Saving the soul of primary care

Over the last few decades, we have lost something essential in the practice of primary care, and I believe virtually every clinician knows it.

We have lost the ability and the time to create meaningful relationships with our patients in a way that facilitates their healing. We can treat their diseases, but we are not able to relieve their suffering. We are no longer able to take care of them as whole people.

We are fed flashy new tools in the form of countless new drugs, new procedures and new technologies. But we have paid for these with the loss of the person-to-person contact and satisfaction that motivated us to become doctors in the first place. As a profession, we need to find our way back to seeing ourselves not as practitioners but as healers. We need to save the soul of medicine, and in the process, rejuvenate our own spirit.

While we may not all be able to change the system we work in, we can make a change in our day-to-day encounters with patients. We can restore the soul of primary care if we add a few new tools to our medical bags that focus on cultivating healing relationships. These tools are not new pills and procedures, but involve new thinking, new questions during the office visit and new ways of relating to our patients. By this, I mean rediscovering and rebuilding the salutogenic bond between a doctor and a patient.

COVID-19 dramatically exposed the weaknesses of our health care system, which is plagued by relentlessly rising medical costs, widening health disparities, growing dissatisfaction among patients and widespread burnout among clinicians. Our system generates massive revenue, but that money is not used to produce health. We know that only 15% to 20% of individual or population health comes from medical treatment. Nearly 80% comes from social and personal determinants that are rarely addressed by health care systems. These are mental health, behavioral and lifestyle factors, and the socioeconomic environment in which a person lives. These factors are crucial to a person’s ability to obtain effective medical care, to improve their health and well-being, and pursue a meaningful life.

We can help our patients achieve this well-being. I have seen it happen again and again during my 40 years of practicing family medicine and working with the Veterans Administration, which has adopted a system of whole health care that is a model for this change. The VA tested this framework with 130,000 veterans and found it clearly improved clinical outcomes and satisfaction levels for both patients and clinicians. Moreover, it also reduced annual costs by more than $4,500 per veteran.

For years, I have incorporated these principles into my practice by providing periodic “integrative health visits” for my patients. During those visits I use specific tools that can be easily adopted into any practice. I start by working with each patient to create a Personal Health Inventory that is used to create a personalized plan focused on their recovery and healing. This is not a plan that I design. Rather, it is constructed in collaboration with the patient in a healing partnership. My role is to help guide the patient to identify and accomplish concrete actions that promote their self-care and health improvement.

The key tool that I added to my medical bag for these visits is called the HOPE note (Healing-Oriented Practices and Environment), which supplements the SOAP note that we all learned in medical school. The conventional SOAP approach aims at identifying “what’s the matter” with a patient, leading to a medical diagnosis and treatment. HOPE is more valuable for getting to the root of healing because it asks the critical question of “what matters” to the patient. It helps identify what the patient really wants and needs and what would motivate them to achieve good health. It seeks engagement in their own healing.

A recent example: I was asked to consult on an 80-year-old patient with Parkinson’s disease who has multiple chronic problems. When we went through the HOPE process, it revealed that his primary personal goal was to improve his sleep. His previous efforts with medications and sleep hygiene had not helped, so we ended up focusing on mental exercises to strengthen his parasympathetic nervous system — mind-body practices, guided imagery, heart rate variability biofeedback — and a few other things, including his diet. Then I arranged to have our health coach follow up with him periodically, with check-ins and tips to aid his progress. When I outlined all this in a HOPE note, he thought it was fantastic and became actively engaged in deciding how to go about implementing these changes in his life.

None of this is magic. But adding these tools to our armamentarium can make a critical difference in getting into a better and more rewarding relationship with your patients and focusing on what helps them heal. And I would argue that the process itself moves the patient toward self-actualizing their personal power to become healthy and stay healthy.

The National Academies of Science, Engineering, and Medicine recently studied America’s primary care system and recommended transforming our current model to one more like the VA’s, one that is person-centered, relationship-based and recovery-focused. Just last month, The Annals of Family Medicine published a report about 16 clinical settings around the country that have adopted the HOPE note toolkit and tested it on more than 900 patients. In a survey, more than 90% of clinicians said they liked the process, and most of the clinics said they planned to expand their use of the tools. Many embedded these changes into their electronic health record and reimbursement systems.

You too can bring more healing into your practice, and there are ways available to help. The Center for Innovation in Family Medicine and Tufts University Medical School offers an online course that gives real-world, step-by-step education on how to embrace whole-person care. The course is free and approved for Continuing Medical Education credit by both the AMA and American Academy of Family Physicians. I urge you to check it out.

A revolution is already upon us in the economics of medicine. HHS and CMS are moving rapidly toward value-based contracts that will change reimbursement rules for public and private payors. Clinicians and health systems will be rewarded not just for services, but for setting up systems that provide whole-person care and produce better health and satisfaction outcomes. You can be ready for and utilize those changes.

Whole-person care is overdue. Too many doctors have burnt out, given up practices for salaried jobs or left the profession altogether. Now, physician leaders are saying “enough is enough” and pushing for systemic change. We each have the chance to decide how to become the healers we always wanted to be. That is a revolution worth joining.

References:

• Center for Innovation in Family Medicine. https://healingworksfoundation.org/clinician-as-healer-in-primary-care/. Accessed May 5, 2023.
• Rosenbaum E, et al. Ann Fam Med. 2023:doi;10.1370/afm.2952.
• The Hope Note. https://healingworksfoundation.org/resources/hope-note/. Accessed May 5, 2023.