Educational Forum, September 12, 2006
“Do We Understand Each Other?”

Co-sponsored with Tufts University Medical School's Department of Public Health and Family Medicine

How can a primary care physician and an energy healer communicate in order to best serve the patient? How can an acupuncturist effectively communicate information, questions and concerns to a cardiologist? How can an oncologist and a massage therapist communicate respect and compassion for each other while discussing a patient's needs?

Questions such as these were addressed at the Educational Forum held at Tufts Medical School in Boston on September 12. More than 80 people, including medical students, CAM providers, nurses, physicians, administrators and others watched, listened and interacted with a panel that explored:

• Ways that complementary/alternative medicine (CAM) and conventional medicine practitioners can effectively communicate with each other in the service of high quality patient care,
• Avenues of interpersonal communication that can foster compassion for and between CAM and conventional practitioners,
• Encouraging constructive and mutually beneficial dialogue between CAM and conventional practitioners,
• Promoting the safe and effective integration of CAM and conventional tools of practice in healthcare,
• Fostering networking, education and collaboration between CAM and conventional practitioners in order to deepen the quality of the human experience of healthcare.

The panel members included:

Paula M. Gardiner, M.D., Director of Integrative Medicine, Tufts University School of Medicine and currently an Osher Fellow at Harvard;

Florence Meleo-Meyer, M.S., M.A., Co-Director, Professional Education and Training The Center for Mindfulness in Medicine, Health Care and Society at University of Massachusetts Medical School;

Kristen Porter, Mac, Lac, Executive Director, Pathways to Wellness - a non-profit holistic public health clinic;

Jeffrey P. Satnick, M.D., Holistic Family Medicine Practitioner, Director, Division of Acupuncturem University of Massachusetts Memorial Medical Center

Harvey Zarren, M.D., F.A.C.C. and President of the Board of IMA, acted as Moderator.

A case was presented:

A 50-year-old male has extensive musculoskeletal pain from over-exertion and unaccustomed activity. His conventional practitioner wants to prescribe non-steroidal anti-inflammatory medicine. A CAM practitioner wants to use acupuncture and reiki.

Questions asked to start the discussion were:

How does the patient communicate about his problem effectively? Can the CAM practitioner call the M.D. and have an interchange such that both come off the phone feeling that they did not waste their time and were not shouting at each other?

Kristen Porter presented the concept of a team approach to patient care rather than an “Us versus them” individual, separate practitioner approach or one therapy versus another. She also mentioned dealing with enhancing the quality of a person's life rather than just treating their disease. “Focus on what is most important to the patient: symptom relief, correction of structural problems or whatever. What is important to the patient can and will change each day. It is important to keep up with the changing focus. Providers must talk with each other. It is uncommon for conventional providers to call each other or communicate routinely in person about patients. Patients wish their providers would talk to each other. The patient can be an effective communication tool between providers and can also help providers understand more clearly what treatments people are routinely getting out in the world creating familiarity with the jargon and terminology of various practices.” Patients can thus help educate all their providers about other forms of healthcare practice.

Paula Gardiner looked more deeply at the issue of practitioners communicating with each other. She mentioned the example of the Marino Center in Cambridge, Massachusetts, “an integrated clinic with a culture of good inter-provider communication, creativity, equal power (not hierarchy) and everybody has an equal voice at the table, everybody's opinion is valued and everybody has their expertise. They have case conferences together, they meet together and they have lunch together. It's truly a team.” Paula mentioned that when she teaches medical students and residents she involves who they are as people and the fact that they and their family members are using CAM practices. She weaves the trainees' personal CAM experiences into their consideration of patient cases. She also stresses valuing a patient's cultures with its beliefs, spirituality and nutrition. That opens up trainees to more than just “What is reiki?” It broadens perspective into who is that person? What does this/her care require to be effective?

Jeff Satnick asks students and residents to “Think with their hands, to examine patients in a way that uses their hands as a tool of communication. This allows the students to begin to understand some of the fundamental differences between conventional and CAM practices. The patient begins to experience that as well and communicates back to the student that there is something different about their experience of being treated.”

Florence Meleo-Myer was asked to comment on the common disparity between the time CAM providers and conventional practitioners get to spend with patients and how that might affect their communication with each other. She mentioned a conventional practitioner who went through mindfulness training and was suffering over the time pressure in his practice. An instructor who had herself been a cancer patient said to him, ”You look them in the eye; you connect with them and even if it's five minutes the quality of the connection is felt.” Florence said that she witnesses a huge strain and grief and suffering that can come from conventional practitioners having to see so many patients so quickly. She said she sees a longing to come to that kind of connection, the longing that brought the practitioners to medical practice in the first place. “That connection is the heart of healing.” Florence mentioned that intentionality can lead to ways to make that connection. Florence also mentioned the example from the story of two of the five daughters of Aesculapius, the Greek god of medicine and healing. Panacea was the daughter who was for healing - the cure, such as a poultice. Hygieia was for establishing wellness, strengthening people's presence and their ability to engage in their life in terms of their health and wellness. Going back to the case presentation, Florence said that the discussion had to extend past communication bringing different modalities of therapy together. She emphasized a culture of care that can look at how the patient's body pain affected his work life and his relational life. “What suffering gets added on by how he is meeting this immediate pain in his life?” Florence spoke about a culture of health caring that investigates the effect of any disease on the wholeness of existence and how that suffering might be addressed with the healing arts.

