Transcript here - Canadian Institute of Stress

An NP/MD Team Approach to the
Management of the Stress Difficile
Patient
Murray C. Woods, MD
Richard Earle, Ph.D
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Satisfaction – The Rolling Stones
( top 10 R&R songs of all time)
• 50 years this month! Any more satisfied?!
• What is satisfaction? How can I increase it on
the job, and at home? Cosmic question!
• I can’t get no… A no no no!
• vs Yes WE can!
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Curious?
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Our Plan For This Morning
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What is this all about? Working Together!
An introduction, and some working definitions
pernts
Action for traction (improved outcomes,
greater satisfaction) with the SD patient
• Share a vision/a new tool
• Sprinkle presentation with clinical vignettes
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Your Presenter
High school teacher, then UBC Medicine
Full Service Family Practice x 25 years, Cowichan
District Hospital, Duncan, BC
• Hospitalist medicine x 3 years, NRGH
• Sand bar/The Wizard of Oz/Tin Man
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But with Courage, Heart and Brain!
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You never know…
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What Now?
• Recovery strategies – bio-psycho-social approach,
incomplete symptom resolution.
• I am inspired by one of Hans Selye’s great quotes:
• “A long, healthy and happy life is the result of making
contributions, of having meaningful projects that are
personally exciting and contribute to and bless the lives of
others.”
• Different paths
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Meet the Stress Difficile Patient
• Nothing to do with clostridium infectious diarrhea!
• Stress Difficile patient features:
• Secondary gain from frequent family doctor/HCP visits
has become their primary gain or goal
• Typically over-stressed and unwell. DRAMA! URGENCY!
• Their presentation is always confusing and time
consuming; exams and labs add little/nil
• Poor adherence to past therapy and poor prognosis.
• HCPs assess their effectiveness and professional
satisfaction with SD patients at 30% and 40% lower,
respectively, than with typical patients
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Friday, 415 pm, sunny and clear…
• Case 1: Peaches just left your office after a
“typical for her” histrionic rant. She can’t make
next month’s rent, her BF is leaving, she has
gained 10 lbs., relies on daily marijuana, has poor
sleep, poor diet, and claims that her dog ate her
1 month Ativan Rx supply, written a week ago.
Dog now very relaxed.”It’s just not fair.” PHx CBT,
yoga, group counselling, meditation and self help
books have not helped. After a long visit, she
leaves with another small quantity Ativan Rx.
Now you’re 30 minutes behind. NO JOY! There’s
got to be a better way…
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Familiar?
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Satisf – Action
What is a satisfier? Think about puppies!
Features…
• How can I get more satisfaction? How can I
improve? How can I get better results, and
greater satisfaction?! At home? At work? How
can I “Be the change you wish to see…”
(M.Ghandi)
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Who is this?
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Satisfaction continued:
Investment banker meets psychologist. Consider
this definition of satisfaction:
• Return on investment (ROI): $out/$in
• ROE =units of satisfaction derived/units of
stress energy invested (Stress IS Energy)
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What a concept!
• ROE with SDs is bound to increase if a new
approach, based on better understanding and
treatment strategies, results in improved patient
outcomes.
• This requires a standardized, share-able, peer
reviewed, EMR friendly, easy to use toolkit,
agreeable to all the SD’s HCPs, where carefully
selected patients contract to build better
outcomes. This can work!
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Back to Peaches…
• What if Peaches had a contract with you? Allow
for ONE top priority complaint, Assess for Mental
Health certification (risk of harm self/others), stay
on track, record diligently…especially no shows,
failure to do homework or fulfill contract
commitments, despite your best efforts. Keep
records on handy SD protocol EMR templates.
• Your record becomes your defense if, upon
patient dismissal, your patient wishes to lodge a
College complaint against you.
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Boundaries vs Entanglement
(It’s Not Yours)
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Think About It!
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SDs = Tough Nuts (TNs)
• Guiding Light: Best efforts at treatment/Practice
pruning/housekeeping can save your sanity
• HCP Agitation as “sniffer test”
• Landing strip for SDs in your clinic/town, vs
abandonment
• Personality traits eg borderline, narcissistic,
dependent, avoidant, odd, histrionic play a big
part…meds alone don’t help much.
• They’re litigious…protect everyone/CYA
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Network/Share the SD Burden
( We agree on our message)
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Common SD Treatment Options
• Meds (anxiolytics/benzos, antidepressants
and analgesics) ad infinitum >> SUD
• All 3 ad infinitum? Vs. as a bargaining chit!
