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CLEAR: A Simple Model for Providing Whole Person Care

Kathy McMillan James McMillan



  • October 31, 2014
    2:00 PM
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so I like to start with little prayer and just ask God to guide us as you talk loving God as we talk about the green whole person care to your people you create your spirit will be with us guide us as we talk and bring those the would like to influence by what we have to say thank you so the way we wanted to present this was to start with a little case of a patient that I dealt with on the wars and a Kathy's going to cut them put together the model that she helped develop Loma Linda for delivering whole person care and then I will wrap it up by a applying that model to the case that I saw so as a nephrologist not only take care of kidney patients but I also rotate on the words is the chief and the internal medicine section and sold this to describe how we do our word work are words are comprised of for teaching teams with usually one residence and two interns and usually to students and so it was in this role about two weeks ago that I saw a thirty three -year-old gentlemen who had come to the hospital with chief complaint of flank pain he had been vacationing in Mexico with you gone to a party was down visiting his girlfriend near Cancun he was in the poor section of Cancun which he told me it is just pathetic compared with the rich section of Cancun and came back with a very bad case of diarrhea is seen the positions down their arguments mathematics and some anti- motility agents and unfortunately continue to have diarrhea thought he was getting a little better but then just before arriving in our emergency rooms really kind of felt so much worse that he felt like you got to see somebody's a counterargument emergency room and they are discovered to have an elevated creatinine of two six he had an orthostatic hypotension his exam was was mostly significant for flank pain when you pounded on his back his belly was a little bit tender but otherwise was pretty unremarkable in the very muscular man was weightlifter tall and handsome men and just otherwise a picture of health had very little other medical problems with on an antidepressant for some posttraumatic stress disorder but otherwise was pretty healthy the emergency room gave him two liters of normal saline and he was continued on a rather rapid normal saline drip in the hospital but unfortunately over the next three days there was very little improvement of his symptoms of flank pain and his creatinine continued to go up we did a CT scan and emergency room with negative frame kidney stones and ultrasound showed no hydronephrosis and in the days wore on it was a Sunday and I was rounding with my team I tend to like to down at the bedside we will round the bed one of us will greet the patient then and just you know explain the agreement talk about them and we like to include the patient around and so this morning was Sunday morning it was the fourth day of this patient's hospital stay and his creatinine had risen steadily and we were starting to talk about doing a kidney biopsy on because you're worried that there may be something more than this just plain diarrhea and volume depletion going on so this student had presented the case very nicely and at the end said in the creatinine continues to go up and the patient who is now the end of that and you can secede crestfallen there was a tear in his eyes as big macho guy crying in front of us and with that I'll leave the case and let Kathy's for the present this model that she's helped develop and will come back to the kids afterward so in recent years there has been a renewed desire at Loma Linda University to teach and mentor medical students and other students on campus through all of the schools and how we provide whole person care and also included the employees in that as well and we wanted to do that in a consistent way because up until a few years ago if somebody from the East Coast during Africa were calling phased out as Loma Linda do hopers and hair and the response within based on whoever they happen to talk to his again how I long only in the way of doing and so on for several years ago and there was a group formed about a dozen people led by Doctor Carla Gober I got to go break the director for the Center for spiritual life and homeless and she pulled together a group of twelve of us from across campus both on the University side and healthcare side to say how can we do this in a way that actually applies all of the disciplines on campus and and it's something memorable and an video we can teach it easily and then people will be able to remember and so we have developed the clear model and in the last couple years it's evolved a little bit we tried to refine a little bit more and we use this with every single employee who comes to work on Melinda and we now are teaching it in the curriculum for both first and second year medical students and then this year it's being also now it's hot with nursing students and physical therapy students all of our allied health students across campus so just when everything in terms of introduction on the model we trying to come up with something that like I said would be used across the disciplines and because of that we realize it's not comprehensive by this is just like a beginning point for how we would teach this a mental health professional would use it differently than a physician or dentist we love the fact that we hadn't and seven for the dental school in our committee and so many times we be talking about patients in the hospital and human phrases innovate what about the dented fender so we may always had to keep thinking about our language so that it would be applicable across that we would never expect how do it out of his model