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Your Best Life

Resiliency and the Art of Medicine

Ring, David, MD, PhD; Johnston, S. Claiborne, MD, PhD

Clinical Orthopaedics and Related Research®: May 2018 - Volume 476 - Issue 5 - p 937–939
doi: 10.1007/s11999.0000000000000268
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D. Ring, Associate Dean for Comprehensive Care, Dell Medical School at The University of Texas at Austin, Austin, TX, USA

S. C. Johnston MD, PhD, Dean, Vice President for Medical Affairs, Frank and Charmaine Denius Distinguished Dean’s Chair in Medical Leadership, Dell Medical School at The University of Texas at Austin, Austin, TX, USA

David Ring MD, PhD, Dell Medical School at The University of Texas at Austin Health Transformation Building 1701 Trinity St. Austin, TX 78712-1850 USA Email: david.ring@austin.utexas.edu

A note from the Editor-in-Chief: I am pleased to present the next installment of our “Your Best Life.” In this month’s guest column, Drs. David Ring and S. Claiborne Johnston from Dell Medical School at the University of Texas at Austin examine how resiliency can influence health, and how physicians can help their patients increase their resiliency in practice.

The authors certify that neither they, nor any members of their immediate families, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of

Clinical Orthopaedics and Related Research® or The Association of Bone and Joint Surgeons®.

From the Column Editor,

This edition of Your Best Life features Drs. David Ring and S. Claiborne “Clay” Johnston discussing the importance of resiliency as a large determinant of how patients experience illness. In fact, resiliency, considered the underlying ability to positively respond to adversity, may correlate more strongly with symptom intensity and magnitude of limitations than severity of disease. This powerful force is best cultivated in a strong doctor-patient relationship, fortified by trust.

David Ring MD, PhD has been a pioneer in the mind-body interaction as a chief determinant of and wellness and the quality of the clinical relationship as the main determinant of patient satisfaction. He has written extensively on the notion that a patient’s emotional state is a large predictor of the effect of disease on quality of life. That is, resilient patients can endure appreciable degrees of subjective disease burden without portraying substantial negative effects on quality of life measures[1].

Known for his innovative approach to both medical education and the delivery of healthcare, Clay Johnston MD, PhD serves as the inaugural Dean and Dean’s Chair in Medical Leadership at Dell Medical School at The University of Texas at Austin.

These thought leaders offer some helpful, evidence-based recommendations on enhancing the resiliency of those we care for. In addition, they posit that the depth and quality of the relationship we foster with each patient may be more effective in generating favorable patient satisfaction than any medical or surgical intervention we may offer.

— John D. Kelly, IV MD

It’s no surprise that an albuterol inhaler increased forced expiratory volume and improved symptoms compared to no intervention in a trial of 49 people with asthma. But it is certainly an eye-opener when a simulated acupuncture and a simulated inhaler are found to be just as effective as albuterol at relieving symptoms even though they had no impact on forced expiratory volume [16]. Simulated therapies improved the comfort and capability of patients as much as a treatment that had a measurable impact on disease physiology.

By impacting symptoms and their manifestations, simulated therapies access a patient’s resiliency, which is the underlying ability to respond positively to adversity such as that brought about by disease [14]. Resiliency doesn’t cure cancer or strep throat, but it does alleviate symptoms and make people more capable (and perhaps more willing) to comply with treatment regimens.

Osteoarthritis at the base of the thumb is an example of a condition influenced by resiliency. If you live long enough, you will develop osteoarthritis of the trapeziometacarpal (TMC) joint [3]. In a comparison of 64 people with incidental TMC arthrosis (detectable on examination, but not causing symptoms) and 64 people requesting help with symptoms from TMC arthrosis, better mood and more-effective coping strategies (components of resilience) were characteristic of patients with incidental disease, and were associated with fewer symptoms and limitations in both cohorts [4]. Static hyperextension posture of the metacarpophalangeal joint (an indication of more advanced disease) was not associated with greater symptoms and limitations. In terms of symptom intensity and magnitude of limitations, the health comes from within.

Another study showed that inert medication labeled “active” relieved migraine as well as active medication labeled “placebo” [9]. The study results confirm our inherent capacity for health and reminds us that attention to resiliency is merited even when administering treatments that effectively ameliorate pathophysiology.

In the United States, both the Medicare Access and CHIP Reauthorization Act and the Merit-based Incentive Payment System encourage the measurement and reporting of quality measures, including patient-reported outcomes (PROs). The realization that resiliency improves symptoms and limitations (what PROs measure) just as well as medication among people with asthma, depression, irritable bowel syndrome, and migraine opens new possibilities for being more resourceful in helping people get and stay healthy [10]. Increased usage of PROs as measures of health and treatment effectiveness emphasizes that physiological changes are largely irrelevant if not accompanied by symptoms or limitations. Our job as clinicians is to make disease irrelevant in people’s lives.

