An interactive, PC-based system with color graphics and a user-friendly format, CHESS is easy to use — even for people with no computer experience. Patients diagnosed with serious conditions such as breast cancer or AIDS/HIV infection are given a computer at home. At their own convenience, patients can access timely, comprehensible information about their disease and take advantage of a variety of non-threatening and anonymous support opportunities.

They can read brief answers to hundreds of commonly asked questions, detailed articles about their health problem and descriptions of services available. They can ask questions of experts anonymously and receive confidential responses. They can read real-life, personal stories of others living and coping with similar problems and communicate directly with these people.

Using problem-solving tools to monitor their health status and risk behaviors, they can think through difficult and important decisions, plan how to overcome obstacles and implement those decisions.

With traditional health education, patients often have little control over the extent, depth or speed of information they receive. CHESS overcomes many of these barriers. Patients get assistance 24-hours a day, 7 days a week. They can proceed at their own pace, deal with issues when, how, in what order, and in as much detail as they wish. Facilitated, online support groups help reduce the sense of isolation and helplessness for patients and their families.

Preliminary results of the CHESS system — one of the first computer-based patient education and support programs to be evaluated scientifically — are very promising:

• Women with breast cancer who used CHESS noted that the system was very valuable and easy-to-use. They reported more positive emotions and fewer negative emotions. CHESS was used extensively by both older and younger women, as well as by both college- and high school-educated women.
  
• In controlled studies over a six-month period, HIV-infected men and women used the system an average of 132 times per person (more than once a day on average) for an average total of 39 hours per person. Minority subjects used CHESS as much as Caucasian subjects. Compared to controls, CHESS users reported significantly improved mental functioning, more social support, less negative emotion, more active participation in their health care, and, in general, a more active life. They spent less time during out-patient visits and reported shorter hospitalizations resulting in an estimated reduction in health care costs.
  

The early lessons from CHESS are clear, with the right motivation (in this case a serious health crisis), encouragement and support, people with no knowledge or even a fear of computers can learn the system quickly and begin reaping the benefits.

Computer systems can go beyond delivery of information and help people connect with others who share a similar life experience. And well-designed computer systems can measurably improve health status and reduce health care costs.
CHESS is now being converted to operate on the Internet which will reduce the cost and offer greater, continuing access.

Patient comments on CHESS:


“One thing I learned from CHESS is how much I don’t know about my diagnosis and prognosis. I can’t begin to tell you how useful CHESS has become for me. So much of fighting this disease is to find a way to get back in charge of my body. This program has been the prime factor in doing that. I feel really in control.”

“I ask more intelligent questions when I see my doctor. I feel more in charge of my health care. I have met people who are in the same situation I am in. This has helped. CHESS has allowed me to give of myself in a way that otherwise would not have been possible.”
“My biggest benefit was the relief I felt after using CHESS that I had made the right decision as far as surgery for me. I wish every woman had CHESS the minute she had a breast cancer diagnosis.”
“This machine came alive and became real, and now suddenly these real people really know me, WOW! I’ve finally started going to groups and meeting lots of new people, and getting my life going again. I guess when I found out I had this disease I decided I was dying. Well, now I’m back with the living.”

For More Information



Gustafson DH, et al. CHESS: A computer-based information and support system for people facing health-related crises or concerns. 17th Annual SCAMC Proceedings American Medical Infomatics Association, 1993.

Gustafson DH, et al. The use and impact of a computer-based support system for people living with AIDS and HIV infection. 18th Annual SCAMC Proceedings American Medical Infomatics Association, 1994.

CHESS (Comprehensive Health Enhancement Support System), Center for Health Systems Research and Analysis, University of Wisconsin-Madison, 610 Walnut Street, Room 1109 WARF Building, Madison, WI 53705-2397.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

One recent study – the first to look beyond the direct cost of treating depression to the use of medical services in general – suggests that in the long run these cuts may be costing the health-care system far more than they save.

Examining accounting records of some 12,000 HMO patients of Group Health Cooperative of Puget Sound, researchers found annual medical costs for patients with diagnosed depression to be double those of patients not diagnosed with depression. The twofold difference persisted for at least 12 months after the patients began receiving treatment for depression.

The estimated price tag for this increased medical service utilization was a whopping $8.9 million over 1 year – compared to just $3.8 million spent on this group for mental health care services. Even among patients treated with antidepressant drugs, costs of these prescriptions accounted for less than half the difference in pharmacy costs.

Significant cost increases were identified in every category of care including
primary care, medical specialty, medical inpatient, pharmacy and laboratory.
Researchers also looked at how chronic disease might bias their findings, assuming that chronically ill patients could be expected to have higher medical costs and a greater likelihood of depression. Even after adjusting for chronic conditions, costs for the depressed group were typically 1.5 times those of the comparison group.

Researchers also point out that since only patients with recognized depression were included in the test group, and since depression often goes undiagnosed and untreated, the real cost differences may be far greater than even their data indicate. Unfortunately, the increase in costs in the depressed patients occurred despite recognition and initiation of treatment of depression. This means that we still need to improve the management of the complex problems and learned pattern of frequent medical visits of depressed patients if overall costs are to be decreased.

Clearly, depression must be taken as seriously as any other chronic medical disease for impact on overall medical costs – and, of course, for the suffering, disability, work loss and impaired quality of life this disease brings in its wake.

All of us must be concerned about the rising cost of health care. These figures suggest that increasing and improving treatment of depression – not cutting services – is the right thing to do.

For More Information


Simon GE, VonKorff M, Barlow W: Health Care costs of primary care patients with recognized depression. 0 1995;52:850-856.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

The greatest discovery of my generation is that human beings, by changing the inner attitudes of their minds, can change the outer aspects of their lives.- William James (1842-1910)

You may assume that “imagination” means “not real.” But the thoughts, words, and images that flow from your imagination can have very real physiological consequences for your body. Your brain often cannot distinguish whether you are imagining something or actually experiencing it.