and go through every question it's just like they said some ideas of how we might go about it so what are symbolic at the bottom of that beginning page where you begin to see the whole person care model our goal if it is to create an atmosphere compassion exemplified by the teaching and healing ministry of Jesus Christ what we want to do is to introduce people to Jesus and so the way that we do that first of all is to connect and you see that summary statement is connecting intentionally with God cell and others second listen being fully present in a sacred time sharing thirdly we explore inviting whole person conversations and we acknowledge empathizing and communicating understanding and lastly respond sharing resources that are firm string and offer hope for clear model we think it's pretty easy to remember in fact for me what was so exciting about it is sometimes you get an accurate aunt and afterwards you're sitting there going what do that El Niño and this is something different the time at our committee finished it and then we were able to easily remember what we were talking about someone start and then with the connect piece connecting intentionally when God self and others is when we think about connecting which seems like a very obvious thing when redoing whole person care we begin by thinking about how we connect with that person but in our model we want to step back even further than that because when we look at the ministry of Jesus we realized that he was Earth connecting with his father factors in the ministry of healing when it talks about as Jesus was approaching the pool of Bethesda when the man was nearby the pool that was Caroline 's on it says Jesus was walking alone in apparent meditation and prayer he came to the pool and I think that's just a perfect example so before we can act with the patient we have to be in connection with God and that's our very first connection piece then we find ways to connect with that patient we may want to connect with them in their environment as a old e-mail incredible flowers there by your bedside area that helps to connect family want to connect them to other people and their family if possible and if there is not some struggles a relationship issues we want to connect them with not so there's all types of dimensions involved in that connect peace of continuing on with the story of the man pool of Bethesda Ellen White talks about the fact that Jesus then came to the pool he saw all of the people around the pool and and then she says the sick man was lying on his mat and occasionally lifting his head to gaze at the pool with a tender compassionate face and over so here's Jesus acting with this man he didn't just stand up above him he bent over he was connecting with him in very significant ways another Bible story that I think that is the woman at the well when Jesus came up and she was drawing water and he said to her and were told that he had approached her in different ways you might immediately walked away but there was he knew how to connect with people and that's so important of the other piece of connection that I think is very important is being connected with ourselves being aware of our own biases our own emotional state Senate for going into a room and were a tremendous amount of stress or or were apprehensive about something to just name that can be aware of it as we go in and turn it over to God in prayer are the L stands for listen and again that seems pretty self-explanatory that we were going to have a significant interaction with someone we got to listen well one of things I like to say that we listen with our eyes and our ears and our heart because so many times the words that someone says to us are not necessarily what's happening in your heart if you heard Doctor Mills this morning he talked a patient who came in with the dermatological emergency and yet that wasn't what it was about because Doctor Mills was listening with his heart he was able to ask what else is going on and again in the light of Jesus when when he asked the man do you want to be well then this man poured out his story about how you he wants to but you can't get into the pool because he doesn't have anybody very help him and it always people who get in first and Jesus stood there and listen to that story the gift of listening he stands for explore on now and in the model you'll see that this one is in is pretty extensive and this is where instant backup plan will have in each discipline has their own assessment process and Rivero on H&P so to speak and so that would be included in the explore section but what we tried to do is come up with the very basic questions that might be asked to work and ask about the patient's physical story of their intellectual story very emotional story and their spiritual story now embedded into this Explorer section is our spiritual history this is an again like I said the very basics that we might want to ask someone within their spiritual story and then another acronym within our acronym and this is 's sources of strength for the first question that we might want to ask someone after we found out about their physical symptoms and what it is that they are coming in preventing for is to save what are your sources of strength to the wonderful question to open things up and allows people an opportunity to to talk about spiritual things or not and we let them direct the conversation so I would ask the patient what are your sources of strength and they said all my family and my kids are so important to me and I is just that's what helps to keep me going but I might think of them after I'd knowledge that could be able to you know you talk about there daily but then to say so I noticed that you didn't mention anything about the community or five is that something is a part of your life so I wouldn't want to just ignore that if they didn't mention