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As Rosie the Riveter Says: We Can Do It—Collaborative and Facilitative Leadership

Posted By Jeri Hepworth, Monday, October 8, 2012
Updated: Tuesday, October 30, 2012


Dr. Hepworth's post is the first in a 5-week collaborative series hosted by the blogs of
CFHA and STFM.

Please check back
each week.

 

As STFM President-Elect, I attended my first meeting of CAFM and Working Party. Forgive the funny names, but they represent the Council of Academic Family Medicine organizations (STFM; ADFM, the organization of departments and chairs; AFMRD, the residency directors; and NAPCRG, the primary care researchers). The Working Party includes the CAFM organizations, plus the American Academy of Family Physicians (AAFP), the American Board of Family Medicine, and the AAFP Foundation. Together, the organizations work to ensure coordinated positions and grapple with vision and leadership of family medicine. These meetings represent ideal examples of Covey’s work of being both important and not urgent, of taking the time to consider what family medicine is accomplishing, and very powerfully, what should be the next steps.

Not surprisingly, attending my first meetings of these groups was intimidating. But, on the first morning, I received this email from my husband, Robert Ryder: "You are not a non-physician. You were elected to represent the educators in family medicine. So you represent the future of family medicine. Go do good work.” I must say, I walked a bit taller after that email, and over the last couple of years of leadership within national family medicine, I take these statements very much to heart. And I want others to recognize these truths.Jeri Hepworth
"I have a
commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions."


Behavioral science clinicians and educators have the skills needed for leadership in our departments, in our health care systems, in our agencies and policy-making arenas, and in our national organizations and advocacy efforts. We know how to listen and include others. We can elicit divergent views and withstand conflict. We know how valuable it is to include the views of those who feel less powerful in systems. We can tolerate the anxiety that emerges in systems under stress or facing change. We know how to help groups create goals and vision, though we sometimes need help determining whether differences actually emerged. So we know we need collaborators, and generally we know how to play well with others. If we have been successful in working in settings in which our professions were the minority, we have learned these skills. And they are exactly the skills needed for effective leadership.

I truly enjoyed giving talks as president of STFM. Unlike presentations about my work, I learned that I didn’t need to hold back, because I wasn’t talking about me. I was representing something greater than me. To be grandiose, and also accurate, I was able to talk about a future and vision of compassionate, effective health care. It wasn’t a form of bragging about my work or ideas; it became a responsibility to do the best I can to help achieve our common goals. I was given a wonderful platform and support to do so.

And the beat goes on. I will still take the opportunities to advocate for family medicine, for primary care, for integrated health care systems that are focused first on patients and families and that require the collaboration and skills of many. But I also have a commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions. The Collaborative Family Healthcare Association and STFM create wonderful platforms for us to advocate. Let’s not waste these opportunities.

 

Jeri Hepworth, PhD LMFT is professor and vice chair of the Department of Family Medicine at the University of Connecticut. She is the immediate past president of STFM. Her professional work has focused on families and health, psychosocial issues in medicine, and managing personal and professional stress. Among her publications, she is co-author of 3 books: Medical Family Therapy, The Shared Experience of Illness, and Family Oriented Primary Care.

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Live Blog of Saturday Plenary: Purposeful Engagement

Posted By Frank deGruy and Jennifer Hodgson, Saturday, October 6, 2012
 This morning's live bloggers are Frank deGruy and Jennifer Hodgson.
Please follow along during the plenary and add your thoughts in the comments.
You can email your comments for uploading to reitz.randall@gmail.com.
 
 
Frank deGruy and Jennnifer Hodgson 
 

 

Jennifer 8:45am Opening Thoughts. Engaging patients in their journey through a health event is a skill that is often challenging for providers. It means tapping into the very thing that we are taught to contain as we are trained in our professions, our emotional connection to patients. This plenary will invite attendees to listen and absorb patient stories and reflect on their work of engaging patients, families, and communities in healthcare.

 

Frank 8:45am Opening Thoughts. The depth and sophistication of the presenters at this meeting has improved tremendously. This morning we will hear from a panel of presenters who will help us think through how to incorporate patients, clients, consumers more deeply into the collaborative partnerships we are trying for here. This should be threatening, exhilarating, enlightening, and edifying.

 

Jennifer 8:54am. Purposeful engagement in patient-centered practice does not mean more time but better use of our time. It takes effort and energy not to listen or to ask about the patient and family experience. So, what would happen if we learned to use that energy in ways that help us to get to "health" faster?

Parinda Khatri (moderator) is introducing the panel of plenary speakers: Danny Sands (primary care physician), Kerri Morrone Sparling (patient blogger), and Laverne Miller (attorney). I am excited to hear their stories!

 

Frank 9:00am. Parinda Khatri is moderating. She sets this up as a conversation not about whether we engage with patients and consumers, but how. Danny Sands, MD, MPH: HIT and participatory medicine. Kerri Sparling: Type I DM since childhood, active blogger whose personal story doesn't define her but helps explain her. Laverne Miller: Attorney at Policy Research Associates with a bug about advocacy, particularly for the disadvantaged and vulnerable.
 

 

The plenary panel

 

Jennifer 9:00am. Dr. Sands opens with a description of his journey and lessons learned along the way. He shares his story about his enculturation into medicine how providers are often trained not to be wrong or are afraid to admit not knowing. He learned how important it is to ask patients questions. Why are some providers so afraid to talk to patients about what they think is going on? Is it really about time or is it about being afraid of not knowing the answers.  

 

Frank 9:10am. Danny heard early on how learners were reluctant to show what they didn't know. He had an early mentor who upbraided him for not asking about what he didn't know. Learned early on to ask, not presume or pretend to know. At Boston City Hospital learned how important the home environment was to how patients ultimately did. Fortunate to have early team-based care experiences, and mentoring by Tom DelBanco, who said, "Nothing about me without me." Heard early on,"The single most important resource in patient care is the patient." These are powerful formative experiences that can shape a life attitude.
 
Because of the accident of colleagues (with whom he frequently emailed) also being patients, learned early on the value of email to patient care; this flowered out to encouraging patients to use email, access the web, and otherwise use technology to stay connected and learn about their conditions.

Important mentor was Tom Ferguson, who helped develop patient portals. All culminated in founding the Society of Participatory Medicine. This is worth checking out.
 
 
Jennifer  9:15am. Dr. Sands talked about a placement he worked at where lots of providers worked under the same roof and side by side. Had a mentor who said "Nothing about me without me." This was in relation to a patient bill of rights. What a powerful statement! Empowering patients is a critical part of healthcare reform. He goes on to say that he learned the single most underutilized resource is the patient. So, he employed patients in his setting and in the early 90's started communicating with patients via email. He co-authored the first guidelines on using e-mail to communicate with patients {insert link}. This decreased the distance between his patients and him. Amazing access!
 
 
Frank 9:17am. Kerri introduces herself as "just a patient," in a sea of people with letters after their names, but it's clear that she sees that as sufficient credibility to speak knowledgeably about her experiences in a way that helps us be better at what we do. She's a blogger! She's out there (here). I'll have to track this down.  Here's the link to her blog.
 