Perhaps you’ve had a racing heartbeat, rapid breathing, or tension in your neck muscles while watching a movie thriller. These sensations were all produced by images and sounds on a film. During a dream, maybe your body responded with fear, joy, anger, or sadness – all triggered by your imagination. If you close your eyes and vividly imagine yourself by a still, quiet pool or relaxing on a warm beach, your body responds to some degree as though you are actually there.

Your imagination can be a very powerful resource in relieving stress, pain, and other unwanted symptoms.

You can learn to use the power of your imagination to produce calming, energizing, or healing responses in your body. You can use imagery and hypnosis to reduce anxiety, fear, and panic; decrease chronic muscle tension; decrease pain and need for pain medications; improve comfort during medical, surgical, and dental procedures; reduce the length of labor and discomfort of childbirth; control bleeding; speed healing and recovery from surgery, injury, or skin conditions such as warts and psoriasis; ease sleep problems; improve management of chronic illnesses such as diabetes, asthma, lung, and heart disease; boost your immune function; increase sense of control and mastery; change bad habits and maintain healthy ones.

Practicing Imagery and Visualization

With guided imagery, you deliberately focus your mind on a particular image. While imagery most often uses your sense of sight with visual images, you can also include the rich experiences of your mind’s other senses. Adding smells, tastes, sounds, and other sensations makes the guided imagery experience more vivid and powerful.

Some people are very visual, and easily see images with their mind’s eye. But if your images aren’t as vivid as a really great movie, don’t worry. It’s normal for imagery to vary in intensity. The important thing is to focus on as much detail as possible, and strengthen the images by using all your senses. Adding real background music can also increase the impact of guided imagery.

Remember, with guided imagery, you are always completely in control. You’re the movie director. You can project whatever thought or feeling you want onto your mental screen. If you don’t like a particular image, thought or feeling you can redirect your mind to something more comfortable. Or you can use other images to get rid of unpleasant thoughts (you might put them on a raft and watch them float away on a river, sweep them away with a large broom, or erase them with a giant eraser). Or you can open your eyes and stop the exercise.

Included here are basic scripts for several imagery exercises. Scores of other scripts and tapes are available. You may want to tape record yourself (or someone else) reading the script so that you can concentrate fully on the imagery. Feel free to change, modify, and personalize the script any way you please. Make it your own.

Skill, Not Magic

To practice these imagery exercises you will need 10 to 30 minutes of quiet, undisturbed time. You may need to put up a “Do Not Disturb” sign and turn off the telephone. Wear loose, comfortable clothing. Sit in a comfortable chair or lie on a pad or carpeted floor with a pillow under your head. Do whatever you can to enhance your comfort. Dim the lights. Put on soft music if you like. You may wish to use a guided imagery audiotape (see below).

Don’t expect miracles. Some relief may come immediately, but often these skills take time to acquire. You may need several weeks of practice before you really start to notice benefits. Practice the techniques once or twice a day, or if that’s not possible, at least three to four times a week.

Watch Out

Imagery techniques are generally very safe. However, if you have symptoms such as pain, diarrhea, dizziness, nervousness, or depression, make sure you first have an appropriate medical evaluation. These imagery techniques may also change your need for certain medications, so be sure to check with your doctor. Don’t practice imagery or self-hypnosis while in a car or in any situation where your safety requires full alertness and quick responses. If you experience very distressing sensations or feelings while practicing these techniques, stop and get professional help.

The Juicy Orange

You are standing in your kitchen. Imagine the time of day, the color of the countertops, the appliances, the cupboards. You hear the hum of the refrigerator. You notice a large, plump, juicy orange lying on the cutting board. You pick it up and feel its weight. You feel the texture of its dimpled, glossy skin. With a sharp knife, you carefully cut a large slice.

As you cut into the orange you notice the rich, liquid, fragrant juice trickle onto the counter top. You see the bright whiteness of the pulp in contrast with the orange flesh. You see the small drops of orange juice forming on the cut surface. Now imagine lifting this dripping slice of orange to your mouth, and smelling its sweet, fresh scent. Your mouth begins to water as you slowly bite into the orange. It releases a flood of sweet tangy juice into your mouth.

This juicy orange imagery exercise causes most people to salivate. Just the words and multi-sensory images are enough to trigger a physiological response.

In this case it’s the flow of saliva. You can learn to use the power of your imagination to control other body functions.

Rx Create Your Special Place

The purpose of this guided imagery exercise is to help you imagine a special place where you feel safe, comfortable, and relaxed. This place can be anywhere.

It might be somewhere you have been, or a place you know well. It could be a place you create from scratch, or by taking bits and pieces from places you know. You may choose to put a dwelling in your landscape: a cabin, a castle, or a cave. Here’s what to do:

• Begin by closing your eyes (or if you prefer, keep your eyes open). Take several slow, deep breaths, exhaling completely after each.
• Now see if you can imagine a place where you feel completely comfortable and peaceful. It might be real or imaginary, one from your past, or someplace you’ve always wanted to go (it doesn’t really matter, just so long as this place feels very safe and peaceful to you).
• Allow that special place to take shape slowly (there’s no rush).
• As your place begins to take shape, look around. Look to your left, to your right, and all around you. What do you see?
• Enjoy the scenery: the colors, the textures, the shapes.
• Listen to the sounds of your special place – perhaps waves gently lapping at the shore, the call of a distant bird, the sound of the wind in the trees.
• Now just listen to the sounds of this wonderful place – a place that is so comfortable and peaceful to you.
• Perhaps you feel a breeze touch your face, or warm sun gently soothing your skin.
• You may feel the crunch of gravel or soft sand beneath your feet, or the comforting support of a favorite chair.
• Now touch or pick up some favorite object from your special place. Allow your fingertips to gently explore its surface (Is it smooth or rough? Wet or dry? Warm or cold?).
• Now take in a deep breath through your nose, and notice all the rich fragrances around you. Perhaps your favorite flower is in bloom. Or you may smell the pungent scent of a pine forest, or the tangy salt sea air, or the aroma of your favorite food.
• Relax and enjoy the peace, comfort and safety of your special place.
• This is your place, and nothing can harm you here. Relax, feeling thankful and happy to be here, in your special place, at this moment.
• Begin to sense that something wonderful is about to happen. Feel the tingling sensation of expecting something good.
• Know the sense of certainty. Everything is right, just as it should be.
• Now notice a soft glow of golden light from above. It begins to bathe your body.
  A tingling, shimmering, vibrant energy surrounds you, energizes you, soothes you, heals you.
• You are washed in bright goodness, and draw everything you need to you, as a powerful magnet. Good wishes and kind thoughts come. This goodness and healing energy seeps into your body, infusing you with a generous, boundless energy and sense of well-being.
• Feel it move through the layers of your body, deeper and deeper into each and every organ, down to the bone.
• Feel it in each and every cell, dissolving any blockages, correcting any imbalances. Enjoy this free-flowing, healthy energy sweeping through your body. Now you are relaxing; healing.
• Your body remembers how to be well, and savors this feeling of well-being. You feel peaceful and easy in your special place – a healing place – one that is always here. You know it’s a place you can visit anytime, and feel this healing energy and peace.
  When you are ready to return, take a deep breath and exhale fully. Open your eyes and spend a few moments savoring this relaxed, healthy, comfortable feeling.
• You may want to explore different special places each time you do this exercise, or one special place may emerge as your favorite. Remember, you can visit this place any time you want to, in your mind.

Script adapted from Belleruth Naparstek

Rx Create Your Inner Advisor

You can use this type of imagery to explore the meaning of your symptoms or illness, and what you can do to improve your health. This imagery is a means of two-way communication between your mind and your body.

Begin with a general imagery exercise such as Creating a Special Place. Once you have entered your special place, invite an inner advisor to come and visit you.

Use all your senses to watch for your advisor, as the advisor may take any shape or form. Or you may have several inner advisors. They may be a person, a voice, an object, or a symbol. If you are not comfortable with what emerges, send him/her/it away, and invite another advisor.

Once you are comfortable with your advisor, ask questions. Feel free to ask anything, such as:

• Are you my inner advisor?
• How can I relax?
• What is causing my tension? Pain? Symptom?
• What do I need to do to feel better?
• Who can help me?

Then wait for the answers. Be patient. They may come in any form: a picture, image, sound, word, phrase, feeling. They can come at any time. Think about what they mean to you.

Sometimes you may be surprised at the directness and clarity of an answer. In response to “What is causing my anger” one person heard back, “You need to learn to say no.” If the meaning or usefulness is not clear to you right away, don’t worry. It may become clearer in the days or weeks ahead.

You can use a similar technique to have an inner dialogue with a symptom you are having. For example, if you are in pain, give it a color, shape or form. Then ask your pain questions:

• Why are you here?
• What can I learn from you?
• When will you go away?
• How can we live more peaceably together?
• How can I get better?

Wait for responses. This dialogue can be done with any symptom or problem.

You have untapped knowledge, insight, and wisdom which is often drowned out by the incessant chatter of a busy mind. You can use imagery techniques to give voice to your inner wisdom, and consult your own inner advisor. There is nothing mysterious or magical about it. Simply by quieting down and bringing your mind into a focused and receptive state, valuable insights can emerge. These include suggestions on how to improve your health and well-being.

Adapted from Martin Rossman, MD and the Academy for Guided Imagery

Rx Imagine Yourself Well

You have the ability to create special imagery to alleviate specific symptoms or illnesses. Use any image that is strong and vivid for you (this often involves using all your senses to create the image), and one that is meaningful to you.

The image does not have to be physiologically accurate for it to work. Just use your imagination and trust yourself. Here are examples of images that some people have found useful. Use any of these images, or make up your own.

Remember, the best ones are vivid and have meaning to you.

For Tension and Stress

• A tight, twisted rope slowly untwists
  Wax softens and melts
  Tension swirls out of your body and down the drain

For Healing of Cuts and Injuries

• Plaster covers over a crack in a wall
• Cells and fibers stick together with superglue
• A shoe is laced up tight
• Jigsaw puzzle pieces come together

For Arteries and Heart Disease

• A miniature Roto Rooter truck speeds through your arteries and cleans out the clogged pipes
• Water flows freely through a wide, open river
• A crew in a small boat all row together, easily and efficiently pulling the slender boat across the smooth water surface

For Asthma and Lung Disease

• The tiny elastic rubber bands that constrict your airways pop open
• A vacuum cleaner gently sucks the mucus from your airways
• Waves calmly rise and fall on the ocean surface

For Diabetes

• Small insulin keys unlock doors to hungry cells, and allow nourishing blood sugar in
• An alarm goes off and a sleeping pancreas gland awakens to the smell of freshly brewed coffee

For Cancer

• A shark gobbles up the cancer cells
• Tumors shrivel up like raisins in the hot sun, and then evaporate completely into the air
• The faucet that controls the blood supply to the tumor is turned off, and the cancer cells starve
• Radiation or chemotherapy enter your body like healing rays of light; they destroy cancer cells

For Infections

• White blood cells with flashing red sirens arrest and imprison harmful germs
• An army equipped with powerful anti-biotic missiles attacks enemy germs
• A hot flame chases germs out of your entire body

For a Weak Immune System (Immune deficiency disorders: HIV, AIDS, and others)

• Sluggish, sleepy white blood cells awaken, put on protective armor, and enter the fight against the virus
• White blood cells rapidly multiply like millions of seeds bursting from a single, ripe seed pod

For an Overactive Immune System (Allergies, asthma, arthritis, etc.)