There are strong ties between PROs (symptoms and limitations) and psychosocial factors (stress, distress, effective coping strategies) [15]. Studies have shown that the beneficial effects of resiliency such as less stress and distress and more-effective coping strategies on PROs can be enhanced by cognitive behavioral therapy and its derivatives [8]. A patient’s social support, financial, housing, and job security [12], and grit (defined by clinical psychologists as a combination of perseverance with meaning and purpose) can also affect a patient’s resiliency [7].

Effective communication strategies can be used to improve a patient’s resiliency as well. For example, among 262 adults diagnosed with irritable bowel syndrome, those receiving simulated acupuncture augmented by a warm, attentive, confidence-inspiring patient-clinician relationship experienced greater relief than people treated with simulated acupuncture alone, and both felt better than those on a waiting list [10]. Indeed, a trusting and compassionate relationship between a person seeking and a person providing care has long been embraced as part of the art of medicine.

The way in which interventions are delivered can improve a patient’s resiliency. Pilot studies of so-called “honest placebos” (an inert substance or simulated procedure that is delivered without deception) documented symptom relief in patients with irritable bowel syndrome, depression, and migraine [11]. This is important because active deception (knowingly prescribing a placebo or over-selling the potential of a given treatment) is unethical [6, 13]. In other words, the ability of a treatment (even an inert or simulated treatment) to enhance resiliency depends more on a trusting, meaningful relationship with the clinician, then on belief in the treatment. Sometimes referred to as relationship-centered care [2], these nontechnical skills are just as responsive to training and practice as technical skills and merit greater attention in medical education [5].

While there might be a best medication or surgery for strep throat, cancer, or stroke, there are many ways to foster resilience. Simulated interventions and an array of traditional and complementary therapies demonstrate the diversity of approaches that create resiliency. The core elements of a comprehensive approach to healthcare combines effective alterations of pathophysiology with a trusting and compassionate patient-doctor relationship, where the physician encourages the patient to be involved in their own care. Patients cultivate healthy habits when they take a more active role in their care, including those that enhance resiliency. Here, we will find the art of medicine.

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Tomorrow Try This

  • Take a genuine interest in each patient. Talk about at least one non-medical thing so they know you appreciate who they are and how their problem is getting in the way.
  • Make the goal of solving (diagnosing, treating) secondary. Aim for a soothing relationship first and foremost. Think “soothe, not solve.”
  • Hone your patient management skills to emphasize the value of healthy habits to improve resilience.
  • Become comfortable with incremental care (expect it to take more than one conversation to get on the same page) and team care (you don’t need to do it all on your own).
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References

1. Ayers DC, Franklin PD, Ring DC. The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues. J Bone Joint Surg Am. 2013;95:e165.
2. Beach MC, Inui T; Relationship-Centered Care Research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med. 2006;21:S3–8.
3. Becker SJ, Briet JP, Hageman MG, Ring D. Death, taxes, and trapeziometacarpal arthrosis. Clin Orthop Relat Res. 2013;471:3738–3744.
4. Becker SJ, Makarawung DJ, Spit SA, King JD, Ring D. Disability in patients with trapeziometacarpal joint arthrosis: Incidental versus presenting diagnosis. J Hand Surg Am. 2014;39:2009–2015.
5. Boissy A, Windover AK, Bokar D, Karafa M, Neuendorf K, Frankel RM, Merlino J, Rothberg MB. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016;31:755–761.
6. Bostick NA, Sade R, Levine MA, Stewart DM Jr; American Medical Association Council on Ethical and Judicial Affairs. Placebo use in clinical practice: report of the American Medical Association Council on Ethical and Judicial Affairs. J Clin Ethics. 2008;19:58–61.
7. Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: Perseverance and passion for long-term goals. J Pers Soc Psychol. 2007;92:11087–1101.
8. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognit Ther Res. 2012;36:427–440.
9. Kam-Hansen S, Jakubowski M, Kelley JM, Kirsch I, Hoaglin DC, Kaptchuk TJ, Burstein R. Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med. 2014;6:218.
10. Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, Kirsch I, Schyner RN, Nam BH, Nguyen LT, Park M, Rivers AL, McManus C, Kokkotou E, Drossman DA, Goldman P, Lembo AJ. Components of placebo effect: Randomised controlled trial in patients with irritable bowel syndrome. BMJ. 2008;336:999–1003.
11. Kaptchuk TJ, Miller FG. Placebo effects in medicine. N Engl J Med. 2015;373:8–9.
12. Levine S. Psychological and social aspects of resilience: A synthesis of risks and resources. Dialogues Clin Neurosci. 2003;5:273–280.
13. Saljoughian P, Saljoughian M. The placebo effect: Usage, mechanisms, and legality. US Pharm. 2011;36:12.
14. Southwick SM, Bonanno GA, Masten AS, Panter-Brick C, Yehuda R. Resilience definitions, theory, and challenges: Interdisciplinary perspectives. Eur J Psychotraumatol. 2014 Oct 1;5.
15. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am. 2009;91:2014–2018.
16. Wechsler ME, Kelley JM, Boyd IO, Dutile S, Marigowda G, Kirsch I, Israel E, Kaptchuk TJ. Active albuterol or placebo, sham acupuncture, or no intervention in asthma. N Engl J Med. 2011;365:119–126.
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