 
The panel
 
 
Frank 9:23. Laverne Miller: What a brave woman! A young professional with a bright, promising future as an attorney, then dealing with mental illness, and facing the prospect of huge losses of career, professional network, income, prestige. She describes an early experience with a therapist who cried with her—made herself completely vulnerable—and thereby opened up the possibility of an actual shared experience. A partnership. She can "tell" when a professional actually understands her—gets her, and will thereby be helpful to her.
 
Great question. Medical clinicians get too busy, too narrowly focused to actually get the big picture that is essential to grasping the problem fully. Can't be helpful or effective without a full picture. Behavioral clinicians frequently add that dimension.
 
 
Jennifer 9:25am. Laverne Miller (attorney) opened up about how she is speaking from the perspective of a consumer and how her experience of her mental health changes started back as a child. She noted that her mental health was never the focus of her visits to her primary care provider, yet she was struggling. She felt different but no one asked her how she was feeling and coping. She did not want a label but wanted to be able to express her experience emotionally, cognitively, and socially. In her culture and community admitting mental health issues was not done. She felt alone. This is a powerful argument for routine screening in primary care and integrated care visits. If only someone would have asked, "How are you doing?"
 
 
Frank 9:30am. Kerri is funny! She describes her relationships with health professionals as though they are part of her personal circle, who remain there only if they act like there is a meaningful relationship going on. Human to human. Dispassionate, objective posture just won't do. She'll fire you if you come at it like that.
 
This business about knowing and being known: We're hearing from the professional side of the river (Sands) that clinicians aren't necessarily up to revealing themselves as people who have feelings, don't necessarily know the answer, are real people. We socialize that out of professionals, and we need to get it back in.

Kerri wonders why this isn't obvious, since we professionals all go the the doctor, and we want to be treated as people by people there.
 
 
Jennifer 9:32am. Laverne said we are not a "monolithic" community and we need to be accountable to practicing from a culturally sensitive lens. We need to understand how different cultural groups make healthcare decisions, come to healthcare visits as a group, and perceive use of medical interventions and diagnostic labels. Dr. Sands agreed that we need to be training providers how to engage patients and set up patient and family advisory boards. We need satisfaction surveys. Kerri asked "Don't doctors go to the doctor?" What a powerful challenge to get providers to think about it from what they would want for themselves, their loved ones, etc.
 
 
Jennifer 9:37am. The question is posed to the panel on how do you engage the patient who does not want to or appear to want to engage? Kerri said to call patients on it but be willing to be called on back if you are not engaging back. Dr. Sands said that you have to try using technology. Laverne said you need to ask about the side effects of medications and how that may be a cultural and practical reason for patients to not want to engage. She also said people are bringing to the table the sum total of their experiences. Some have trauma stories and they don't want to be touched and are often not asked what they need to feel safe.Their visit is often not orchestrated around what they need but rather what the healthcare system thinks they need.
 
 
Frank 9:40am.  Kerri is so thoroughly imbued with the necessity of having a human-to-human relationship! She likens it to dating: "I went to a new primary care physician, and we called each other out on engaging and taking responsibility for our respective parts of the relationship; it was kind of hot. This could be a great relationship."
 
 
Frank 9:45am. What a balanced panel! All bright, equal floor time, different perspectives, provocative questions from Parinda.  Laverne has this exquisite ability to lay out for us how just a tone, just an attitude of superiority, can be so damaging to a healing relationship. She is convincing me that we really need to sit still, listen, and get inside the others' story before good work can be done.
 

Jennifer 9:48am. Laverne, wearing her attorney hat, said to make sure to explain to patients know who their information is being shared with, why, and how. Patients who do not want to share information may benefit from peer specialists to help explain why it is so important. Dr. Sands challenged that he should have the right not to take care of a patient who will not let him or her have access to her medical record. He provided the example of providers not having access to mental health records and how that is complicated and can prevent good care.

Who owns the patient record? Kerri thinks the patient should have full access to their record. What are the limitations around full access?

 

Frank 9:50am. Parinda! Raises the difficult issue of a patient's unwillingness to give permission to disclose personal information (I.e., ETOH consumption) to all the members of a team. Interesting discussion about winning the confidence of other team members, HIPAA's requirements that actually allow disclosure of records that affect care, etc. Daniel makes the case that we just have to share that stuff in order to avoid bad outcomes. Kerri argues that they are her records and she can decide who sees what, but thinks her care depends on all the clinicians talking to each other with full information.

 

Jennifer 9:52am. Parinda posed the question to the audience on what is one thing we can do differently to move this conversation of engagement forward.

Kerri: Said we are having these discussion in a bubble. Leave the conference and hold yourself accountable to looking your patients in the eyes. Be human!

Laverne: Said go back and step up. Demand change! Focus more on practice-based evidence and go out and observe and take risks....walk the walk in all your interactions.

Danny: Influence your office by changing policy to get patients and family input. Open up patients' records to them. Lower the barriers for patient engagement.

 

Frank 9:52am.  Parinda: Engagement 2.0. What can we go home and do that will cause our conversation to be more advanced, more effective next year. Kerri says don't go home and do the same thing you've been doing. Go home and look patients in the eye. Let them know you have a heart and eat apples. Be more human.

Laverne says step up and move to practice based evidence—observe, take risks, be vigilant, be brave.

Danny says if you can influence your practice to make sure you get more patient input. Put patient advisory boards in place, lower the barriers to access. Be at least as available to family input as your vet is.
 
 
Frank 9:55am. Kerri just keeps insisting that she is a person, needs to be treated like a person. For example, she is a person with diabetes, not a diabetic. Her family needs to know what's going on with her health so they can have a better life.
 
 
Jennifer 9:57am. Danny talked about the Annuals of Family Medicine published an article this week about Open Notes...check it out here!
 
 
Frank 10:00am. Laverne closed us with a reminder that she is not fragile, she is not broken, she is resilient and sturdy and capable of participating! Good one!
 
 

Jennifer Closing Thoughts: I learned from this presentation that I need to be more accountable and purposeful in the way I train providers to engage with patients and families, include them more in my writing and presentations, and focus on their perspectives more in my research. I also value the act of looking at them in the eyes and realizing that I need to more culturally aware of the systems outside the office that support and challenge them. What an amazing panel representing a diverse sets of experiences all unified by one theme: we need change the way we think about healthcare to be more inclusive.

What are you willing to do to purposefully engage patients and families more in the healthcare experience?

 
Frank Closing Thoughts. This was an exceptionally well balanced panel that took us beyond where we were. Perhaps we should bake this plenary (this kind of plenary) into our subsequent meetings.

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Live Blog of Friday Plenary: The Great Debate

Posted By Laura Sudano, Stephanie Trudeau-Hern, and Pete Fifield, Friday, October 5, 2012
This morning's live blog is hosted by Laura Sudano, Stephanie Trudeau-Hern, and Pete Fifield. Please follow along and add your thoughts in the comments section.
 
 
 

8:55am: The anticipated intensity of this debate was such that it may have altered the actual "Ways” of the Universe and subsequently caused one of the debating members to be absent. Yes folks, we have already lost a presenter. Well lost necessitates a "found” and to that matter, he was found in the airport at Grand Junction, Colorado. The reason: his plane had a flat tire. A plane with a flat tire, sounds a bit like "the dog ate my homework”. We hope sabotage isn’t involved in this unfortunate event.