it because sometimes people of faith oh yes that terribly important to me I just didn't mention didn't think to mention it here out of times people might say something like well you know I I used to go to church there is not part of my life anymore and I would want to follow up with that as well to say something like so how's that working for you because in any times when people are presented in a time of crisis in their life they are at a point of wanting to really explore that even if they might have closed the door on an earlier man on second question that we would ask is what religious faith group will be distant has shaped you the most and we asked that question specifically that way because we felt like the question what denomination you belong to is a little bit too narrow because there are people who may be they may been baptized a member of the Adventist church but they no longer attend so they might really technically have membership but it's not really where they are out right now or conversely you might have somebody who's been attending administrate it ever been baptized and are not officially a member and so we felt like this question is broad enough to save the environment it's shaping you that has brought you to where you are and it also allows more of an open-ended conversation for people to be asked people to explain where they're coming from the third question is what significant life event do you want us to be aware of as we care for you this is a question is not included a lot of the spiritual history so you'll find that you do research on the subject and we felt like it was important because there is research that shows that a person 's physical health is affected by many of the emotional events that are taking place in their life we had an interview with the class of medical students not too long ago it was out last ring where we are together they were interviewing a woman about her medical case and at the very end of the interview we were coming to best and we asked her in or any other important events in your life that we should now under the care for you and she sat for a moment and then her eyes that cut it she said that while my my sister just about a month ago and it wasn't pertinent to her medical case at the moment and that if we had not asked that question we might not have heard about so I think it it sometimes gives us an important insights into where a person is is living else stands for links to tears over what religious practices or beliefs do you have that would be important for us to know about us we take care of you now this is a question and ask if these four questions are all asked in our admission assessment when patients come to Loma Linda that weird encouraging all of the disciplines to incorporate this as of this question would get at things like depending on what a person 's religious background is if they were Jehovah's Witness that would be the place where we would learn that they didn't want one product it might deviate the patient was a Muslim that they would want to talk about a time for their prayer five times a day if someone did about Christian they want some quiet time in the morning to be able to pray we would ask them at that point where many of our nurses will ask the patient if they would like someone to pray with them so that is the explore section for the spiritual peace then we would ask them about the relational story and other aspects of care that warm affection can expand a lot depending on the discipline the jury in which area that you go into but that's also where you would do your physical assessment and this kind of thing only get all analysis and go back to that pool of Bethesda I went when Jesus asked the question do you want to be well that was the beginning of his exploration with the woman at the well it's an interesting conversation takes place when you read this story in John four because Jesus Jesus explorations in place in the climate text as making statement I was in a series of questions and I guess maybe because he was divine and he knew exactly where he was going in this woman's dory he had a little different experience than we have sometimes we have to ask more questions that he was able to dive in and to say the new radios he says to you give me a drink you asked for water and it turned interest in her curiosity and that was part of that explore section for Jesus and her story acknowledge I think even though this it looks small in the model I believe it is one of the most important pieces of whole person care when someone is hurting and suffering if they don't feel like somebody has heard them they are not able to move on and so many times we get in the habit of just reassuring people and in a pattern on hand and say everything can be fine and we miss this opportunity to really acknowledge where some about it you can remember back to school when you were in school at the very very worst casting ever talk I don't have never had to experience are you actually walked out of a test if Akamai just failed that there is not fine it's a horrible place to be and if you go home to your family or remains or whenever anything is now any thing I just the most likely response you will get from them is what know you can you identify this is what has been that it's so frustrating if you feel like somebody hasn't heard what you said several years ago my kids are outside playing and our daughter fell and skinned her knee and she came running in the house I was in the kitchen making dinner and she came in she was crimes law might even be made and I looked down and there was no blood is why I think you'll be okay and she went into the other brown I happily went back to making dinner and a few minutes later I heard her son being in the other will and my mother 's heart finally came to life and I will not be in a antislavery fiddling science tells