Paula gives patients her card and asks them when they next see another provider to give the card to the provider and ask that provider to communicate back to her so they can form a team. Teams can “Hold, contain, care for” chronic illness patients more effectively than can individual providers who can be overwhelmed by such patients. Paula said, “If you don't have cards, make them, and use them to stimulate communication and see what happens. I actually do hear from other practitioners.”

Kristen mentioned that in conventional medicine there is an acceptance by practitioners of each other because there are accepted specialties that everyone recognizes. In CAM there are not such clear specialties. There are not such defined hierarchies. It makes it harder to decide who is best suited to treat a specific condition. There is a challenge in CAM of how to credit specific training and experience. This needs to be addressed within the CAM field and can create a lack of acceptance and respect within the CAM community.

Discussion was held about thoughtless, adversarial comments made by practitioners about other practices. Jeff mentioned that all must be very careful about talking to patients about specific therapies in specific situations so as not to put other practitioners on the defensive. That can be a communication barrier. He also mentioned that a CAM provider, communicating with a conventional provider, needs to present her or himself on an equal level. “If you come in presenting yourself as inferior or less scientific or “less than” you will be met that way. Communicate with a certain sense of feeling comfortable with your craft and feeling comfortable with who you are. Then you have human equivalency that gives you standing and people respond to that.”

Florence talked about the need for experience and exposure by CAM and conventional providers with each others modes of practice and then the need to follow the exposure and experience with dialogue “Such as this panel,” She also spoke about attention to how we listen to and speak to one another. She asks people to think of a time in their lives when they really wanted to communicate with another person and for whatever reason that person would not, could not be there for them. She mentioned her clarity of how those occasions are a source of huge pain for many people. She said that, “We do it to each other and we must wake up to it. We must recognize the actual power of offering attention and presence and listening to another human being. People to whom attention, presence and listening are offered say the feel loved and seen.” Practitioners coming together must offer attention, presence and listening. “The word respect means to look again, to bring a freshness to the hearing to the meeting of another person.”

Florence mentioned a memorial quote about Henry Russek, M.D. “He knew how to listen so others could talk; he knew how to talk so others could listen, so love and the best medicine could win the battle.”

Kristen spoke about how communication was enhanced in the context of a relationship. “Building relationships is an important piece. In all relationships it starts with manners. Those manners in the context of medicine have very structured ways of doing it. It's, thank you for your referral, referral notes, progress notes, it's communication collaboration, it's let's have lunch, all kind of structured ways that are part of the culture among conventional providers. CAM providers don't often learn those manners, don't often understand that this is the standard of care.” “If you don't know the manners it can feed into a feeling of inferiority.” She mentioned the need for lots of education in schools of all practices.

It was mentioned that most of the discussion is about how conventional practitioners need to gain experience with CAM providers but that CAM providers need more experience and understanding of the practice experiences of conventional practitioners. This needs to be in addition to their own experiences of conventional medicine so that more objectivity can be applied. Tufts Family Medicine residents work alongside New England School of Acupuncture students. That can enhance exposure of each to the practice experiences and concerns of the other.

Paula spoke about the use of dispute resolution in helping practitioners communicate about patients. She mentioned Getting To Yes by Roger Fisher as a good reference. She spoke about finding common ground, where do they both meet - a win-win approach. She spoke about separating the people from the problem: how to get a particular person to a specific activity or behavior. She also spoke about the concept of the best alternative among choices to get resolution of an issue.

The panel explored the concept of compassion between providers of a certain practice and between CAM and conventional providers. Kristen related that CAM providers often feel that there is not a lot of compassion for them. Education and experience can open compassion. She invites conventional providers to have CAM therapies. She mentioned that there is often divisiveness in the CAM community and that mindfulness can be useful in that area. Florence spoke about how everyone is caught in scheduling issues and how compassion for self and others can emerge from pausing. “Providers need to have the intention and the authentic allowing of what hard work we're doing, all of us, whatever work that each of us is given to do and how we're bringing the best of ourselves. Honoring that and how many of us are pushed over the edge with the sense of urgency.” Florence quoted Marshall Rosenberg's work of getting to the need. “What is the need of each person and if we can honor the need and speak from that place then connectivity can happen. There is urgency, but coming from that place is not healing.”