Dr. Randall Reitz, Dr. AJ [Ajantha Jayabarathan], and Dr. Eduardo Sanchez take the stage with music to welcome them to the great debate. Shaking hands, each take their respective podium to open up with their position statement.

9:00am: Dr. AJ opened up her position statement with a reference to the Triple Aim. The Institute of Medicines focus on access to high quality care, care that results in improved health outcomes and the care must be sustainable; all of these happening all together. Dr. AJ, an eloquently and soft yet direct spoken Canadian physician, speaks of the Canadian Rubiks Cube to demonstrate the micro, meso and macro levels of systems care. She urges for U.S.A. to adopt this as their own model.

9:07am: Dr. Reitz speaks towards the historical connections of the nascent nature of collaborative care. Relative historical physician interactions as Reitz have included, removing humors, enemas and leeching. We now are in a new phase of care, one that he would admit needs to be aligned over the Three World View:Clinical, Financial and Operational.

9:15am: A metaphor has arisen already that may represent this debate. Dr. AJ during her opening statements referenced s a graphic of what she described as a "Rubiks Cube”. Dr. Sanchez has referenced multiple times his love of baseball; perhaps his Dominican roots are showing--Yogi Berra being his favorite philosopher. Although Dr. Reitz, arrived in his red U.S.A. sweat jacket, tear-away warm-up pants, and donning boxing gloves, I can’t help but think that the Xbox version of this boxing idol may be a more accurate representation of American ways (and subsequent health level). Is it possible that these three icons represent us well? Rubik’s Cube, the Intelligent Canadians, Baseball, the athletic Dominicans and Virtual Boxing, the lazy Americans? In many ways, we need to put away the game controller and act. I might have missed on this one but you may get where I’m going.

Dr. Sanchez, focused heavily on behavioral and mental health related co-morbidities as one of the most significant players in the ill-health of America. Sooner than later, the financials of this situation will come to realization. We are headed towards collaborative care because of the financial models.

Dr. AJ disagrees and states that to make an omelet, you have to crack some eggs. If the omelet is collaborative care, you’re the egg. How are you going to feel about "being broken” if you are the egg. Currently the "Rub” comes at an individual level [PCP] and we must create. I want to be the quarterback that counts; you must change my mind at the individual level

Dr. Sanchez recommends we create an omelet without eggs? Possibly. They do agree that it needs to change. He uses the concept of a team that changes to the game; to meet the new rules. The opposite of this approach is changing the entire team to meet one player; please reference Tim Tebow’s offense to challenge to this idea.

Randall states that commercial insurance is to collaborative care as condoms are to pregnancy: They are 92% effective at prevention.

Dr. Sanchez questions what we are paying for is evidence based (EB). There are PCMHs out there that are not PCMHs but we are going to call them one. Us bloggers question, "Is that a misunderstanding of the definition or an abuse of system?” The dollars are going to drive this change more so than people gathered around a podium bantering.

 

The debaters 

 

9:28am: Barry Jacobs, audience member, states that collaborative care is not going to happen. Treatment via a care management approach, not necessarily treating the mental health illness connected to the problem.

Dr. AJ comments that Political Will and a Leadership Socialist approach are what Americans are afraid of as a possibility. Triple Aim reference to treatment being local and grass root generated. She discusses the Canadian use of office redesign; something that they created out of a grassroots collaborative care model – every person needs to make small changes and expand their own scope of practice within each professional position.

9:31am: PCMH are words that are used, doing Integrated care before it had a label.Overall, it is recognized as a team approach. Practice medicine the way football was played 50 years ago, you really can be a one person team back then. Primary care is a team, health team, driven endeavor. W

9:37am: Dr. Reitz points out that our medical system lacks a general contractor. Medical care has too many outlets in their "home” because the electrician makes a lot of money for each outlet he installs. We need a GC. Through federal CPCI initiative, clinics in nine states will earn a $20/per patient per month for collaborative care. Put BH in primary care and it will be paid for.

AJ continued to speak towards the micro level of change; the grassroot generated individual impetus for larger change. If every office, every worker made small changes, it would collectively make a more significant change. To follow the football analogy, it would be like having every player on the team be more universally trained [say simply in MI or trauma focused care] , than having "special teams”.

9:43am: If you have a safe place but people are not honest, that does not work out that well. Honesty in this case is driven by finances.

9:45am: Dr. Sanchez states that in Texas they are working on a system of payment that focuses on bundled payments. The model's first draft showed that the MH community became very nervous; fearing being "cutout” of the process. Second, when a plane comes down when the wheels just touch ground, you get the traction "we love this” but a bit of a jerk because it is scary. The pushback was around "we cannot do it” not because of the lack of unity in the idea, but there are no true systems to make or even allow it to work. We cannot get a new model without fracturing the process.

The "Culture of Shared Benefit” is it really a question of Health vs. Wealth?

Those with the money and power are not interested in collaboration.

Dr. AJ points out the Mental Health Commission: Canada--they are transition funds and incentives for treating the behavioral side

The question by moderator, Ben Miller, asks if Integrated Behavioral Health costs more - is this correct? Dr. Sanchez responds with no, it is cost-effective. Dr. Reitz states that it doesn't cost more, but does cause significant cost shifting.  Counties with a higher percent of primary care always have lowest overall healthcare costs.

AJ: You Americans put the man on the moon w/ a focus on the change, once again, we are a shining model for the rest of the world but we have to put a focus on it at an individual level.

An audience member asks if there are any Financial Benefits managers and large corporations in the room. Crickets. The member goes onto state that they are the ones who pay for care. If we are going to change this (have collaborative care carry on), we need them. They are trying to control cost; not pay more to the people and not cost more at the end. The payers need to understand we bring something to the table that helps them. We need to talk to the benefits managers.

Another take home message: If we really do want to push this forward, who is not at the table: Employers? Who else?

9:57am: One main point of this discussion around the future of collaborative care (whether we will be a mainstream healthcare model CC by 2022) is that we need to look around the table and realize who is not there. Mainly, invite those to the table who can help us move the field forward. Dr. AJ challenges people to stop being onlookers and become motivated to seek out others. She asserts her stance on changing others at the microlevel.

Dr. AJ states that for all of the eggs out there, in every end there is a new beginning. We (U.S.A.) put man on the moon, the Rubiks cube with the traffic lights, a very robust depiction of how to do this micro and meso levels; now we need to move on to the macro.

Onlookers, we pass the flame on to you: support collaborative care and disseminate the word. 2022.


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Live Blog of Opening Plenary Session: Sarah Kliff

Posted By Benjamin Miller and AJ Jayabarathan, Thursday, October 4, 2012
 Tonight's Live Blog is hosted by AJ Jayabarathan and Benjamin Miller. 
Check back often to read their posts and to add your comments. 
You may also email your comments for posting to reitz.randall@gmail.com.
 
