BY VICTOR S. SIERPINA, MD, ABFP, ABIHM, Distinguished Teaching Professor, Family and Integrative Medicine, UTMB Health
“Generosity he has, such as is possible only to those who practice an art and never to those who drive a trade; discretion, tested by a hundred secrets; tact, tried in a thousand embarrassments; and what are more important, herculean cheerfulness and courage. So it is that he brings air into the sick room and often enough, though not so often as he desires, brings healing.”
---Robert Louis Stevenson
Last month, we started on the journey to discuss the challenges of creating an optimal healing environment in the tough zone that is medical practice today. We discussed personal and professional characteristics that could enhance this setting.
This month, we will look at practical business and practice structures that may be useful to you. If you would like more detailed and practical methods of optimizing the environment of your healing practice, consider attending the upcoming Holistic Primary Care’s Heal Thy Practice- Transforming Patient Care conference, Nov 9-11, 2012 in Long Beach, CA (1). A preview by one of the speakers, Dr. Kennealy is about freeing yourself from “McMedicine.’ She offers three tips: 1) Shift your perspective and embrace business thinking, 2) Tap your entrepreneurial spirit and engage in acts of radical creativity, 3) Master authentic from-the-heart marketing. This annual conference is a chance to truly reform your practice and approach to medicine and this is just one of the many practice-related presentations.
Optimizing the healing environment can and should incorporate several levels of change. Holding the intention to create a healing environment among all doctors, nurses, and staff in the practice is essential. You wish to promote an authentic, heartfelt desire and concerted effort to provide a patient centered medical home and relationship based experience. This should result in a service-oriented encounter perceived as a “Wow!” experience by patient. This changes things in the radical way they need to move.
Transform your office into a healing space by incorporating natural elements such as light, music, wood, water effects, art, and comfortable seating and exam rooms. This gives a powerful message, “We care how you feel and how you experience your visit from start to finish.” Such changes don’t have to be highly expensive or complicated. Simple effects and conscious design can offer patients a holistic, artistic, positive healing space that invites them to activate their innate healing response and to feel respected as whole persons. For those so inclined, there are a number of “green” and “holistic” architects and interior designers that specialize in making medical spaces less coldly clinical and more warm and inviting.
Rakel’s textbook of Integrative Medicine(2) introduces the 4 A’s of the healing encounter: 1) Awareness, 2) Awakening, 3) Authenticity, 4) Awe. This approach incorporates nothing less than a mindful approach and consciousness that both sides of the healing encounter are in a mutual transformation. As Carl Jung stated, “The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed.”
An example of this is what Rakel refers to as the “salutogenesis-orieneted session” (SOS) healing encounter. The term comes from the Latin, salutaris, meaning health. Salutogenesis is thus the generation of health. It can be fostered in either a brief encounter or a prolonged discussion. Longer sessions require protecting time in your schedule and framing patient expectations about the visit. This requires deliberate planning, the creation of ceremony, and ritual. This extended visit cannot be applied to every patient, but can certainly be planned for some.
For example, though my primary care practice is fully booked and closed to new patients, I continue to offer holistic consultations, which include an extended initial session of at least an hour, plus follow-up visits as needed. This allows me to manage the practice and my panel size. It also provides an opening for complex, intensive visits that are challenging for me professionally and personally. These SOS visits stimulate my mind by making me bring out the best of all I have learned in medicine. In these consults, I incorporate tools from the entire integrative spectrum of nutritional medicine, mind-body therapies, functional medicine, acupuncture and Chinese medicine, spirituality, motivational interviewing, botanical medicine, and lifestyle change.
Billing and coding is an essential part of maintaining your integrative practice. It is essential that you create a consistent cash flow to manage the expense of your time and other overhead expenses. Some practices do this by making such consults a cash only basis. Others incorporate them in the standard insurance billing model. Attention to proper documentation on complexity of decision making, key elements to history and physical will allow insurance coders to allow the highest level of reimbursement for your time spent. One way to improve your collections are to use the “counseling” statement. This requires your statement that at least 50% of the visit was spent on counseling. This counseling service needs to be detailed, for example, lifestyle, changes, mind-body instruction, nutritional advice, exercise prescription, coordination of services with other specialists of alternative practitioners, etc. Any time over 45 minutes is likely qualify for a level 5 visit and over 30 minutes for a level 4 if all other documentation requirements have been met. This is the way I manage to get reimbursed for the SOS type, extended or comprehensive level visit.
Though it is a challenge to optimize the healing environment in the current health care system, practices can utilize some of the principles described here to make a big difference in how medical services are delivered. Incorporating health coaching, developing the Patient Centered Medical Home, modifying the physical environment, working to improve people attitudes, making processes more efficient with are all useful tools to improve the patient interface.
By changing the way we do medicine and changing the medicine that we do, we embrace the opportunity to revitalize ourselves, our practices, and most importantly, the health of our patients. This allows us to face squarely whatever surprises health care reform may deliver to our doorstep. We do this by returning to our root Oslerian principles, bringing joy and idealism to our work once again if we have sadly lost them.
1.http://holisticprimarycare.net/heal-thy-practiceconference 2. Rakel D. Integrative Medicine. Edition 3, Elsevier/ Saunders. 2012, p.22-24