Florence spoke about how it's not about being perfect, about the need to come with a lot of humility and about holding ourselves with a lot of compassion for how much we're doing and wanting to offer the world. “From there, looking around and seeing our colleagues and how can we bring all that into the dialogue, into the conversations?” Florence suggested that then plans be made to allow 5-minute healing intervals into the day.

Jeff related that there is a sense of being with present with yourself and making choices the best you can in your own life that reflect how you want others to treat you and what you expect out of your interactions. He mentioned that we need to also acknowledge a certain animal interaction that happens between humans and that it needs to be there or relationships miss something. When it is not there, patients don't continue in his practice. Not all people fit well together. “There's a sense of creating a space to begin an interaction with the patient that starts by being consistent with who you are and how you deal with all situations, with all the communications not just with other practitioners but with people on the street, with people in your life. There is a lot of suffering out there with colleagues' intensity about time, billing, coding and all this stuff having to do with modern practice. They're struggling, trying to find ways off of the treadmill. Just acknowledging it is often enough in a moment to engage them.”

Paula said that patients are saying that they want their doctors to talk to them, to listen to them, and that they want a different type of healthcare. Practitioners are saying that the current form of practice does not allow them to be healers which is what they went into the profession for. Paula feels that more balance is coming into conventional practice with education changes. She says she speaks the allopathic (conventional) language and she speaks the integrative language and there is common ground: patient-centered care, what works (evidence), what is safe for the patient and what can I do for this patient. These are common goals for all practitioners.

Further discussion with the audience brought out the concepts of honoring CAM teachers as well as conventional medical teachers and of learning about the philosophy, language and terminology and mental processes of different modalities of practice not just about their techniques. There was discussion about non-verbal communication skills such as the arts to allow a chance to pause, reflect and gain insights. This allows opening and mindful speaking and listening. The concept of 7% of communication being in the words, 38% being in tone and phrase and 55% being in the body language was mentioned. Storytelling skills to help communication were mentioned. Medical students asked how they can better prepare for integrative practice? The IMA Mobile Clinics that offer exposure to a variety of CAM experiences was mentioned. The idea of medical students insisting to their Education Deans that time, space and opportunities for exposure to CAM and integrated experiences be provided was offered. Kristen mentioned that Pathways to Wellness offers experiences for medical students.

Kristen also discussed the issue equality of CAM providers at the discussion table. As a traditionally trained CAM provider it is a challenge when conventional practitioners want to learn CAM practices. She mentioned that there seems to be some fear by the conventional practice community of letting CAM providers work as they're trained to do. She thought that came from the lack of CAM providers in positions of power in hospitals and medical schools. Kristen suggested that CAM providers need to be teaching the workshops and clinics in conventional institutions. Traditionally trained CAM providers need to be in positions of leadership. She asked medical students to honor the traditionally trained practitioners and advocate for them to do the training in conventional institutions.

There was discussion about the how practitioners of all kinds need to step out of a power hierarchy position to align themselves with patients and to further the possibilities of useful therapeutic relationships. The concern that CAM practices can be steamrollered by conventional attitudes and practice patterns was raised. The issues of care access and profit motivated healthcare were raised. The fact that CAM modalities can actually be very cost-effective was offered. The example of acupuncture being used during chemotherapy infusions to decrease side-effects was mentioned.

The entire evening, followed by networking time (attendees were furnished with name tags to facilitate the process) was a rich source of information, discussion, exploration, sharing and expression for the panelists and the attendees alike.

What can you do?

All of us who care about IMA's mission -- improving the quality of the human experience of healthcare, can do something to advocate better communication and collaboration.

Here are some tips suggested by the panelists throughout the evening about what your can do as a patient, student or provider.

• Build relationships with practitioners of other practices, CAM and conventional.
• Mind your manners: i.e., create “thank you” notes for referrals, write referral and progress notes, foster communication
• -Use and embody the practices you use in your own care for the care of others.
• -Pause a bit every day allowing compassion to emerge.
• Honor yourselves and your colleagues for the work you provide.
• Let your practitioners know what other treatments you are receiving and what benefits and problems result.
• CAM providers – spend time in conventional medical settings; learn about the practice life experience of those providers.
• Conventional practitioners - spend time in conventional medical settings; learn about the practice life experience of those providers. Try some CAM experiences for yourself.
• Medical students: start now to learn about CAM so you can prepare to have an integrated practice, and let the dean of your school know it's an essential part of your training.
• Hospital administrators: Learn what other hospitals are doing about making CAM a part of the hospital setting.
• Look at your own pain resulting from failed communications and be mindful of it when you communicate with others.
• Join the IMA. Communicate to us and through us your successes in communications between CAM and conventional providers. We are looking for examples and models to share. Help us carry this discussion onward.

Together we can deepen the quality of the human experience of healthcare.

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