 
Ben and AJ

 

A.J. 6:25pm. Sarah: NEJM carried a paper that looked at a comparison between states that expanded medicaid and others that did not....the population health outcomes clearly favored the states that expanded medicaid. Sarah's response to a question about changing human behavior..is it possible with the current emphasis on education ex. calorie labels being affixed to fast foods? Would making a big mac more expensive be the true way to change behavior and therefore manage health outcomes...Humana is presently looking at making healthier choices easier and incentivised to affect human behaviour.

 

A.J. 6:18 pm. Audience member question: There are many demonstration projects and pilots going on...how do they all fit together?

Sarah: I don't know how they are going to fit together, however with everyone moving towards value based, high quality care, the hope is that it moves people along in a positive direction which will effect positive change.

Audience member (Dr. Sanchez): We have the highest number of uninsured people in Texas....just like we have a lot of bats...and our Senator has announced that Texas does not need to expand medicaid. However, a reputable economist is soon to refute his position with strong evidence to the contrary.

Sarah: Wait until the election happens. Right now it is easy to say these things, but should President Obama be re-elected, there will be a powerful force for change afoot.

 

Ben 6:16pm. Sarah taking questions now. This has been a good (and fast) plenary. I am thankful that there are really smart policy people out there who can write (and talk) about this. The information that Sarah brought was grounded in evidence and rationale in its delivery. There are very few out there covering health policy that do it as well as Sarah Kliff. Using up to the date research (and amazing graphs), Sarah helps explain some of the most complicated issues around healthcare policy in a very easy to understand way. For example, here write up last week on "Increased obesity is wiping out most health benefits of less smoking” used one graph to describe this phenomenon and why it is happening. This is one blog to have in your RSS feed (plus, how many reporters will integrate the Simpson’s into their work?). Thank you Sarah for an excellent plenary session. 

 

A.J. 6:13pm. Closing anecdote: Doctors salaries were tethered to quality of care determinants. A check list of deliverables were developed. In the first month 3 doctors got bonuses, then 12 ...etc, etc. It set up a positive competition amongst the group of surgeons that stayed, and it was felt that this shifted direction. Sort of like atheletes being paid for performance???? 

 

A.J. 6:09pm. In all fairness, the subject matter is dry and full of numbers! Study after study after study after study.....mind numbing! Is it any wonder, we glaze over like donuts after some time?

 

Ben 6:06pm. Sarah discussing the state of Oregon and healthcare innovation. However, a state, very similar to Oregon is Colorado. In Colorado, we have a wonderful innovative community known as Grand Junction. To really know why Grand Junction matters, you have to look under the hood and examine the engine.

"Unlike in most communities, where doctors are paid less for Medicaid patients than insured ones, physicians here agreed among themselves to charge a little less for regular patients and a little more for Medicaid patients. That way doctors would be happy to treat all comers.’”In effect, we created a community health system,’ said Steve ErkenBrack, president of Rocky Mountain Health Plan.”

The engine in this case is a nonprofit health plan willing to take some risks to delver better care. The reasons of this may be lost on many initially, but think about it for a second and I will return to this.

And again, we are back to the need for transformation in our payment systems.  

 

A.J. 6:05pm. Organizations are stepping forward and taking on the challenge to reform provision of services...and they are "sticking" out their necks it seems and taking on risks. How come? Because at the micro, meso and macro level, "everybody knows" (check out Leonard Cohen's song...very apt) that the current system is doomed. So, those that want to be saved and save their systems of care are strapping on the parachute of "Obamacare" and jumping before the aircraft crashes...

 

A.J. 6:00pm. 2014 heralds the start of the affordable care act...the biggest expansion to medicare since 1965. A new set of acronyms to define unicorns it seems, creatures that no one has seen before?

Nay, the act seeks to lay down new foundations (no matter how boring and dull they sound) that will grow new outcomes. Because it is more strategic, more comprehensive, much more grounded in the reality of the population health issues that face 314 Americans every day.

 

Ben 5:56pm.  Sarah just brought up the magical unicorn, ACOs. Accountable Care Organizations are partnerships between healthcare providers designed to be accountable for the quality and cost of the healthcare they provide in return for financial incentives. How these partnerships are implemented may vary, with some focused purely on primary care, while others include sub-specialists and hospitals. In all cases, primary care is expected to form the core of these organizations, the center of the wheel, and base for the ACO.

ACOs are risk-bearing entities and require capitalization. To this end, hospitals and other healthcare professionals like physician groups are partnering with insurers to form these entities. The partnerships that participate in the MSSP will likely cross over into commercial plans, and Medicare will not be the only health insurer to benefit from the cost reductions realized by ACOs.

There are indeed interesting opportunities within ACOs for collaborative care.

 

Ben 5:51pm. Sarah just nailed one of the most important points about healthcare – we have an irrational system that rewards bad behavior in healthcare. We have a system that pays for healthcare through fee for service that often rewards behaviors whether or not they work. As Dr. Peek has taught us, we must change healthcare in three worlds simultaneously (clinically, operationally, and financially).
 

A.J. 5:50pm. Health care spending is the primary driver of the National debt. But despite spending more, fewer people are covered for health care needs. Covering fewer people with more money, is NOT the objective for the future....is it?

The rate of insurance has actually gone down because of the affordable health care act policies...for those younger than 26.
 
The kindergarten approach expecting all health care providers to cooperate is an important element that needs to happen in order for silos of care to change.
Doctor's roles are determined by how the system of care is set up and they follow them...however, what is irrational is how they don't work in unison! What gives?
 

A.J. 5:44pm. The affordable health care act asks fast food places to post the calorie labels on their food. When Sarah asked a consumer of fast food at MacDonalds what their reaction was towards this, he remarked that this made sense and should be part of what Government is doing to improve health care!!!!! When informed that it was part of "obamacare", he appeared to loose interest in the matter.


Ben 5:44pm. Sarah just told us about a story about McDonalds and talking to people about healthcare policy. She mentioned a gentleman who believed that something was in PPACA that was in reality not in the law. And it’s true, there is a substantial need for accurate information in healthcare policy. Finding the most accurate source of information is hard and made even harder by the fact that we have our own opinions and political biases.  

 

Sarah Kliff at #CFHA2012
 

A.J. 5:35pm. Austin hosts 1.5 million bats as a colony housed under the bridge over Lady Bird Lake. 84% (ballpark) of the audience watched the presidential debate last night. Ben Miller 's interest is in the policy development of healthcare. Sarah Kliff covers healthcare policy in her writing and has a remarkable grasp of data as it pertains to healthcare. However, "The dream of reason did not take power into account" , so, this talk is perfectly poised between the presidential debate last night and the elections to come 

 

A.J. 5:30pm.  We heard from Dr. Eduardo Sanchez, Lynda Frost and Katherine Sanchez about the numerous initiatives in Texas that have further the field of Collaborative care at a grass roots, horizon and blue sky level. The Hogg Foundation, Amerigroup Real solutions, VA Health Care, Blue Cross Blue Shield of Texas, American Psychological Association, Forest Institute, St. David's Foundation, The Meadows Foundation have provided sponsorship and support for this conference to be held in Austin, Texas!

