Master Clinician Storyteller - Episode 9

Patient Engagement - The Neuroscience of Relationship

Joel Gaines:                        00:00                     Welcome to another episode of master clinicians storyteller. I am Joel gains from IAOM US

John Woolf:                        00:08                     I am John Woolf from IAOM US

Joel Gaines:                        00:12                     So we're bringing you another really great topic today. We've heard Ad Nauseum, John...

John Woolf:                        00:18                     that's a lot. Joel,

Joel Gaines:                        00:19                     ... this buzz phrase of patient engagement and we've given this phrase from healthcare. We've given this phrase to the marketing people and they've run with it in ways that has made it sound completely ridiculous at this point. Yeah, I just think it's so misused anymore. Right? And I think the intention was good when it, when it first started, we wanted to focus more on the patient and give them more of what they wanted and then engage them better. But what gives with this thing, it's everywhere and mostly meaningless I think to a lot of us.

John Woolf:                        00:52                     Yeah, well I hear you and I'm seeing it to where what people sends is that people want to be engaged with and they want to engage. So I think back to the whole idea of a social group, especially with the advent of social media. The new buzzword is about engaging customers. So everyone's on the bandwagon right now, frankly, I think healthcare is probably late to the game with regards to engaging the customer and I suppose maybe even late in this idea of referring to the patient as a customer, but because the environment is getting relatively more competitive where our customers are becoming more educated, more informed, more, uh, more in the sense of looking for value. I think that engagement is an important part of, of, uh, any business model right now. So I think that's what we're, what we're seeing is that the business people are using it in order to constantly appeal to the emotional side of what they can do for the customer. Right? So we see this in our television commercials and we see it in everywhere. It's about how do we tap into the emotions of the customer. Uh, social media is predicated on it. In other words, the whole platform is based on this idea that it's a, it's a give. And again, it's like I ping the system and, and uh, or I, I post something and Joel, what are we looking for? As soon as you post something?

Joel Gaines:                        02:21                     Yeah, we're looking for a value barter - we're looking for an exchange of value.

John Woolf:                        02:26                     Yeah, we get a hit and there's a hit from it, right? Somebody likes our thing. Wow. It feels really good. And uh, so social media is about not just advertising and pushing something out there, but it's actually pushing something out there and getting some response in, responding to the response. So, you know, patient engagement is kind of falling into the same general kind of neuroscientific category of satisfying this steep down need and desire to connect. And that's kind of a, that's kind of a big deal. So for businesses who are looking for a customer to engage with, uh, in a long-term basis, you know, they're, they're talking about customer life cycles. I'm a long-term engagement platforms where they can connect and get feedback and check in on people. So it's really coming down to this idea that relationship matters in all aspects of our lives, especially in business. And I'm going to contend, especially in healthcare.

Joel Gaines:                        03:20                     OK. So you, you, you brought up the cue for me, the keyword which is relationship. And I think people might try to define this in several ways. So in the context in which we're using relationship today, what is relationship?

John Woolf:                        03:37                     Yeah, good question. This is like a test though, right? I can't really answer this and use the word in the, in the definition because the word. All right, so let me, let me try this. Well, I'm going to google that and see what I get. And the, you know, the definition is the way in which two or more are connected or the state of being connected. So you're in relationship with someone if there's some level of connection and connection can mean a lot of different things. It can take many different forms. You know, at this stage of our evolution, we're in brand new ways of being in relationship or being connected with others. So I think, I think there's going to be a lot of discussion of exactly what relationship is nowadays. Let's take an example because I'm want to emphasize kind of the neuroscience behind what relationship is. And I want you to get a feeling for what this might look like. You have teenage kids and you know, you ever get a conversation from one of your kids to all that goes, hey, that I liked her a lot. She's really cute, but I'm not sure exactly if she likes me.

Joel Gaines:                        04:45                     Yeah, except it goes more like I like her a lot, but she's not very good at math.

John Woolf:                        04:51                     That can happen too, but oftentimes it's the same thing in a work environment where you know, we're not sure what relationship we are with our boss because our boss said something weird and we have to try to figure out what that means or that co-worker said something weird. Where am I in relationship to that person? Back to the teenager example. There's a lot of angst with not knowing how you're in relationship with somebody, so I think a lot of our energy goes to trying to clarify the state of these relationships in a healthy relationship or is it something I need to do something about.