me because I have had screens before and I know they hurt really badly even when you're not leaving right address before and so I opened that then need and I put on her knee why is now whether they are called in the months ahead I believe you I know without the knowledge that they were talking about it is no different with people 's heart when people are going through a crisis whether it be an emotional crisis or physical crisis they want somebody to come alongside them and say how you this must be so difficult is the knowledge that even does not take very long and it is a learned response for some people who are the interests of the group the group better in a Myers-Briggs testing it comes naturally for those of us who are not an athlete have to learn to do it because my natural response is to do when I get my daughter sometimes what patient comes to us in a Taliban style scanner in our instinct to reach out and have them on hand at all everything just right take good care that wanted knowledge keys more is really what they need this pattern on hand is not to be all that helpful right of zoo lived in the story of the woman at the well when he said go call your husband insisted on no husband that acknowledgment piece for Jesus was when he said you're right the husband and it's not in quite the same way that we talking about here but he took that moment to acknowledge and name them for her and send to let him know that he had heard her a ministry of healing out we have this quote that we have heard small many times it is so important Christ's method alone will give true success the Savior mingled with men as one who desired their good he show his sympathy for them minister to their needs and one Aircon and then he bade them all on me that's responded were to get to that in just a minute base she goes on the air and that the last time were given to sermonizing and more time was spent in personal ministry greater results would be seen poor are to be relieved and cared for sorrowing and bereaved comforted we are to weep with those that we rejoice with those who rejoice that to me is that acknowledgment please week how can we bring comfort we weep with me rejoice that his acknowledgment and then finally to talk about the respond section of the model this is the opportunity to have it to actually share our own Tory analysis where we have an opportunity point people to Jesus so of the first of all we can talk about their own personal resources what kinds of strength they hounded to talk about professional resources we can refer to them if they need something greater than we have twenty minutes in the purely medical Center at primary care doctor might refer events with specialist at that point the Willy comes to spiritual peace spiritual part of the model this is where we have an opportunity to share our own story the chance that we have to say to them that one of the things that really helps me when I'm afraid it's too green with VR would be helpful if I would pray with you if the opportunity we have to share our own they with our patients to be able to hock about experiences where God has helped me through a time of crisis in my life that might be similar I think when we talk about the state story which is something we heard in a seminar from the Christian medical and dental Society a number of years ago the idea would be the motion without other person is spirit and sing we may have never been through the experience that that person is going through the link probably experienced a similar emotion and find a time in our life when God helped as through a time of crisis when we fifth felt that emotion so that is the key when you think that why does we keep the focus on the patient story that we may share a personal experience of how God helped us through that for the patient talk to me and so I feel afraid that I might be able to Sharon Satan I remember time is really afraid when our kids were about six months old I was diagnosed with thyroid cancer and remember lying in bed the night before the surgery just wide awake wondering if I would live to see my kids grow up wondering if I would have a voice when I got done with surgery and wildly variant member the first coming to me where Jesus says I am with you always and it wasn't as if God said anything to define but I didn't experience that knowledge of him saying no matter what happens to be with you and I experienced peace I was able to closely enough one of my favorite stories it's very short I'm a good thing when I could make that story last ten minutes if I wanted to ready in order for it to be helpful to that patient in my response is going to be short because we never want the patient to feel like they shared their crisis and Middle East he would hold up enough in the auditor about the time I was afraid and then we take it to Ari our story so we want to keep it very patient focused and pointing them to God so that is the respond now when we look at the stories of Scripture where we talk about how died how do you visited that I think of the woman at the well worth she said no we know that the Messiah is coming and Jesus simply says I speak to you and he are what a beautiful heart of that story and that is the story of the pool of Bethesda the response barely Jesus is arrive take up your Mac will so when we are taking care of those who are sick and suffering I think our ultimate goal is to help them look to Jesus and live so that's just an real brief summary of our whole person care model and Appalachian finish thank you Kathy so back to her thirty three -year-old gentlemen and we were rounding on for those of you that were here earlier this is a thirty three -year-old it is gone to Mexico gotten a severe case of gastroenteritis in return had done acute kidney injury we admitted him on the ward and I was rounding with my team four days later his creatinine was still