 

A.J. 5:10pm. Journalists are the story tellers of our time. Instead of campfires of yore, we huddle with our mobile devices for the warmth of human company and the draw of the "narrative” element of storytelling. But how closely does media portray reality? How much reality can we handle? If you asked someone who has experienced mental illness, domestic violence, bankruptcy or their family member, the raw emotion of pain and suffering is tangible. And, our story tellers use these elements to sell their stories. Tonight I look forward to hearing from a "truth teller”. Sarah’s pieces carry the simplicity of fact and the review of relevant evidence to help put stories in context. Tonight I look forward to seeing and hearing her.

 
Ben 5:00pm. Healthcare policy is always moving. It is a complex adaptive system constantly interacting with all kinds of other components. Tonight’s plenary speaker, Sarah Kliff, begins her talk telling her story. It is a story about becoming involved in politics and the complexity of politics and healthcare policy. It is a story that often highlights the differences between public perception, our politicians, and law. It is a story that highlights how disconnected we can be in healthcare policy from that which actually happens on the ground with our patients.

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Sara Kliff, Healthcare Reporter Extraordinaire, to Speak at CFHA's Austin Conference

Posted By Administration, Sunday, September 30, 2012

Prepare yourselves for a treat at next week's conference in Austin: Sara Kliff of the Washington Post presents our opening keynote address. She is a wicked smart writer on healthcare policy who will lay out the current landscape and predict the near future of healthcare reform efforts.

Here is a sampling of her blog to catch you up to speed:

The effect of media campaigns to change health behavior;

Is the Presidential Physical Fitness Test that we all suffered through in elementary school testing the right aspects of fitness?

Health insurance costs grew slowly for 2 years, why are they speeding up now?

A comparison of President Obama and Governor Romney as it relates to insurance reform to cover pre-existing conditions;

An analysis of what has contributed to a recent improvement in the rates of the uninsured

What science tells us about behavior modification from fast-food nutritional labels (would you like a 930 calorie McFlurry with your Big Mac?)

A live video stream of 6 adorable puppies!

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The Great Debate

Posted By Benjamin Miller, Friday, September 21, 2012

Changing healthcare requires an ability to gracefully navigate between competing interests and ideologies. Depending on "where you sit,” what type of change you want may be different than what your neighbor wants. Change is relative, and aims, goals, and objectives are often dependent on who you are professionally and who you work for. Integrating care, specifically behavioral health and primary care, brings out some of the best and worst of this "where you sit” phenomenon.

To this end, CFHA will host a presidential-style debate for the Friday plenary at our October 4-6 conference in Austin. We will grapple with the question: "Will collaborative care be a mainstream healthcare model within a decade?"  To get you excited for this event, our blog today presents the opening statements of our 4 debaters. As the moderator for the plenary session it will be my job to engage these leaders and hear all sides of the argument. Who will win this debate? Whose side will come out on top? That decision is up to you, dear reader.

 

Randall Reitz

Randall Reitz PhD
is CFHA's Director of Social Media and the the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO.

Collaborative care is still a gangly, pre-pubescent David amongst the Goliaths of healthcare. We lack the scale, strength, and resources of the major industry players. That being said we are on the precipice of something great. Within the next decade the clinical, operational, and financial aspects of collaborative care converge to push our model into the mainstream of healthcare:

  • Clinical: We now have empirical evidence published in top scientific journals that demonstrates the proven effectiveness of collaborative care in terms that even the most hardened insurance executive or corrupt government official could not deny.

  • Operational: The simple reality is that we have experienced exponential growth in the adoption of collaborative care operations at all levels of the American healthcare system. We have already conquered the public sector and are within a decade of conquering the entire system.

  • Financial: Our research and policy advocacy has already won the hearts and minds of policy makers. The teeter-totter of policy and payment is already reaching the tipping point at which the laws, regulations, and reimbursement standards will align to insist on financially sustaining collaborative care as a wholly necessary, fully-funded, and central feature of American healthcare.

Paul Simmons

Paul Simmons MD is a faculty physician at St. Mary’s Family Medicine Residency Program in Grand Junction, Colorado. He enjoys Apple products, black coffee, fountain pens and eponyms.


In this group of true believers, I have the honor of standing boldly as the lone skeptic who has not yet drunk of the collaborative care Kool-Aid. There are several reasons that collaborative care will not, unlike flying cars, be mainstream by 2022.

  • First, the collaborative care clan cites supposedly supportive studies that are flawed, biased and not generalizable to the real world. The evidence-based emperor has no clothes.

  • Second, collaborative care will not be able to overcome its own vagueness and impassioned, but unfocused, hand-waving. If advocates cannot clearly and rigorously define what they’re advocating, passion fails to persuade.

  • Third, the fevered dream of collaborative care will be exposed to the harsh, bright light of financial and payment system realities.

Despite these hard truths, I can hardly hope to persuade the diehards who have pledged their lives and fortunes to the cult of collaboration. Disillusionment is difficult, but we should always prefer reality to the pipe-dream of wishful thinking.


AJ Jayabarathan

Ajantha Jayabarathan MD
20 years of practice in primary care, 10 years of working on television and radio, 8 years of association with the Canadian National working group on shared mental health care, 16 years of raising a family while living in Nova Scotia, Canada, inform my opinions of how health care is evolving in 2012.


Yes and No… so states my reading of the tea leaves of time.

In ten years’ time, if Obamacare is actualized in the United States of America, integration of mental and physical health through collaborative, co-located mental and physical health services will become the mainstream model of care. If the injection of funds and faith into this model of care is thwarted by the politics of 2012, the rate of uptake of this model will be slower and the United States might well be left ten years behind as health care evolves because of this model in the rest of the world.

Meanwhile, in Canada, Australia, New Zealand and the United Kingdom, this model of care has already seeded fertile health care fields and is growing in strength, outcomes and diversity. Coupled with the parallel explosions of the information age via the internet, virtual social networks via social media and electronic management of health care it has steadily gained momentum …..and is now unstoppable.


Eduardo Sanchez

Eduardo Sanchez MD is
Vice President and Chief Medical Officer, BlueCross/Blue Shield-Texas

Opining as a health plan chief medical officer, I believe that the health system will have evolved to a collaborative care model by 2022. The direct and indirect medical costs associated with behavioral health, when it is not recognized and not well managed, can no longer be ignored.

Employers and health plans are beginning to appreciate that better employee health status correlates with higher productivity and an upside bottom line and that medical costs decrease and, more significantly, workplace productivity improves when behavioral health is appropriately and "collaboratively” managed. As a result, employers (whether they are corporate America, small business owners, government, and non-governmental organizations) and health plans across the United States will join health care providers and patients to accelerate the realization of a competent, considerate, culturally-relevant, compassionate, collaborative health system.

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Can't Miss Austin Possibilities

Posted By Katherine Sanchez, Friday, September 14, 2012

It has been quite a year, spent planning the 14th annual Collaborative Family Healthcare Association (CFHA) conference to be held in Austin in three weeks. After four years of immersing myself in the collaborative care research literature, I attended my first CFHA conference last year in Philadelphia. Wow! What an incredible, real world synthesis of everything I'd been researching during my PhD program, presented by some of the most prominent names in the literature!