• Hyperalert immune cells in the fire station are reassured that the allergens have triggered a false alarm, and they can go back to playing their game of poker
• The civil war ends with the warring sides agreeing not to attack their fellow citizens

For Pain

• All of the pain is placed in a large, strong metal box, closed, sealed tightly and locked with a huge, strong padlock
• You grasp the TV remote control and slowly turn down the pain volume until you can barely hear it; then it disappears entirely
• The pain is washed away by a cool, calm river flowing through your entire body

For Depression

• Your troubles and feelings of sadness are attached to big colorful helium
  balloons, and are floating off into a clear blue sky
• A strong, warm sun breaks through dark clouds
• You feel a sense of detachment and lightness, enabling you to float easily through your day

For Behavior Change

• If you are somewhat shy, imagine a vivid, detailed picture of yourself walking up to people and chatting with them confidently
• If you want to be more physically active, see yourself walking in the park, riding a bike, taking a dance class, or joining a sports team

This article was adapted from The Healthy Mind, Healthy Body Handbook by David S. Sobel and Robert Ornstein. Publisher: DRx, Los Altos, CA, 1996. May not be reproduced without written permission.

This approach does not mean dissuading those who are truly sick from seeking care. In fact, physical illness is not a good predictor of medical utilization and expense. Many people with disease do not seek care, while others with little apparent disease tend to visit the doctor frequently. The decision to seek care is more determined by anxiety, worry, stress, lack of confidence, lack of information, job dissatisfaction, and unhealthy lifestyles than it is by the presence or absence of physical disease. Therefore, it is reasonable to think that mind/body interventions which address the underlying distress that prompts visits to physicians, might reduce distress and medical expenses.

A recent, preliminary study in Quebec, Canada suggests that the practice of one common such mind/body intervention meditation and relaxation may indeed reduce the cost of physician services. The study focused on Transcendental Meditation (TM), a practice introduced by Maharishi Mahesh Yogi which involves focused concentration and relaxation for 15 to 20 minutes twice daily. This practice tends to produce physical and mental effects that are opposite to the stress response.

In this study, payments to physicians were analyzed for 677 patients practicing TM. For the three years before starting to practice TM, adjusted payments to physicians did not change significantly. After beginning TM practice, patients expenses tended to decline 507% annually.

These impressive results must be viewed with caution. There was no comparison or control group. The patients chose to start and continue TM practice and elected to participate in the study. Therefore, it is unclear whether the results would apply to other groups of people.

Unanswered Questions

What led to the reductions in physician costs? Less stress? Increased self-confidence and less dependence on professional medical care? Improved health habits such as less smoking and substance abuse or better diet and exercise? A shift away from conventional medical care to alternative medicine?

Do the findings only apply to the use of TM or to other daily meditation, mindfulness and relaxation practices?

Even with these questions still to be answered, the preliminary results of this study suggest that mind/body interventions hold real promise for improving health and reducing costs.

For More Information:

Herron RE, Hillis SL, Mandarino JV, et al: The impact of the Transcendental Meditation program on government payments to physicians in Quebec. American Journal of Health Promotion 1996:10:208-216.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

When faced with a surgical decision, who better to be than a physician? You would be among the best informed consumers. You would be well aware of the risks, benefits, and alternatives to the proposed procedure. And, according to the results of a new study, you would be less likely to have surgery at all.

Researchers compared surgical rates for physicians, lawyers, and their families to the general public in a large population in Switzerland. They looked at rates for the surgical removal of tonsils, gallbladder, uterus, hemorrhoids, appendix as well as repair of hernias and D&C (dilatation and curettage of the uterus).

For all of the operations except appendectomy, the general public went under the knife much more frequently than physicians or their families. For example, if you don’t have a physician in the family you are 50% more likely to have had a tonsillectomy, hysterectomy, or hernia repair and 80% more likely to undergo removal of hemorrhoids or gall bladder. If you want to avoid surgery, it also helps to have a lawyer in the family. Their surgical rates were almost identical to physicians!

These differences don’t seem to be due to financial barriers since all patients were covered by the public insurance programs and even the poorest had access to needed surgical services. Nor does it appear to be differences in how sick the general public was compared to physicians and lawyers. While some disease rates do vary by level of income and occupation, there is little evidence of variation in the specific types of disease for which these surgical procedures are indicated.

It appears that the more informed you are, the less likely you are to ask for or agree to elective surgery. Lawyers seem to have a special immunity to surgery. Lawyers may be more likely to challenge the surgeon’s authority and have greater potential for causing legal problems. Physicians may tend to be more cautious and prudent about recommending elective surgery to these “risky” patients.

We don’t know for sure the optimal rate of these surgical procedures that yields the best overall outcomes for patients. Nor do we know whether the reversal of financial incentives from fee-for-service to prepaid, managed care will lead us closer to optimal surgical rates. Nevertheless, we suspect that more operations are performed than are needed and that we would all do well to more closely follow the example of the most informed consumer, the physician-patient.

For More Information:


Sobel D, Ornstein R: Preparing for Surgery, Mind/Body Health Newsletter, Volume V, Number 2, 1996.

Domenighetti G, et al: Revisiting the most informed consumer of surgical services: The physician-patient. International Journal of Technology Assessment in Health Care 1993;9(4):505-513.

Domenighetti G, Casabianca A: Rate of hysterectomy is lower among female doctors and lawyers’ wives. British Medical Journal 1997 May 10;314(7091):1417.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

Fifteen minutes is hardly enough time to uncover psychological and social factors that may be causing symptoms or be key to the solution. There’s little time for learning about the disease and how to manage it, or for exploring how the disease may be affecting the patient’s moods, emotions, and ability to function at home. Brief office visits certainly do not provide social support or the opportunity for patients to experience how others cope with day-to-day challenges. In fact, both patient and physician often emerge from traditional visits feeling time-pressured and shortchanged – a situation getting worse as pressures to reduce costs force doctors to serve more and more patients.

What if you could have a full two-hour visit with your physician every month? And what if during that visit you could learn not only from your doctor, but from other members of the health care team as well as from other patients with similar problems?

These were the questions that led John Scott, MD, and his colleagues at Kaiser Permanente Medical Care Program in Colorado to rethink the office visit and try a completely different model: the group visit. The pilot project for their “Cooperative Care Clinic” involved group meetings of 20 elderly patients with multiple chronic conditions, their personal physicians, and a nurse team. The patients met once a month for two and one-half hours and were encouraged to bring a spouse, other family member, or caregiver.