rising and so we stood around his bed with him tearful I happen to be right next to him I put my hand on his shoulder and that this is fairly difficult I know and I could tell he was fairly embarrassed being a macho guy he has muscles that were no kind of out there and and crying was not exactly the persona he wanted to forgive him I said to be all right if I come back after rounds and talk with you little bit partly to my time hardly because I think we didn't want a lot of an audience of this point and so the team and I stepped out of the room I had to medical students to interns I believe the senior was off doing something else I think there was there were the five of us in weeks paused outside of his room and I said you know how we can approach this an interesting way to the students have been through the religion class religious path is clear model and one and spoke up and said well thinking through the clear model first connect to him many of us praying before we arrived here with and connected with God we've been connecting with this patient for the last for five days we know him pretty well he knows us we also needed to listen and as we thought about it you listening as Kathy very nicely said listening is not just with your ears with your eyes and he wasn't sobbing and dad but the tears were clearly running guys cheek and and so listening involves seeing that we could see that there was heard in his heart didn't he was in Albion as I mentioned earlier you knew what potentially was phasing in of his kidney failure continued progress and really didn't want dialysis and so we had listened to him but we felt like we needed to listen more we didn't quite understand what was behind those tears so that was one of the things that we needed to do and we went back and talk with them and then as we went on to explore you know we had gone around and around this medical condition we've done a CT and followed it up again after he was hydrated with the alters make her that he didn't have someone of instruction given the flank pain that he had we had taken a specimens urine and spun it down and looked at it that he has a few granular casts that I wasn't completely convinced that this was the cue to the necrosis I was a little worried about hemolytic uremic syndrome given the diarrhea and so forth yet didn't quite fit that well and so as the creatinine continued to rise we were we were thinking of biopsy so we haven't explored this medically exploring it spiritually we didn't quite feel like we had a handle on that we really didn't know what was behind those tears so forth so we needed to do some more exploring when he came to acknowledgment we had briefly acknowledged it on around said you know this is tough we realized we'd be emotional if this was our kidney function as well but that was kind of all we had done and felt probably there was more we could do there and then as far as response at this point we hadn't really done much in terms of response other than this they will be back so that I was kind of cool of the medical students brought this up on their own and and actually were quite excited to apply this model and so it turns out unfortunately the medical students had a conference redone with rounds and liver in the residence also as finance he came back by myself and I was able to explain to them what we did afterwards but I sat down at his bedside care and recap a little this he was in a little better spirits it wasn't crying anymore and seemed like he was eager to sort of get to the bottom of where we were going I I did a little more asked arrange found out part of his tears were in his cell phone battery had gone dead he didn't have a charger and he tried to find somebody in the floor that had a charger the phone in the room yes you could call a local call that he needed to make a long-distance phone call is particularly wanted to call his girlfriend down in Mexico and he couldn't do any of those things here he was in a medical crisis and he had no connection and that was a big issue i.e. I did a little bit more acknowledgment with them I made this told him you know I realize as a nurse you know kind of where this may be heading a over my I understand and I would be emotional about it and then responding I said let me see by complying somebody with the charger and unfortunately he was ambulatory and we took off the new my secretary had a cell phone similar to his went up to her office took his phone and sure enough she had she had a phone like his but unfortunately the charger wasn't the right side and buy food nor height and I have some of the other students around with nobody the charger so I told him just leave the phone with me let me see if I can figure this out and I had to go to brief meeting and then I took off to the store down the street and thought him a cell phone charger and brought it back to him just overwhelmed that I would even take the time to do that gave the phone back with the charger is and I immediately said no guy has some believe here and I sat down again with them he says that you know you're going through something pretty top when I am in trouble I always turn to God and wondered if you would mind if I is a prayer he does latched on me reached out grabbed my hand and we grade and he prayed and have just realized me talk about connection that's really where you finally connected with Craig and so that's kind of how we work through that clear model I sat down with the students and explain what we've done in clinical use and how it ended and the best part was the next day when I was arranging to your kidney biopsy on his creatinine started to come down and so God gave him healing we prayed for so we like to open it up to questions or comments to you all I think we got like ten more minutes or so any questions since certainly the goal of this limit is reiterated the comment it appears