• Rejected? This becomes part of Pt record
• ( Rx’s hinge on pt commitment, and wean
medications responsibly, at the right time)
• Codependent relationships, entrapment
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Building Enduring Change
• In the biopsychosocial model of recovery and
rehabilitation, a unimodal medication
approach will rarely bring lasting gains.
• Big Pharma’s $ interest (40 million Rx/yr)
• Consider an SD action plan as meds adjunct or
meds alternative!
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Treatment Options 2?
“New Age”
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Cognitive Behavioural Therapy CBT
Mindfulness, mind-body training
Meditation
Yoga,
Spiritual growth and development
Combinations…invent your own personal
solution!
• Structure is the common denominator in all
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Wellness Defined (NIW)
• An active process of becoming aware of,
making choices and taking actions toward a
more successful (increased satisfaction and
improved outcomes) existence. Wellness is
very personal…”to be able to do whatever you
want, as much as you want, whenever you
want, for as long as you want.”
• Wellness is personal, involves feelings
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The Wellness Evidence states that:
• Greater gains (requiring honest introspection and
hard work) will come from addressing:
• RELAXATION
• COMMUNICATION
• CLARIFICATION OF GOALS AND VALUES
• (You don’t see diet, exercise and vitamins here!)
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Stress Defined
• Core – a bio-psycho-social syndrome, the
body’s nonspecific response to any demand
(especially uncertainty or anticipation) placed
upon it;
• Commonsense – the common conduit through
which life’s many stressors degrade bodymind-emotion systemic efficiency e.g. rate of
aging.
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Hans Selye, MD, DSc, PhD, CC
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Chronic Stress-Illness-Disability
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DISTRESS STAGES:
1. Fatigue
2. Diminished relationships
3. Emotional distress
4. Chronic pain
5. Illness… disability…death
Where is your SD patient?
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Canadian Institute of Stress CIS/Hans
Selye Foundation
• Hans Selye and 8 Nobel Laureates began it in
1979 in Montreal, PQ, later in Toronto, Ont
• A world class organization: Evidence-based
solutions for stress and successful adaptation
to change.
• Richard Earle, Ph.D is their current Managing
Director, one of Selye’s last graduate students
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SWC for NPs?
• Online Stress and Wellness Consultant (SWC)
certification course began in 2003; I took it in
2013-14. Highly recommended, very relevant
to primary care medicine! (stresscanada.org)
• 14 weeks, Wednesday and Saturday, twice per
week on line, interactive web based format,
GoToMeeting (Saturday am and Wednesday
pm)
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What is the CIS? The Experts!
Creativity, Rigor, Solutions – global stature
For 35 years, applied research at Dr. Selye’s
Canadian Institute of Stress has translated
resulting Foundation insights into evidencebased tools and know-how, evaluated and
refined in clinics, with proven effect on
individuals and corporations internationally.
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Wise Man from the East
• The career of the Institute’s Managing
Director, Richard Earle Ph.D., has integrated
applied research and direct service in both the
public and private sectors in Canada and
internationally. Dr. Earle has held adjunct
appointments in Faculties of Behavioural
Science, Medicine and Nursing [MScN
program]. He has also done post doctoral
training at Harvard.
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An Idea!
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Need?
• Asking key questions yielded similar answers
among FPs and NPs.
• Dr Earle and I collaborated to create a NEW 4
week CME course, intended for a wide range of
HCPs, Also on line, interactive, with meetings
twice per week. Starts Oct, 2015
• College of Family Physicians of Canada Mainpro
accreditation, across Canada (16 M1 credits)
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The Evolution of Primary Care
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Action for Traction with the Stress
Difficile Patient – A Shared Care Plan
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Collaboration
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FP/NP(HCP) Dx code Realities
• Anxiety/Depression/Stress are the most
common diagnoses, by far…past, present
and…
• 2.2 x more HCP time spent cf average pt.,
accounting for >50% of caregiver time!
• Stress’s impact on primary mental
health/addiction, chronic illness, occupational
health and even palliative care
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Reports from the NP Trenches
• NPs in all practice settings observe an
increasing need for this skill set, as they are
finding on their own, or are being delegated,
this aspect of patient care more and more
• The search is on for a cohesive approach:
standardized, brief and to the point, EMR
friendly, defensible, responsible, and proven.
• NP educators across Canada are interested.