Joel Gaines:                        05:24                     All right, so let me. Let me tee this up this way. In most interactions with the healthcare system, a typical person's interaction with the healthcare system, you have someone that really doesn't know a whole lot about the system. They don't go to the doctor very often. Most people, they don't go to the hospital very often. Most people and they come into this relationship where maybe they're kind of a junior partner and to me it's like when we say patient engagement, we're trying to. I guess we're trying to kind of balance the relationship or are we. I mean, what, what,

John Woolf:                        05:58                     how does this apply to patients specifically who I think the patient provider relationship is unique from many others in large part because just as you said, there's kind of a subordinate relationship from the provider and the patient and that's, that's back in the old model of the expert-centered care, right? Where the expert was the physician or the doctor and you're the patient and you're kind of going in with a sense of awe that the doctor knows everything. Yeah. It's like the doc knows everything. So, um, I'm just really passive and I'm just here to experience whatever that person tells me I need to do. But if you deep dive, dig rather into the research and really look back at kind of how this healthcare provider-patient relationship started, it goes way back to this idea of one person caring for another with the intent of improving, improving the social structure.

John Woolf:                        06:54                     So it kind of begins as an altruistic like, here, I'm going to take care of you and you're going to be cared for. And as I mentioned, the typical person off the street to in today's world may feel this idea where, where, you know, the doctor is all knowing. And uh, I'm, I'm just a passive player. In recent years we've heard a, a drastic shift in that, in that pendulum has swung very hard to what's now called a patient-centered care model. I think patient-centered care and its intent is absolutely brilliant because what it does when it does successfully is it begins to shift the focus from one person, which was the expert to the other person, which is the patient pool in a lot of ways. Because now it begins to engage. Here's that word again, engage the patient in a process of participating in their care, so the research on the efficacy and the value of patient-centered care has exploded and continues to build in its popularity.

John Woolf:                        07:58                     The trouble I have and the trouble I'm I'm standing on the highest building to proclaim is that I just don't think it's. I just don't think it works because the challenge with shifting the emphasis from one person and swinging and completely to the other person in a relationship means that it's only focused on one or the other. You could be expert focused in or expert centered and it's all about the doctor or you could try to try put on this idea that it's patient centered and it's all about the patient and the trouble with that, as I mentioned, is that it fails to recognize what's really, really important, which is the space between the two or how both of those individuals relate to one another. The level of their connectedness, specifically their relationship. And so kind of flying parallel with this idea of a patient-centered care model is this idea of a therapeutic alliance and the therapeutic alliance is the closest thing we have for an evidence based process that gives us a framework to begin to define the success of a relationship with a specific intent of accomplishing a therapeutic outcome.

John Woolf:                        09:12                     You know, uh, there's a story behind this for me. And, and you know, this is a topic I'm diving deep into because I think it's really one of the cornerstones of what we need to do in healthcare. And I learned this from a colleague and he told me a story. He said, you know, anywhere in the world, anywhere you go in, uh, in the human race, healing requires three things, three elements. The first is intention or an expectation, an intention by the patient to get help or an expectation. So if you're in the jungle in South America and you have a thing growing on your, on your deal, and it's causing problems, you would have an intent to get that veteran and you would seek out a relationship, which is number two. So the first thing is an intention to get better in the second has a relationship, so you might travel to the next village and you might know that the medicine man or the woman is in that village and that Shannon will have a sense of who you are from what tribe you are, and then you will be subject to some sort of a ritual so that that [inaudible] will likely hit you in the head with a rattle or blow some bone dust on you.

John Woolf:                        10:18                     Some, some ritual that begins to initiate a healing response. If you take a look at these three elements required for healing based on this generalized model, you know, an intention and expectation. The second is relationship, and the third one is ritual. You know, I've, I've reflected on kind of what's missing in our current healthcare system now. Our rituals are fantastic. They're double-blinded, controlled rituals. The stuff we do to people has efficacy beyond just what a ritual could do for our nervous systems to initiating healing response. So it's really pretty impressive. We have people who want to get better. I think that's pretty clear, but what we're missing right now in much of our healthcare system is relationship. We just don't have a typical model or an infrastructure anymore because we've industrialized medicine so much, we just don't have room for relationship, which in my mind creates a set of problems that are going to be very difficult to solve.

