (and most patients, by the way) agree that to successfully manage chronic pain patients must be active participants in their care. That is to say, they have to learn effective ways to cope with and self-manage pain. It’s as true of chronic pain as it of other common, chronic diseases. Most everyone would agree that patients with heart disease or diabetes wouldn’t manage their disease successfully if they themselves didn’t engage in self-management: who would argue with the importance of maintaining a healthy diet, weight loss, exercise, and stress management, among other health behaviors, in the successful management of these diseases? Similarly, most everyone accepts that patients have a role in the successful management of their chronic pain syndrome. Successful management requires the ability to self-manage and cope with pain very well. But where do chronic pain patients learn how to do it?

Patients with chronic pain seek care from many different types of providers, all of whom specialize in the management of chronic pain. However, it’s only one kind of chronic pain provider who specializes in teaching patients how to self-manage and cope with pain.

Typically, it is not spine or orthopedic surgeons. Surgeons tend to have relatively brief appointment times with their patients and they tend to focus on surgical procedures and how to aid in recovering from such procedures. Now, certainly, there may be a time and place for the care of a surgeon. The point here is not to criticize surgeons or surgery. Rather, it is simply to point out that the focus of surgeons is typically surgery, not in teaching patients how to cope with and self-manage chronic pain.

It is also typically not the role of interventional pain physicians. Their appointment times are also commonly brief and focused on providing injections and other minimally invasive procedures. The point is not a criticism. Rather, the point is that their focus lies elsewhere. It is not on spending time with patients and teaching them how to cope with pain well.

It is also typically not the provider who prescribes opioid pain medications on a long-term basis. Of course, there can be exceptions, but most such providers have relatively brief appointment times, usually around fifteen minutes. The focus of much of this time is on obtaining updates about your well-being since your last appointment and on how well the medications are working. There is not a lot of time left over for teaching, clarifying, and reviewing strategies for coping and self-management. Again, the point is not a criticism. It’s simply that the focus of prescribing providers is typically on managing the medications and not on teaching patients how to self-manage pain without the medications.

All these providers typically know it too. It’s why they tend to refer chronic pain patients to pain psychologists.

So, where do you go to learn how to self-manage and cope with pain well? You go to healthcare providers who specialize in teaching patients how to do it. You go to health psychologists and you find them in chronic pain rehabilitation programs.

Health psychologists have been running chronic pain rehabilitation programs for the last thirty to forty years. You can find such programs throughout the world. Research consistently shows that they are one of the most effective treatment strategies for chronic pain (see, for example, this article here).

They are so effective because they focus on teaching patients how to self-manage and cope with pain very well. Self-management and coping very well are essential to manage chronic pain successfully.

Most patients, though, have to learn how to do it. Such learning requires appointment times that are longer than fifteen minutes or so, and more frequent than once a month or so. It also requires having a good, solid, therapeutic relationship with an expert provider who listens to you and gently coaches you over time on how to do it. You find such care with a health psychologist who works in a chronic pain rehabilitation program.

It’s possible to self-manage and cope with chronic pain very well. You just have to learn how to do it. And you learn from a health psychologist. It’s why you would see a psychologist for chronic pain.

Author: Murray J. McAllister, PsyD

Date of last modification: July 1, 2013