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Trends/LinkedIn NP Survey (“You Have
Spoken”) April 2015
• Increasing and expanding role of NPs, increasing
“market” share noted in US, and in Canada
• NP is becoming primary HCP with SD pts ie there
is a “transfer of function” underway
• NPs satisfied with job, but could be more so…
• Patterns are seen: stress connection to illness
• The need for a new toolkit is acknowledged
• We want to learn more
• Dedicated, engaged, communicative group
• Great balance: heart, head and Kissinger, too!
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Q: How do you eat an elephant?
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A: One Small Bite at a Time!
• Imagine…HCPs working together to identify SD
patients, using an appropriate definition
• Assess degree of impairment, comorbidities,
motivation, suitability to participate in brief
counseling intervention
• Sell the idea, engage the patient in this
contract (motivational interviewing)
• Use a comprehensive inventory to enable pt
to identify THEIR top priority for change.
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Coach/Contract
• HCP uses an evidence based protocol to
establish with SD patient THEIR top priority,
then on sequential visits, walk them through
the protocol, where they are accountable for
self–discovery, self- motivation and selfmanagement
• Short, defined and focused followup meetings,
no more rambling!
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Inspiration/Goals for Change
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Focus: My Better Future Self
• Self Portrait – very personal
• Affirmations - words
“Action Focus”
• Visualizations – pictures
• Daily encounters with “Where I am going!”,
much different from Where am I going?!
Reinforce opportunity situations! An
application of positive self talk!
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The New and Better Me!
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Show me your Spots!
(SD protocol helps you to see this)
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Case 2
• “I don’t wanna play!” response suggests a
coverup, or Munchausen syndrome/factitious
disorder/malingering…obtain confirmatory
second opinion (NP, MD), en route to
consideration of change in treatment strategy,
search for mitigating circumstances, referral or
even patient dismissal. Record interactions like
the Tragically Hip: “Fully and Completely.”
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Case 3
• Pt. unable to complete the Pillars of Wellness
inventory >>new diagnosis visual impairment,
cognitive impairment or limited IQ, suitable
for visual aids, living assistance and supports
eg provincial DB2 pension
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Case 4
• A trusting relationship has been established over
18 months between NP Nancy and Eddy, a 54 yo
gay male with PHx HCV, IVDU, and remote
alcoholism, with minimal social supports, living in
a sketchy rooming house. Unable to complete
interferon/ribavirin Rx last year due to
depression. Over the past year, using the Pillars of
Wellness inventory, Eddy has selected and
created action plans to produce enduring
improvements in weight loss, his diet, no added
salt and cessation of daily marijuana use.
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Case 4 cont’d
• Today Eddy seems apathetic, inappropriate,
and has impaired arithmetic skills. He
reluctantly admits to returning to alcohol.
Today’s sudden cognitive decline leads Nancy
to have him redo Pillars. Relationships and
Community scores have gone down, because
his younger sister has left town following an
argument, and he is largely left on his own.
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Case 4 cont’d
• Eddy is connected by NP Nancy with
community HCV supports, home care nursing
and AA, which he used to attend in the past.
• Nancy and colleagues pursue LFTs and
discover elevated NH3, Grade 2 hepatic
encephalopathy, which, over time and serial
lab monitoring, they were able to correct with
EtOH cessation and ongoing community
supports.
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Case/Goal Selection is Key
• Prochaska and DiClemente 1992 (relapse is
integral to the change model)
• Factor in prescribing habits prn/sharpen the saw
• Choose behavioural change goals carefully:
• S = specific
• M = measurable
• A = acceptable/achievable
• R = realistic
• T = Truthful
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Pre- Vs Post Test Comparisons
• MOH/HA’s want proof of improvement
• Working/sharing with other HCP colleagues
(community care workers, social workers,
medical specialists, counsellors, etc) increases
the power and impact of the protocol.
• EMR sharing of the action plans allows for
pattern recognition, and to track progress (or
not) over time.
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Summary
• 1. Increased understanding of satisfaction,
stress and wellness
• 2. An understanding of a method by which
NPs and MDs (and other HCPs) can work
together to improve clinical outcomes and
derive greater professional satisfaction in
dealing with stress difficile patients.
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Summary
• Patient selection, a clear understanding of roles
and responsibilities, and selecting patientinitiated small SMART behavioural change goals,
is a good start. Regular supportive followup visits,
with consistent application of action plans, are
key factors in achieving lasting results. Aim for
better. One Top Priority Change at a time!
• Collaboration between MDs and NPs offers great
opportunity for patient and provider benefit!
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Questions?
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