John Woolf:                        11:21                     So I've set out to try to investigate this. I wanted to try to determine, well, what is it about relationship that's so important? Assuming that it is and the research is pretty clear that it is. The therapeutic alliance has been studied to be when incorporated into a treatment plan can generate results. So I thought, well, what is it about relationship that can make a difference? And if you're, if you go back to to uh, you know, some of our listeners had developmental psychology as a class at one point and every developmental psych class, there's the research that set to a surrogate monkey. Mommy's in a room and they put a baby monkey in the room and the two surrogate monkey mommy's were set up in a very specific way. One of them had four and a bottle with a nipple on it that didn't have any milk and the other one was a cage, you know, just a cage with a nipple and a bottle that had milk in it.

John Woolf:                        12:15                     And uh, everyone in the class can remember who took that class. Can you remember that? What ultimately happened to the baby monkeys at a died because it was drawn to kind of the more a sensate side of the relationship. The one that they sensed was more cuddling and more fed. Another part of the nervous system, which was the relationship side. They preferred that monkey over without milk than the one that had milk. And you know, and this is just one example, I think it's a, it's a good example because it helps to, you know, emphasize this idea that we as social animals and social beings strive to establish these kind of relationships. Another interesting theory that's a, that's a over 50 years old is attachment theory and attachment theory speaks to the idea that our brains are formed early on based upon the quality of the relationship that we have.

John Woolf:                        13:13                     So attachment theories based on their levels of attachment in this fascinating research, we can get into some detail as sometime is based on this idea that if I have a sick your relationship early on, that my nervous system, the actual structure of my brain is going to be formulated in a way that leaves me more resilient later in life. And this, this research has, has, uh, gone further and been studied even more extensively with the advent of the aces score and some of our listeners may have heard of this as well, and there's a great youtube out there by a Dean Harris. She's a physician at Stanford and she presents the entire concept that I just mentioned in a pretty succinct to talk that, that, um, that presents the community with a way of beginning to measure the likelihood or the possibilities that early childhood experiences, which is what a stands for, are currently influencing somebody's health problem to a great degree.

John Woolf:                        14:13                     In some cases, I mean multiple morbidity type diseases linking back to early childhood trauma and things like that. Exactly. You know, when, when, uh, you know, we worked with the, uh, the echo group in, in chronic pain, in our transdisciplinary rounds, every time you sit in a chronic pain, a multidisciplinary approach, you will hear over and over and over again the frequency with which patients have had an adverse childhood experience, you know, either abuse of some sort, emotional, sexual abuse. It's just really horrific. But the percentage is of people with chronic pain who have had this kind of abuse early on is astronomical. And what it does though is it keeps us getting back to this idea that what's important is relationship. So when we talk about the neuroscience relationship, we're actually talking about how the brain formulates and creates its chemistry and the specific chemistry of trust.

John Woolf:                        15:15                     Because a successful relationship is predicated on this level of trust. How much trust do I have in my healthcare provider or my employer or, or whatever environment you're in. And you know, I just had a conversation at lunch today with somebody who, who said pretty specifically, you know, I went in to see this physical therapist. He's telling me a story. It wasn't our group, but it was a different group who said, I want to see if this is a physical therapist and I just got a sense that they really didn't know what was going on. I mean they just didn't seem coordinated and they didn't really. They didn't really include me in the conversation and, and I could just tell by his body language that there was very little trust in the organization, so he really didn't trust his provider. And if you don't trust your provider, you're not gonna, you're not gonna.

John Woolf:                        15:58                     Make that connection. Failing to make that connection. The result is an inability to really set the nervous system in a position to optimize the motivation strategies necessary to get better. The actionable items necessarily follow through and also the general chemical, uh, environment that would allow your brain to either better manage pain or decrease stress. So there are a lot of implications back to our story of the Shaman with having a secure and trusting relationship and the healthcare experience. And if we don't have that, that chemistry of trust that, that oxytocin, which is the hormone responsible for that experience, you know, we're just going to be, we're just going to be floating out there, but you know, getting procedure or uh, or sometimes just going through the motions.