The group appointments allowed time for socializing, interactive educational sessions, extensive questions and answers, blood pressure checks, x-ray and lab test ordering, review of medications, and discussion of preventative medicine, nutrition and exercise, living wills and advance directives, stress and relaxation, coping with grief, loss, and chronic pain. Time was reserved (but not always needed!) for brief, one-to-one visits with the physician for physical exams and symptom evaluation.
The patients began to take over the group, setting the agendas for future meetings. If they were concerned about medications and drug interactions, a pharmacist was brought in. If they wanted to learn more about safe exercise, a physical therapist was scheduled for a future group appointment. The patients began to feel more confident, involved, and responsible for being informed, active partners in their own care.

As group trust developed, most members eventually felt comfortable discussing very personal matters, including sexuality, death, and disability. Physicians noted that the patients often raised concerns they hesitated to discuss in individual office visits. Group support blossomed. When one member was ill or hospitalized, others rushed to help. Patients learned as much from each other as they did from the professionals. Physicians and nurses got to know their patients and could share their own personal sides. As one care team member commented: “We taught them medicine and they taught us life.”
The pilot results supported these observations. When compared to a similar group of patients who continued to receive traditional, one-to-one care, the Cooperative Health Care Clinic patients were more satisfied, reporting that their health care needs were better met and overall access to care was improved. Physicians, too, were more satisfied, noting that they felt they had more time to deal with the patients and that patients were more informed, helping the physicians to better diagnose and treat their conditions.

Medical costs and utilization decreased; group patients made fewer individual doctor visits, visits to the emergency room, and spent fewer days in the hospital and skilled nursing facilities. Preventative care also improved. More group patients received influenza and pneumonia immunizations. And more group patients had completed a living will or durable power of attorney to designate someone to make decisions on their behalf if they were too ill to do so.

Most patients could not conceive of going back to the old way of care. The pilot has been extended into a larger, three-year evaluation and the model is being tried for patients with diabetes, hypertension, and routine well-baby visits.

The Cooperative Health Care Clinic appears to be a win-win solution. With careful structuring and evaluation, this group model offered better-quality care – care that is more satisfying for patients and physicians – while significantly lowering costs.

For More Information


Scott, John C. and Robertson, Barbara J.: Kaiser Colorado’s Cooperative Health Care Clinic: A Group Approach to Patient Care. Managed Care Quarterly 1996;4(3):41-45.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

Same Disease, Different Response


Arthur suffers from severe arthritis. He is in pain most of the time and can’t sleep. He took early retirement because of his arthritis and now, only 55, he spends his day sitting at home bored. He avoids most physical activity because of the pain, weakness, and shortness of breath. He has become very irritable. Most people, including his family, don’t enjoy his company anymore. It even seems too much trouble when the grandchildren he adored come to visit.

Isabel, age 66, also has severe arthritis. Every day she walks several blocks to the library or the park. She works two days a week as a volunteer at a local hospital. When her pain is severe, she practices her relaxation technique and tries to distract herself. She also loves going to see her young grandchildren and even manages to take care of them for a while when her daughter is out. Her husband is amazed by how much zest she has for life.

The difference between Arthur and Isabel is one of attitude. Attitude
cannot cure a chronic illness. But cultivating a positive outlook and
learning self-management skills can make it much easier to live with.
The more confident and determined you feel, the more you will be able
to maximize your health. Whether you have arthritis, diabetes, heart
disease, cancer, lung disease, multiple sclerosis, or a combination of
chronic conditions, you can learn to be more active, cope better and
be more in control.

To live well with chronic conditions you need to learn skills for managing three areas:

• Your illness and symptoms
  
• Your normal daily activities
  
• Your emotions
  

Managing Your Illness


Any illness is a learning experience. You may not even know you have a pancreas gland until you’re told you have diabetes. To manage a chronic illness, you need to become an expert in your disease. This doesn’t mean you become a doctor, but you need to learn enough about your condition and how your body reacts so you can take action to minimize disability and complications.

Be an Active Partner


Learn about your medical condition. What makes it worse or better? What action plan should you take if symptoms flare? What are the warning signs that you should get professional medical help? What can you expect from medical care and what must you do for yourself?

There may be specific skills you need to learn: how to measure your blood sugar if you are diabetic, how to properly use an inhaler if you have asthma, how to exercise safely with a heart or lung condition, how to use assistive devices if your have arthritis.

Learn how to prepare for a medical visit – what questions to ask about medical tests, medications, and surgery.

Find community resources:

• Check out the Yellow Pages of the telephone book. Look under “Health,” “Hospitals,” “Community,” “Social Service Organizations,” “Local Government, Information and Referral.”
  
• Call the national or local chapters of voluntary agencies such as the American Heart Association, American Cancer Society, or
  National Arthritis Foundation.
  
• Ask the reference librarian in your local library to help you find information.
  
• Check out the calendar of events in your local newspaper.
  

Learn to Cope with Symptoms


Most chronic disease symptoms wax and wane. When symptoms are bad, take some consolation in knowing that “this will pass.” Learn and practice the proven techniques for dealing with pain, tension, depression, anxiety and insomnia.

Managing Daily Activities


Life doesn’t end if you have chronic illness. There are still chores to do, jobs to perform, and relationships to maintain. Things you once took for granted can become much more complicated, but you can learn new skills to maintain your daily activities and continue to enjoy life.

Break the Cycle


Chronic disease often brings fatigue, pain, shortness of breath or other symptoms that support a “vicious cycle” of physical inactivity. You can’t sleep and your energy drops. You become weak and deconditioned. Deconditioning leads to feeling helpless, which in turn discourages physical activity. And so on.
The solution is to break the cycle with gentle, gradual physical activity. As your physical activity increases, your strength and stamina grow, your mood improves, and soon you’ll be carrying out your normal daily activities.