As co-chair of the planning committee, along with Lynda Frost from the Hogg Foundation for Mental Health (a trailblazer in integrated health care in Texas, and nationally) and my fabulous husband, Eduardo Sanchez, I am proud of the conference that we have assembled. And though there are many spectacular aspects to the CFHA conference in Austin, I want to highlight a couple of remarkable opportunities that I find particularly exciting.

Katherine Sanchez

Register today to take part in this amazing national conference that promises to highlight relevant, cutting edge collaborative care innovations on a spectrum from clinical practice to the research literature.
One truly unique offering this year is a preconference site visit to an indisputable leader in integrated health care in Texas, Lone Star Circle of Care. A limited number of registrants will be able to hop on a shuttle and head up to Lone Star's Round Rock "hub” located at the Texas A&M Health Science Center. Lone Star Circle of Care is a Federally Qualified Health Center committed to being a "behaviorally-enhanced patient-centered health care home” that provides care with a focus on underserved populations. Participants will have the opportunity to tour Lone Star's site, where fully-integrated services are provided including behavioral health, pediatrics, adolescent health, family medicine, senior health, and women's services. Participants will hear from various multi-disciplinary team members about the planning, implementation, funding, and current practice of integrated health care at Lone Star. Clinical as well as organizational/administrative perspectives will be included. The all-day workshop is scheduled from 10:45 a.m. to 4:00 p.m., departing from and returning to the Hyatt. Transportation and lunch included.

Another pre-conference workshop unique to Texas will present clinical teams from existing models of integrated care to discuss the art of the "warm handoff.” Physicians and social workers from three distinct settings will discuss their own experiences to help participants think through the various aspects of providing integrated health care and to develop potential models that may fit their particular system. Workshop participants will learn, practice and problem solve several strategies for summarizing and validating a patient's concerns for common types of behavioral health issues. Through role-play and discussion participants will learn how to describe the Behavioral Health Specialist/Consultant and the role that person will play in the patient's medical care. This is a talented group of experts!

Eduardo and I are really looking forward to visiting Austin at its most beautiful time of year. Though we miss Austin terribly, and all its cool things, one thing I don't miss is the heat – except in the fall. There is no more gorgeous time of year. We can't wait to go for a run on the lake, take in some live music, and grab some delicious eats on South Congress. Bringing your walking shoes and your adventurous spirit. You won't want to miss this!

Tomorrow is the last day to register early! CFHA has extended Early Bird Registration through September 15. Register today to take part in this amazing national conference that promises to highlight relevant, cutting edge collaborative care innovations on a spectrum from clinical practice to the research literature.

 

Katherine Sanchez, LCSW, PhD., is an Assistant Professor at The University of Texas at Arlington School of Social Work. Dr. Sanchez practiced as a bilingual clinical social worker for 15 years, primarily in medical settings with monolingual Spanish-speaking populations. Her principal area of research is in integrated health care and the provision of socio-culturally, linguistically adapted models for the treatment of co-morbid mental and physical illness.

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It's Not Too Late to Be an Austin Early Bird

Posted By Lynda Frost, Friday, September 7, 2012

It's hard to believe that the summer is winding to a close. In Texas, that means saying a welcomed goodbye to scorching days and steamy nights. This year, it also means getting excited about hosting the 14th annual Collaborative Family Healthcare Association (CFHA) conference. As the co-chairs of this year's conference, Katherine Sanchez, Eduardo Sanchez and I have spent the last 12 months planning for what is sure to be a dynamic program on the future of integrated health care.

While I could write volumes about our engaging plenary speakers, rich breakout sessions and innovative pre-conference offerings, I am most looking forward to the increased participation of consumers and e-patients at this year's conference. Consumer and patient engagement is central to this year's conference theme, with more than 10 breakout sessions on related topics over the course of two days. In a pre-conference session titled A Catalyst for Integration: The Central Role of Consumer/Patient Engagement in a Recovery-Oriented System of Care, Bill Gilstrap, Anna Jackson and Wendy Latham will explore how activated consumers/patients are essential to quality integrated health care services. And in a plenary on Saturday, nationally-recognized consumers, e-patients and allies can bridge the gap between providers and consumers of integrated health services.

For the first time, CFHA will be presenting an Award of Distinction to a Consumer, Patient or Family Advocate. This award recognizes "an individual, team or consumer run organization which embraces and promotes the core value that the participation of the patient, family, consumer and community are instrumental to the healthcare process and critical to positive health outcomes.” I can't wait to see who will be honored!

The Hogg Foundation is supporting scholarships for Texas consumers to attend the conference and join in the dialogue. We've already awarded more than 15 scholarships, to include travel costs, registration fees, food and lodging. Don't miss out on this opportunity to have your voice included in the discussion about integrated care!

While you're at the conference, don't forget to stop by the Hogg Foundation Wellness Room. Staffed by consumers and e-patients, this quiet space away from the hubbub of the larger conference will provide an opportunity to engage in conversations about the important role that consumers can and should play in our health care delivery systems.

If you haven't registered yet, you're in luck! CFHA has extended Early Bird Registration through September 15. Register today to take part in this energetic national conference that prioritizes consumer voice and participation.

Lynda Frost

Dr. Lynda Frost is co-chair for the 2012 CFHA conference in Austin, TX. She serves as the director of planning and programs at the Hogg Foundation for Mental Health, where she oversees major initiatives and grant programs, leads strategic and operational planning, and manages program staff. She joined the foundation as associate director in 2003. Dr. Frost has a law degree and a doctorate in educational administration from the University of Iowa, a master's degree in international education from Lesley University, and a bachelor's degree in English and American Studies from Amherst College.

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CFHA Comes to Austin. You Should, Too

Posted By Meagan Anderson Longley, Thursday, August 30, 2012

The Collaborative Family Healthcare Association (CFHA) is hosting its annual conference in Austin this year. Lynda Frost, the director of planning and programs for the Austin-based Hogg Foundation, is co-chairing the conference and I’ve had the pleasure of serving with her on the planning advisory committee. I can say with the utmost confidence—you won’t want to miss it.

CFHA promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, consumers, providers and communities. Their conference has a reputation for being high energy, content rich and forward thinking. Plenary gatherings will keep you engaged and spark new thinking. The four breakout session tracks allow for deeper learning and include: Organizational & Implementation Issues, Clinical Care & Direct Practice, Consumer & Patient Engagement and Public Policy. Finally, poster presentations offer an opportunity for conversations about innovative research and programs.

If that hasn’t convinced you to register yet, I’ll let you in on another exciting detail – CFHA is offering scholarships for consumers, e-patients and family caregivers. CFHA is committed to the engagement of patients and consumers in the ongoing dialogue about how best to deliver integrated health care across the country. As such, the organization is putting its money where its mouth is (with the support of generous donors, of course!). Read more about who is eligible, how to apply, and what is included by clicking here.

So, what are you waiting for? Register and apply!

 

 


Meagan Longley, a recent graduate of The University of Texas at Austin’s School of Social Work master’s program, joined the Hogg Foundation as a mental health fellow. Previously, Longley served as a social work intern at the UT Counseling and Mental Health Center, where she provided individual and group counseling to the University’s diverse student population. Before returning to graduate school, she spent four years as a program officer at the Austin Community Foundation and one year as a bill analyst for the Senate Research Center during the 79th legislative session. In addition to her master’s degree in social work, Longley earned a bachelor’s degree in psychology and women’s studies at Furman University in Greenville, S.C.