to be a model that is not only the nurses but the whole care team is involved in and you probably have a question or comment as he and he and okay so the question is how is it initiated in and where does it go to a the honeymooners in Florida and in the rest of the team picks up on it goes from there and I think all all answers and also let Kathy to talk some about it I think there are many levels at which this was developed for and not just for nurses for sure it was developed I think if nothing else in my context that allow us to teach a sort of a comprehensive approach to looking at a person not just medically but spiritually and so forth as well so in my contacts it just helps me remember as I'm interacting with the patient to think of all the different dimensions but absolutely it's also for the nurses to initiate then and I'll let Kathy is a nurse originally she's also got her Masters in clinical ministries over a letter talk about the nursing part in the whole shirt you me me give you to hang the spiritual assessment the soul model is done at Loma Linda on the nursing assessment so that's where that takes place in other people can look at that that's a very brief spiritual history so like I said this is just the very basics we would hope that Dan and other disciplines would look at data may be asked further questions if they want on the family medicine residency program is teaching all of their doctors to ask that sold assessment in their outpatient setting said they have that as a baseline so were trying to get it used in many many different settings and because were not telling anybody to ask the same questions it's more of just a general guideline and a set of questions because we don't expect it we don't want people asking the same questions over and over it's one of the concerns you don't want it to be just a checklist that you go down although the checklist is better than nothing but but ideally it would be something that sort of custom-made thank you for the question okay so the question is how do you distinguish between this and a behavioral method that Hugo medicine approach spiritual versus psychological maybe Kathy you are in all the discussions on what you speak I think means working for I don't I don't think what you want to differentiate downward were wanting to think about all of those areas as we do the whole person care and maybe I was working on my microphone didn't catch that reiterating well aware we are wanting in that connect please send one of our goals is to connect that patient to guide and certainly in my response he should be able to point them to Jesus and I think to me as as an internist out of the behavioral medicine person i.e. I would view anything that I knew her medications are the behavioral medicine content area context of a relationship with Jesus and if it's not it is not somehow hoping them understand more about God am I missing some of the core issues that so I'm thinking that it is hard to distinguish them because they do intermingle and Mashburn me the core of what I do ask me about Jesus and I think psychosocial and spiritual care very much interwoven at the core and you can do psychosocial care without spiritual care but I'm not sure you can do spiritual care renowned and psychosocial care combined with it and is now in okay so the question is who is being taught this model at Loma Linda and I believe as of this fall that it has gone out into all of the schools curriculums and so it's happening in Allied health dentistry dentistry I'm pretty sure they are already certainly we do first and second-year medical students I kept all the nursing students when they come in their first year so it's something now that has broadened out to the whole campus the first year medical students get a quite briefly in a class called orientations religion and medicine and we present a model Yahoo to go out and do a patient interview based on the model is within the first two weeks of their on-campus and that's really their first patient exposure as they are while they are doing two weeks of shadowing the clinical course and then the second year students have a class called the art and integrated here and during that and that whole quarter we spend talking about this model and we have about six or eight simulation labs where will bring in physicians and have been interview a patient and then will have the students do some role-playing an interview so that we can talk about how we implement this model and then once again they do another patient interview yes we're still in the provision she was asking whether it's going to be extended other residency program that I think that is still kind in the rollout phase than the monolith jazz we finally got the board approval I think last spring and it's been in this evolution process for a couple years where it gets once we started teaching it we realize there were maybe some little tweaks that we wanted to do with it and so now we're in the process said that whole education and getting out across campus and I think in a depending on the various residency programs will be working individually with them to figure out how that happens okay so he's asking whether they are the clear model would be in the initial encounter with the patient we actually believe the clear model can be used in every interaction actually works when Gemini talk with each other and at a editing you would do different parts of it at different encounters with the patient but if we go in with that model and acting listening exploring acknowledging and responding it happens all of the nine hundred and ninety one this media was using my audio verse four amen 's medical amendments are you going to learn more about the men please visit www. evenhandedness I will like to listen more free online certain www. money verse one


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