One Step at a Time


When living with chronic disease, it’s easy to focus on limitations and disabilities rather than potential. The tendency is to overemphasize the risk of exertion. There are safe limits within which people with chronic disease can live a vital and fulfilling life.

Identify a specific action you would like to take. Break it down into small steps. If you want to walk a mile to the park, start by walking a block. Each successful step brings satisfaction, boosts your mood and enhances your confidence.

Managing Your Emotions


When you are diagnosed with a chronic illness, your life changes. The future looks different. Your familiar routine is altered. Life plans may be thwarted. The resulting emotional shift can magnify your symptoms and disabilities. Watch for the following common feelings:

Anger: “Why me – it’s not fair. I am frustrated that I can’t do what I used to do.”

Anxiety: “I’m afraid of what might happen to me. The future is so uncertain.”

Depression: “I can’t do anything anymore. What’s the use of trying.”

Isolation: “No one understands. No one wants to be around someone who is sick.”

Learn the skills to manage these negative, limiting emotions.

Explore Your Feelings


Learning you have a disabling chronic disease can be a profound shock to your sense of self. It changes your perceptions of who you are, who you were and who you will become. Suddenly you discover that you are not invulnerable after all. “These things” don’t always happen to other people. These traumatic feelings can hit hard so give yourself the time and space to come to terms with them. Like bereavement, chronic illness can bring with it powerful feelings of loss: loss of aspirations, plans, or physical abilities.

People often go through various stages of feelings when diagnosed; Denial: Denying or not believing the diagnosis; Anger about being ill and blaming others; Bargaining or guilt: Attempts to reverse the diagnosis by offering something in exchange; “I’ll give up smoking if you’ll take away the disease.”
Depression: Feelings of helplessness and loss of control; Acceptance: “I don’t like being sick, but I can live with it.”

These stages are all normal responses. Express your feelings. Pent-up anger or unvoiced sadness can undermine important efforts to manage your illness. Take time to learn the proven skills for managing angry feelings and depression.

Watch Your Self-Talk


The explanations you give yourself about your symptoms and disease can strongly influence your mood and ability to function. Many limitations and restrictions associated with chronic illness lie more in our beliefs than in our bodies.

Your expectations can become self-fulfilling prophesies. If you think heart disease means that you’ll never be able to work, have sex, or see your child graduate, then your actions and feelings are likely to reflect these beliefs. Learn to “eavesdrop” on your internal dialogue. Challenge and rewrite restrictive, inaccurate, negative self-talk.

Don’t Do It Alone


One of the side effects of chronic illness is a feeling of isolation. As supportive as friends and family members may be, they often cannot understand what you are experiencing as you struggle to cope with a chronic illness. There are others who know first- hand what it is like to live with a chronic condition just like yours. Connecting with these people can:

• Reduce your sense of isolation
  
• Help you understand what to expect
  
• Offer practical tips on how to manage symptoms and feelings on a day-to-day basis
  
• Give you the opportunity to help others cope with their illness
  
• Help you appreciate your assets and realize that things could be worse
  
• Inspire you to take a more active role in managing your illness by seeing others coping successfully.
  

Support can take many forms. You can read a book or newsletter about how someone lived with a chronic illness. Join a support group. Talk with others on the telephone or participate in an online chat session. Whatever means you use to connect, be sure to practice clear communication skills to express your feelings and wishes.

You’re More Than Your Disease


It’s very tempting for chronic disease sufferers to identify with the disease. Remind yourself that you are more than your disease – more than a “heart patient” or “lung patient.” And life is more than just trips to the doctor and managing symptoms.

Cultivate areas of your life that you enjoy. Small daily pleasures can help balance uncomfortable symptoms or emotions. Experience nature; grow a plant or watch a sunset. Indulge in the pleasure of human touch. Enjoy a tasty meal or celebrate companionship with family or friends. Such special moments of pleasure are vital to chronic disease self-
management. Focus on your abilities and assets rather than disabilities and deficits. Celebrate small improvements. If chronic illness teaches anything, it is to live each moment more fully. Within the true limits of whatever disease you have, there are ways to enhance your function, sense of control and enjoyment of life.

Illness Can Be an Opportunity


Even with its pain and disability, an illness – like any crisis – can enrich our lives. We may be forced to reevaluate what is really important, shift priorities and move in exciting new directions that we might never have seen before.

Jill has breast cancer. Since her diagnosis she has lived more fully than ever before. “I was lost and aimless after my children grew up and left home. One of the first things I did after the diagnosis was learn to swim with my head in the water. I had always kept it above the water, too scared to put my whole self in. That had been the story of my life. Now I do whatever I want. I don’t think about how much time there is, just what I want to do with mine. I feel less afraid of living.”

Heart attack often provides the motivation for people to slow down and enjoy life. Deepening relationships with family and friends becomes a first priority.

A chronic disease that restricts movement may lead some to think again about unused intellectual talents: Meg learned a new language and found a pan pal; Fred finally wrote his novel. Chronic illness may close some doors and open new ones.

Plan for the Future


Living well with chronic illness sometimes involves preparing for death. Death is feared, welcomed, accepted or, all too often, pushed away. Fear of death is a fear of the unknown; facing the fear can intensify living.

The most useful way to come to terms with your death is to take positive steps to prepare for it. Here are some suggestions:

• Talk openly about your feelings about death to the people around you. Most family and close friends are reluctant to initiate such a conversation but appreciate it if you bring it up.
  
• Take care of unfinished business. Mend relationships. Say what needs to be said to those who need to hear it. Don’t leave words of love, forgiveness, and thanks unspoken. Forgive others and yourself.
  
• Put your affairs in order. Make a will. Get your financial records organized. Make arrangements, or at least plans for your funeral.
  
• Make your wishes known. Let others know how and where you would want to be during your last days, when you want life-support procedures to be stopped.
  
• Write out a Durable Power of Attorney for Health Care, which documents your wishes and designates someone to make decisions for you when you cannot. Discuss these wishes with your family and physician.
  