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Mindful Ruminations of a Triathlon Tourist

Posted By Randall Reitz, Friday, August 17, 2012

Prologue:

I write this post in a minivan while driving from Boulder to Grand Junction after my first attempt to complete an Ironman 70.3 race. It includes my internal dialogue during the race, flashbacks, wisdom from the thumping music in the transition area, and announcements from the P.A. system. I hope to convey insights about collaborative care without being too explicit or corny.

1. Swim—samba snare

"Athletes please move to the beach, the race will start in 20 minutes”. Pushed along by a veritable arctic seal mating ritual of athletes in black wetsuits and color-coded swim caps, I descend to Boulder Reservoir.

"O’er the land of the free and the home of the brave!” Wow, a flock of doves, a very nice touch. The crowd claps furiously as the pros plunge into the 1.2 mile swim.

"What doesn’t kill you makes you stronger, live a little longer!” Eight waves to go until I start, plenty of time to perseverate. Other than 1980’s Speedo-guy, why am I the only person revealing my knees? Does the ankle-length material provide extra buoyancy and efficiency? If so, why are people evenly split between the wrist-length and the Farmer John arms? This swim is long—even the pros seem to be plodding through the course.

"Cause I told you once, Now I told you twice, We gon’ light it up, Like it’s dynamite.” "In wave 6, we welcome a number of military heroes, including (name) who lost 2 limbs fighting in Afghanistan and now leads a military program to train other veteran amputees to compete in triathlons”.

Wading, waiting in water for the countdown for my wave, "On my mark, 3, 2, 1, have a great race!”

OK, hold back a little, let the faster swimmers go first. This is a long race, no need to try and win it all in the first minute of the swim. OK, start with freestyle and attempt to maintain it for at least 10 minutes. You can do this.

I get kicked in the head and my goggles get lodged under my nose. Uh oh, this feels all too familiar. A flashed mental image of my first open water triathlon: impenetrably murky lake, aspirated water, tightness in chest from a wetsuit I borrowed from a guy who weighs 140 lbs. Ten minutes of dread, panic, and self-doubt.

OK, you can do this. Tread water, empty goggles, get them back on, and you’re off. I can barely see a thing. Even the buoys seem miles apart. Check watch, how can it only be 1 minute so far? Crap, my high-dollar goggles are already fogging. Need to get back on track. OK, breaststroke: easier breathing, get a glimpse with every stroke. Now back to freestyle, now breast stroke, now freestyle. Only 3 minutes? Tread water, spit in goggles, rub out the fog. Treading is exhausting. I’m not going to make it. I need to flag down 1 of the wave runners to take me back to shore. No, just swim until the first turn. The first leg is always the hardest of the 3.

OK, I made it to the turn. I get swum over by a person in a pink cap. What? How can I already be getting lapped by someone in a wave that started 5 minutes after mine? I’ve only been swimming 15 minutes. I am a miserably slow swimmer. Where is that wave runner?

Just focus on your breathing: right-left-right-breath, left-right-left-breath, right-left-right-breath. Hey I know this rhythm, I practiced it yesterday. Quick image of the first-ever Colorado Brazilian Festival that was celebrated in Boulder the day before. I’m in the drumming workshop, practicing the snare drum’s every-third-beat accents: RIGHT-left-right, LEFT-right-left, RIGHT-left-right. OK, just practice the snare. Swim mindfully, BREATHE-left-right, BREATHE-right-left, BREATHE-left-right.

I still can’t see a thing in these goggles, I’m only halfway done and exhausted. This must be how Matt feels each time we train together. I see myself at the Colorado Mesa University pool, my first time training with my friend, "Matt”. I provide a few pointers, dive-in, swim across and back, and see he is still standing in the chest deep water. He informs me that he’s never been a swimmer. I coach a little more and he performs a halting, thrashy, 25-yard swim with his head never going under water. I encourage him a little more, suggest a 10-minute regimen, and take off on my own. I swim 500 yards while noticing that he hasn’t swum at all and eventually disappears from the water. I walk to the locker room where I find him setting on the bench looking despondent. We talk for a few minutes, then walk back to the pool together and I swim by his side for the rest of the work-out. Flash forward 2 months to Matt’s first sprint triathlon, in which he was the slowest swimmer (and the only person to mix-in the back stroke), but he finished.

OK, 2 legs down, 1 leg of the swim to go. Just get through it and you’ll be fine. Hey, this snare drum breathing is also like the samba steps I learned yesterday:

Left foot back, right foot forward, left foot forward.

Right foot back, left foot forward, right foot forward.

Left foot back, right foot forward, left foot forward.

LEFT, right, left. RIGHT, left, right. LEFT, right, left. How did those crafty Brazilians figure out that the feet and drums should move together? Man, I’m self-talking constantly. It’s like I’m doing self- therapy in the lake. I wonder if this is what it’s like for one of my patients with panic disorder to go to Walmart on a Saturday? I must be a jerk in the exam room. I can’t imagine enduring this trauma each day of my life. Does it really ever get easier? Nietzche and Kimberly Clarkson were wrong. If I swam open water every day, it would make me stronger, but it’d definitely also kill me. Fade to a counseling session from 10 years earlier with a patient with OCD. He explains his metaphor for OCD therapy. "It’s like living in a house full of cockroaches. You know they’re there, but will only see them if you sneak into the kitchen in the dark of night and turn on the light. You need to continually expose yourself to your worst fears to overcome them.”

Flash further back to swimming lessons in Dallas as a kid. Each summer morning the surface of the pool was covered in floating "June bugs” that would cling to my hair and back and occasionally get swallowed during a breath. Exposure therapy is not for sissies. That’s the last thing I need to be thinking about right now: cockroaches floating in the reservoir. BREATHE-left-right, BREATHE-right-left. Hey, this would make an interesting blog post.

Hit the beach running. "You’re on the right track, baby. You were born this way!”

2. Bike—Boulder sustainability

After a leisurely 10 minutes in the transition area (don’t ruin the physical endeavors with a haphazard transition!) and I’m on the bike. "Our lead rider just finished the first of the two 28 mile laps.” I merge onto the county road just in time to be blown by a hard charging phalanx of super-fit pros. I’m never going to see them again, but I’ll take dry hot air over murky cold water any day.

I’ve been spinning for 10 minutes and averaging 14 miles per hour. Extrapolated over a 56 mile ride, that’s exactly 4 hours. That is way too long for my goal of less than 8 hours total. It’s not looking good. But, now downhill: 18 mph, 20 mph, 25, 31, 37. Thank you Jesus!

OK! The first aid station. I approach a line of volunteers, each holding out a food item and calling out: "Gatorade!” "Water!” "Gu!” "Bonk Breakers!” "bananas!” "Chomps!” I call back "Gatorade!” and a volunteer steps out to the road with a full Gatorade squirt bottle (cap already opened). I lean in, grab it without slowing down, and slide it into the water bottle holder. I yell out "Chomps”, receive a bag of energy gummies, tear them open drop all of the contents in my mouth and drop the bag in the garbage heap at the far end of the aid station. What a slick operation that was. Like an idealized collaborative clinic. I’m the primary care doc surrounded by teammates of other disciplines eager to help me out without slowing me down.