Joel Gaines:                        16:48                     So when your story, John, you were talking about this missed opportunity between the physical therapist and the patient to connect and it seems like it could be multiple layers of potential multiple you can connect with, with connect with someone or not connect with someone because of a number of things like a really wide variety of things.  What are some good opportunities for a clinician to connect quickly with a patient? What are some system quick things to make sure that patients don't get that? Oh, I don't. There's not a trustful thing here.

John Woolf:                        17:21                     What hospitals are doing now and how they're training, they're trying to train physicians right now is at this level of just doing this. For example, if you touch the patient that's going to engender an increase, a level of trust. If you sit on the edge of the bed while you are explaining your findings to the patient, that's going to create an atmosphere of trust and the atmosphere of trust is based in part on the patient's experience. So for example, when you're the patient and you're touched by the provider, you, I mean, that's pretty powerful stuff. I mean, we don't think about it that way. Of course, if you're the business, you're touching people all the time, but the truth is being touched by a stranger in many instances is a pretty high deal and you have to have a certain amount of trust just to let that happen.

John Woolf:                        18:06                     So there's some prescribed things that we can do and it's out there though. I think those lists are out there. I'm not a big fan of just the list. So because it's like procedure and people still say, hey, all you need to do a smile and if you smile for this, show your teeth. Um, and then you touch the patient and then you sit on the bed. I mean, you're really going to make a giant difference. I think that's the wrong way to go about this kind of training, the best ways to kind of head into it and really learn specifically about how the nervous system responds to these kinds of specific cues. When you, when you teach somebody kind of the fundamentals and the basics and the, in the kind of the complexity of how nervous systems connect in a relationship, you know, you can extrapolate and have a infinite number of ways you can connect to people.

John Woolf:                        18:48                     One of the first things you can do is engage them engaged, right? What does that mean exactly? You, you approach them in a way that, uh, with your eyes, with your, with your entire body, mindful of the fact that, uh, you know, they have some sort of reflection that they're coming with and there's specific word phrases that you use to make sure that you don't, you don't get them thinking in one direction or another. So there's a host of their host of things that you can do, but in teaching what to do is as important as learning why you're doing what you're doing.

Joel Gaines:                        19:18                     Neuroscience of relationships. Part of the title of today's Podcast, right, so we're not just guessing about some things here because we used neuroscience and we use relationship both really strong words and we're connecting those and it seems like a lot of times they might be competing because head versus heart or I don't know what, but we deliberately used neuroscience of relationships in our podcast today.  So it's not a guess.

John Woolf:                        19:43                     It's not a gas.

Joel Gaines:                        19:43                     What is it?

John Woolf:                        19:45                     Well, it's a science, which means it's an, uh, it's an evolving set of theories that continually to be research and the research is showing that relationship can change. The nervous system and healthy developmental process is predicated on healthy relationships. And I would say that outcomes specific clinical outcomes are enhanced in the context of a successful and healthy patient provider relationship or a healthy connectedness or a healthy engagement process. And when those things don't happen, then the result is they'll, you're to optimize the patient's nervous system for healing response. And you've heard me say this before, the best surgeon in the world can't heal a cut. You know, the providers not doing the healing, the provider is setting in motion a set of chemical and mechanical events to improve the environment in which the patient does the healing.

John Woolf:                        20:40                     That's the science behind it and you know it's far beyond what we can get into this time, but we should come back to this and start cracking this one open because I think I think our listeners will really start to appreciate that the tools that they have in their toolbox or not just the the manual therapy tools that we teach them, more of the specifics matter, century control or exercise protocols that we teach them. You know, there's a lot more to it in optimizing a healthcare outcome and a good deal of that are the language and communication skills that we have

Joel Gaines:                        21:13                     And we feel that to become a complete clinician, you need all of these skills together. There is a course that you teach called strategic communications as a clinical tool where people can learn exactly how to create strategies for better and more immediate connections with their patients.

John Woolf:                        21:29                     Yes. With the intent of inspiring a nervous system and the patient that's going to better respond to any of the mechanical interventions that you do with the patient. So everything you do with the patient from a therapeutic intervention standpoint is going to have a better result in the context of a therapeutic alliance, which can be defined in large part on the quality of the relationship you have with the patient.