Having a chronic illness doesn’t have to close down your options. You can still participate actively in life, learn new and interesting skills, make a contribution, and have a rich and satisfying life.

For More Information:


Dollinger, Malin; Rosenbaum, Ernest H.; Cable, Greg: Everyone’s Guide to Cancer Therapy: How Cancer is Diagnosed, Treated, and Managed Day to Day. Kansas City, MO: Andrews and McMeel, 1991.

Franz, Marion; Etzwiler, Donnell; Ostron-Joynes, Judy; Hollander, Pricilla: Learning to Live Well with Diabetes. Minneapolis, MN: DCI/ChroniMed Publishing, 1991.

Jevne, Ronna Fay and Levitan, Alexander: No time for Nonsense: Getting Well Against the Odds. San Diego, CA: LuraMedia, 1989.

Kane, Jeff: Be Sick Well: A Healthy Approach to Chronic Illness. Oakland, CA: New Harbinger, 1991.

Klein, Robert A. and Landau, Marcia Goodman: Healing the Body Betrayed: A Self-Paced Self-Help Guide to Regaining Psychological Control of Your Chronic Illness. Minneapolis, MN: DCI/ChroniMed Publishing, 1992.

Lerner, Michael: Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer. Cambridge, MA: MIT Press, 1994.

Lorig, Kate and Fries, James: The Arthritis Helpbook. Reading, MA: Addison Wesley, 1990.

Lorig, Kate: Holman, Halsted; Sobel, David; Laurent, Diana; Gonzales, Virginia; Minor, Marian: Living a Healthy Life with Chronic Conditions: Self-Management of Heart Disease, Arthritis, Stroke, Diabetes, Asthma, Bronchitis, Emphysema & Others. Palo Alto, CA: Bull Publishing Co., 1994.

Pitzele, Sefra Kobrin: We Are Not Alone: Learning to Live with Chronic Illness. New York: Workman Publishing, 1986. Practical, firsthand advice on how to cope with chronic conditions.

Spiegel, David: Living Beyond Limits: New Hope and Help for Facing Life-Threatening Illness. New York: Times Books, 1993. Guide to confronting the emotional challenges of cancer and other life-threatening conditions.

Time Life Medical: At Time of Diagnosis Video Series. New York: Time Life Medical, 1996. Thirty-minute video tapes and workbooks on over 30 topics including insomnia, hypertension, prostate cancer, thyroid disorders, breast cancer, diabetes, coronary heart disease, and hepatitis.

[sidebar] Research Links Mind and Chronic Illness


Thousands of studies link psychological states and social conditions to the onset, course, and recovery from chronic illness. Even when the underlying physical disease cannot be reversed, positive mental states can change the way people experience symptoms and how disabled they are. Though mental factors are, of course, not the only determinants of who
becomes ill, the accumulation of evidence makes a very strong case that mind does matter. Here are a few examples.

Onset of Disease


Inadequate social support is associated with twice the overall rate of premature death.

An analysis of over 100 studies suggests people who experience chronic anxiety, depression and pessimism, incessant hostility and cynicism, tend to have double the risk of many kinds of diseases including asthma, arthritis, ulcers and heart disease. For example, chronically nervous, tense, anxious people are more likely to have abnormal heart rhythms, and are two to six times more likely than less anxious people to die of a heart attack.

Women younger than 45 who are divorced, separated or widowed have significantly higher levels of total cholesterol and “bad” LDL cholesterol than married women.

Men with high hostility are seven times more likely to die within 25 years from any cause than less hostile men. Reducing anger and hostility appears to reduce the risk of recurrent heart attack, and may even prevent heart disease.

If you are wealthy, well-educated and hold a high-status job, you are less likely to have or die from nearly all chronic illnesses.

Over a seven-year period, older people who believed that they were in “poor” health were nearly three times more likely to die than those who rated their health as “excellent.” These self-ratings more accurately predicted who would die than their doctors’ objective reports.

Health pessimists who thought they were in poor health, despite a clean bill of health from their doctors, had a slightly greater risk of dying than the health optimists. These optimists, who viewed themselves as well even though their doctors’ reports suggested their health was poor, had a slightly less risk of dying.

A long-term study of college graduates found that optimistic men were physically healthier and had less chronic illness in later life than the more pessimistic alumni.

Women with a history of depression have 15% less bone density than nondepressed women of the same age. Bone loss is the critical factor in osteoporosis, the disease marked by thinning of the bones which often leads to crippling fractures.

Course of the Illness


Among patients with arthritis of the knee, depression is a better predictor than x-ray evidence of physical damage of how limitations and discomfort will affect the person.

Group education sessions for patients with arthritis led by other patients reduced pain levels by 20%. They also decreased visits to the doctor by 43%, saving an average of $400 per patient over four years.

Women with advanced metastatic breast cancer who received group psychotherapy and support in addition to standard medical care survived on average more than twice as long as those who received standard care only.

Recovery from Disease


Patients with coronary heart disease who are depressed are more likely to have heart attacks, undergo bypass surgery, and suffer other heart-related problems than heart disease patients who aren’t depressed. In a study of patients who had a heart attack, depression related more closely to future heart problems than the severity of artery damage, high cholesterol levels, or cigarette smoking. In heart attack survivors, depression triples the risk of dying within six months.

[sidebar] Try This


Try keeping a journal of your experience with your chronic illness. Write down exactly how you feel about what has happened to you.

• How did you feel about yourself before the diagnosis?
  
• How do you feel about yourself now?
  
• How do you feel others will react to you?
  
• What is the meaning of the illness to you?
  
• When you replay the diagnosis, what thoughts and feelings come to mind?
  
• Have you known others with this condition and how does that experience shape your hopes and fears about the future?
  

You will come up with very useful information. You’ll find areas you need to work on to build back your self-esteem and sense of control.

Watch Out: You Are Not to Blame

Chronic diseases are caused by a combination of genetic, biological, environmental, and psychological factors.For example, stress alone does not cause most chronic illnesses. Mind matters, but mind cannot always triumph over matter. If you fail to recover, it is not because of lack of right mental attitude.