I see a man holding a box roadside about 200 yards ahead. Look at that dude’s dread-locked beard. It’s as thick and ropey as DaVinci’s iconic Moses statue. What is dude doing? Cool, he’s handing out whole organic peaches. Boulder definitely comes as billed.

Hey, I’m 30 minutes into my ride and haven’t yet used my clipped-in up-pedal. I need to get into that groove. Help me samba: UP, left, right. UP, right, left. UP, left, right. Was that a twinge in my hamstring? Be careful brother. Don’t even think that, you might increase the risk of cramping or pulling something. Don’t picture a pink giraffe. Don’t picture a pink giraffe.

Look at that guy’s bike: all carbon, super-light tires, self-adjusting derailleur, aggressive profile. And, I just blew right by him. Based on his calf number he’s only 24. I love passing younger people on super expensive gear.

Lots of Obama bumper stickers, haven’t yet seen a Romney. Boulder definitely comes as billed.

I approach the last aid station of the 1st bike lap. This one is sponsored by the Boulder Triathlon Club. The volunteers are all-decked out as disco superheroes. So, if this is the BTC, who is staffing the aid station. Maybe it’s the WAGs. What’s the male equivalent of a WAG…a BAH?

"Ain’t no mountain high enough! Ain’t no valley low enough!” Sing it Diana! OK, passing through transition area after first lap. I averaged 18 mph for 1:35. That’s a better time than I’d expected. I need to pace myself on the 2nd lap so I have legs for the half marathon.

Pace-Your-Self,

Pace-Your-Self,

Up-Right-Left

Up-Left-Right

The second lap seems easier than the first. That’s a good definition of self-efficacy—re-tracing a familiar path. Up-Right-Left, Up-Left-Right…Hey, what was that twinge in my hamstring? OK, stop the up-stroke.

I look to my left where there is a female rider with "You’re stronger than you think” written on her arm in marker. That’s a good narrative. I wonder where that came from: a therapist, an athlete self-help book? Facebook? Is she competing for sport or for therapeutic reasons?

There seem to be a lot of similar gear. I wonder what of it is empirically-supported and what of it is unproven fold tradition, or worse—shameless marketing? Pressure socks, that funky body tape from the London Olympics, the disk wheels from the Los Angeles Olympics, triathlon handle bars, the lycra bike short/tank-top combo that everybody (except for me) is wearing. I like the triathlon handle bars with water bottle and straw that pokes up inches from the rider’s mouth, but worry I’d get a chipped tooth or black eye.

"Boom, Boom, Boom, Even brighter than the Moon, Moon, Moon.” Katy Perry signals the end of the ride. 3:10, exactly the same pace as the 1st lap. Feeling good. "Welcome back our first female pro, Liz Blatchford of Australia who finishes in 4:07:48!”

3. Run—Broken down, but not beaten

Call my W(AG) in the port-o-John. Re-apply Boudreaux’s in strategic places to prevent chaffing. Apply nipple bandages. After another 10 minute transition I’m off on the run. Just before leaving the area I stop at a station of speedy volunteers with medical gloves slathered in sunscreen who wipe down my face and arms. This race has 2 categories: triathlon pro and triathlon amateur. Apparently, I’m in my own category: triathlon tourist.

The first mile of the run is always the hardest. The transition from bike legs to run legs is brutal. I just need to do two 6.5 mile laps. You’ve done dozens of half marathons before…just never after swimming and biking.

Well, that wasn’t that bad, the first mile only took 8:50, which would equal…under 2 hours for the full run. Legs and lungs are feeling strong. The calf number on the walking man in front is a 75. Holy cow, I’m just now passing old dude in the run? "Fantastic job!”

Good, the first running aid station. I’m saggin’. "Gatorade!” "Chomps!” A volunteer holds out a sponge. I grab it, drench my head in the ice cold water, and drop the sponge in the pile. "Fantastic!”

I feel a twinge in my lower right knee. Uh-oh, that’s the IT band. Not a good sign with 9 miles to go. Flashback to 6 weeks of pain and abandoned runs after an IT band inflammation 2 years previous.

With the mile 5 aid station in view the IT Band flares horribly simultaneously with cramps in the calves and lower quads of both legs. No!! OK, just gimp into the aid station and see how you feel afterward. "Gatorade!” "Bonk Breaker!” I quickly down both. Still hobbled, I grimace past the sponge volunteer, who pipes-in with "You look like you could use a sponge, sir.” I’m not a family doctor, I’m a freakin’ surgeon! I just scowl and someone hands me a sponge. OK, let’s try running a little….Ouch, no, too soon. Let’s walk to that next bridge and see how it feels.

OK, a little better. I run for 3 minutes before giving-in to the returning cramp and IT band pain. I follow this same pattern through the end of the first lap of the half marathon.

"We are the champions, my friends." I love that song, but not…right…now. I’m feeling more like "you got blood on you face, you big disgrace, kicking your can all over the place.” Or is it "And another one’s gone, another one’s gone, another one bites the dust”?

OK, Reitz, pull it together. Find a way to finish this race in 1 piece. Six miles to go, what would I tell my chronic pain patients? Manage the pain; strive for optimal performance without pushing so hard that I break down.

Looking up the trail I see a young runner wearing what appears to be a diabetic pump. I strain to catch up with him. "Is that a pump?”

"Yeah, we have a whole team of diabetics running today. Are you diabetic?

"Nah, my brother is”.

We chat for about 5 more minutes, until he tells me that his legs are failing him and needs to pull-up. I run ahead another minute and pull-up myself. Over the next 5 miles we repeat this pattern: I pull-up, he catches up to me, we run together a little then he pulls up. I run a little further, then pull-up.

One mile to go, the pain is unbearable, I can’t go more than 200 yards without walking. I…will…not…finish this race walking. What would I tell my patients? Breath into the pain, breath into the pain. Breath into the pain…

Well, that was a crock of new age pseudoscience.

I walk until my diabetic friend catches up to me. We walk together until we can hear the music thumping and then run the last 300 yards to the finish line together

"Get up, get down, put your hands up to the sound. Get up, get down, put your hands up to the sound.

Everyday I’m shufflin”

Done!

Drop plastics in the plastic bin, organics in the compost bin, and garbage in the trash bin. Boulder comes as billed.

   ***

Thank you Boulder,

Thank you Jesus,

Thank you samba,

Thank you snare,

Thank you grimacing surgeons,

Thank you inspirational marker tattoo,

Thank you evidence-based practices,

Thank you folk traditions,

Thank you rich young athletes who are slower than me,

Thank you older athletes who are faster than me,

Thank you diabetic kid who finished alongside me.

 

Boulder Ironman 70.3
Randall Reitz , PhD, LMFT is the Director of Social Media of CFHA and the Director of Behavioral Science at St Mary’s Family Medicine Residency in Grand Junction, CO. When younger, he liked to trail run. Now older, his body appreciates cross-training. He posts his ideas at CFHA's Collaboblog and tweets at @reitzrandall.


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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.