There are many things you can control that will help you cope with chronic illness. Remember, you are not responsible for causing the disease or failing to cure it, but you are responsible for taking action to manage your illness.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

A study of patients with heart disease found that relaxation, taming hostility, and helping people change the way they look at life’s challenges can reduce their risk of having further heart problems by 75% compared to people given only usual medical care and medications. Reducing stress proved even more beneficial than getting exercise.

In this study, 107 heart patients were randomly divided into three groups. The control group of forty patients received usual medical care. Another 34 engaged in a vigorous exercise program for 35 minutes three times a week for 16 weeks in addition to their usual medical care. And 33 patients along with their usual care from physicians also participated in a stress management program that included: Weekly group sessions, educational information on heart disease and stress, and muscle relaxation practice and biofeedback. Patients were taught skills to monitor automatic irrational thought patterns and to develop alternative interpretations of situations and thought patterns. They were also instructed how to recognize signs of stress and manage moods such as anger and depression.

The patients’ medical records were tracked for the next two to five years for heart attacks, bypass surgery, and angioplasty. In the control group that received standard medical care, 30% had additional heart trouble compared to 21% in the exercise group (not significantly different from usual care). But the stress management group showed a dramatic difference– only 10% had further heart problems. This translates into roughly one-quarter the cardiac risk compared to those not receiving the additional psychological skill training. The stress management training also resulted in lower levels of psychological distress, less hostility, and fewer episodes of ischemic chest pain. If a new drug produced the same 75% reduction in cardiac risk as stress management, it would be headlines and rapidly prescribed by physicians. Until this becomes standard of care, patients may have to seek out their own opportunities to learn stress management as part of their treatment.

For More Information

Blumenthal JA, et al: Stress Management and Exercise Training in Cardiac Patients with Myocardial Ischemia: Effects on Prognosis and Evaluation of Mechanisms. Archives of Internal Medicine 1997;157:2213-2223

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

In a recent study of over 1200 men and 500 women subjects were
confidentially interviewed about their sexual activity in the hours,
days, and year preceding their heart attack. The fndings: a little bad
news, but mostly good news.

The Bad News


Only half of the patients (age 20-92) reported having any
sexual activity in the year preceding their heart attack. (This raises
an interesting question as to whether lack of any sexual activity
itself increases the risk of heart attack.)

Among those who were sexually active, the act of intercourse about
doubles the risk of heart attack in the subsequent 2-hour period. But
not to worry . . .

The Good News


The absolute increase in risk of heart attack following sexual
activity is so slight that even doubling it is not much of a danger.
For example, the risk of having a heart attack in the two hours
following intercourse might rise from one chance in a million per hour
to two chances in a million per hour÷probably not something to lose
sleep or sex over.

There’s more good news. For those who exercise regularly, there is no increased risk of heart attack following sexual intercourse. Habitual physical exertion two to three times per week protects against all heart disease and effectively eliminates any excess risk associated with sexual activity. In other words, if youâre physically fit, you can put your heart into sexual activity without taxing it!

These findings should be reassuring to the half a million people in the US each year who survive a heart attack and over 11 million patients who have existing heart disease. Patients, partners, and physicians can now reassure themselves that:

sexual activity after heart attack is generally very low risk

regular physical activity promotes a healthy heart and safer, satisfying sex life

As Stanford cardiologist Robert F. DeBusk put it: “Patients should be interested not only in the years in their lives, but also the liveliness of their years.”

For More Information:


Muller JE, Mittleman MA, Maclure M, et al: Triggering myocardial infarction by sexual activity: Low absolute risk and prevention by regular physical exertion. JAMA 1996; 275:1405-1409.

DeBusk RF: Sexual activity triggering myocardial infarction: One less thing to worry about (Editorial). JAMA 1996;275:1447-1448.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.

A new study from the Mayo Clinic found that patients frequently forget
what their doctors tell them. Following a general medical evaluation,
566 patients received advice from their doctor about health problems
and cardiac risk factors that were uncovered in the examination. When
these patients were asked several weeks later at home, they did not
remember 68% of the health problems discussed by their doctor,
including 54% of the most important diagnoses-colorectal polyps,
obesity, hypothyroidism, osteoarthritis, and tobacco abuse.
Fortunately, patients were most likely to recall a new diagnosis of a
major health problem.

The reasons for the “disconnect” between what physicians say and what patients hear and remember:

• Doctors do a poor job of explaining and use medical terms patients don’t understand.
  
• Patients experience information overload.
  
• Patients listen “selectively,” screening out certain information.
  
• Patients experience “denial” of certain problems such as smoking and obesity.
  
• Patients’ perception of the seriousness of a health problem may differ from that of their physicians.

Both patients and physicians need to take action to improve this
communication. Patients must become more involved in decisions,
especially the important aspect of defining their problems. Physicians
can provide, and patients can request, written lists or summaries of
major diagnoses and problems. Patients can make notes and at the end
of the visit clarify their understanding of what action steps they and
the physician will take. Good communication, a vital ingredient for a
healthy doctor-patient partnership, requires effort.

Rx: Be Clear on Diagnoses and Follow-up Plans

Repeat these four key points to your doctor at the end of your visit.


1.The diagnosis, the nature and cause of your symptoms or what might be causing your symptoms and the prognosis, the expected duration, course, and outcome of the condition

2. Treatment recommendations and instructions

3. The follow-up plan – Should you return for a visit? If so, when and why? Should you phone for test results? Are there any danger signs you should watch for and report back to your physician?

4. What actions you are going to take? – This confirms that you clearly understand the most important information. Repeating also gives the doctor a chance to correct any misunderstanding. If you don’t understand or remember something the physician said, admit that you need to go over it again. You might say, for example, “I’m pretty sure you told me this before, but I’m not sure I understand.”

For More Information:


Scheitel SM et al: Patient-physician agreement about medical diagnoses and cardiovascular risk factors in the ambulatory general medical exam. Mayo Clinic Proceedings 1996;71:1131-7.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.