First, a story.
Nearly 20 years ago, a close colleague in seeking to bring multifactorial integrative practices into conventional medical delivery was Eileen Stuart-Shor, PhD, ANP-BC, at Harvard Beth-Israel. Stuart was then working with Herbert Benson, MD, one of the pioneers in mind-body medicine research. Benson had worked since the late 1970s on the “relaxation response” —a translation of transcendental meditation into a Western model that didn’t threaten fundamentalists. His research was helping break medicine’s then prevalent denial of a link between mind and body, between emotions and physical health.
Stuart’s chief work with Benson—which led to co-authoring the breakthrough 1993 The Wellness Book—was in translating Benson’s findings into practical, multifactorial programs for delivering these mind-body services to populations. Stuart led research and reported the often strikingly positive outcomes at cardiology meetings worldwide. The touchy-feely, whole person approach was quite out-of-the-box, particularly in that day.
“If the outcomes were from a drug, they’d be flocking around me”
One evening following an effort on which Stuart and I were consulting to interest a Portland, Oregon hospital in the program, she shared an insightful frustration. She’d recently presented terrific results before a large audience of cardiologists. Almost no one came up to her afterward with questions, or for more information. She said, “If our outcomes had come from a drug, they’d have been flocking around me.”
This memory came to mind not long ago when a team from what is now the Benson-Henry Institute for Mind-Body Medicine at Massachusetts General Hospital published dramatic results of a new study of what they now term the Relaxation Response Resiliency Program. They examined the impact on service utilization in those using the intervention.
Perhaps more powerful than the startling outcomes was a “policy recommendation” the research team tagged on at the end. The present state of our medical industry and the recent British Medical Journal report on medical deaths suggest we should be flocking to each.
The astonishing outcomes were these: the retrospective analysis of over 4,000 patients who’d used the program, compared to those with regular care, showed a whopping 43% reduction in service utilization. The findings held across multiple fields: clinical encounters (41.9%), imaging (50.3%), lab encounters (43.5%), procedures (21%) and emergency room visits by over 50%.
Imagine if those outcomes—to recall Stuart-Shor’s conjecture—had come from a drug!
Consider the media headlines, the television deluge, the magazine inserts—the John Oliver spoof!—the interruptions of our pleasure in the violence of a football game by the sight of people learning to breathe— and to stop, to look, to listen.
These potentially profound economic impacts are linked to decades of clinical research findings via the Benson-Henry program and a similar one, founded by Jon Kabat-Zinn, PhD, called Mindfulness-Based Stress Reduction. Studies have found effectiveness across a broad range of markers: “reducing and managing the clinical manifestations of stress, reducing anxiety, and increasing patients’ resiliency.” In addition, the Benson-Henry program “has demonstrated its effectiveness in reducing the need for chronic pain therapy, improving cardiovascular parameters, improving of anxiety and chronic stress, menopausal symptoms, and promoting positive health behaviors.”
In the case of the Benson-Henry program, the clinical intervention includes, in the words of lead investigator James Stahl, MD, CM, MPH, now at Dartmouth Giesel School of Medicine: medical practice, cognitive appraisal and restructuring, positive psychology, yoga, resiliency training and “tools like humor.” I asked Stahl about the seemingly incredible economic finding of 43% reduction. He laughed: “The paper was delayed five or six months because I was checking. The signal was so large.”
An intriguing initiative for population-based outcomes
What part of the Triple Aim is not furthered by these outcomes? The power of the findings convinced the researchers to conclude the article with the remarkable recommendation that stimulated this column. I include it in full, adding only the bolding.
“The data suggests that the intervention should be applied to all at risk populations, since the intervention has minimal risk, minimal cost and yields substantial benefits for patients with a wide variety of illnesses. The long-term effect of these interventions on healthy populations is unclear, but the data suggests that mind-body interventions should perhaps be instituted as a form of preventative care similar to vaccinations or driver education. Such interventions are likely to be useful in population management and supported self-care, have negligible risk and cost and may help reduce the demand curve in healthcare. While the risk benefit ratio of this intervention is very favorable to further elucidate the effect size a prospective evaluation is called for.”
Stahl has no hesitancy about the potential vaccination-like public health benefit from spreading such mind-body programs as broadly as possible: “There’s no significant debate about it. It’s rather obvious. This is a set of tools that prepares people for stress and strain of life and protects them from future injury. This shows that prevention is not only drugs.”
The leg of Triple Aim that is less certain is how to scale up from groups of patients to influencing population health outcomes. The team is attacking this in a variety of ways. They are looking, as Stahl said, “at the minimal dose that is effective and durable.” Best data suggests an eight-week program, with social support. The Institute is looking at a train-the-trainers program. A certificate program is under consideration.
The Benson-Henry medical director, Darshan Mehta, MD, MPH shared that plans for a prospective study are well under way.
Stahl is not waiting on further research. As the physician responsible for all general medicine people in the Dartmouth system in New Hampshire and Southern Vermont, he has a network for delivering services. The first population target may be employees, for which the program will be paid through their health benefit package. He sees the health benefit that plans are required to have under the Affordable Care Act as a payment vehicle for spreading the program.
Proliferation through school programs?
Mehta shared that the program’s profile has definitely ascended the ladder of influence inside the Institute’s parent organization: “As a consequence of the paper, we are thrown into the mix.” Work is very active internally, with the program manualized and the “very clear training pathway, with certification,” in development.
The finding arrives in an interesting moment. A growing network of professionals are spreading a grassroots movement to bring mindfulness into schools. At the National Institutes of Health National Center for Complementary and Integrative Health, a new draft strategic plan has prioritized research opportunities “to study and assess the safety and efficacy of complementary health approaches in non-clinical settings such as community- and employer-based wellness programs.”
Might the schools be a target? My first encounter with mindfulness in schools was through a federally-funded pilot project developed by then wellness entrepreneur Peter Amato for the Scranton, Pennsylvania area. A documentary video shares a clip of a young girl who’d had some training, about to fight with her sister, taking a moment to pull back and breathe. And then a young man into whom I fully projected my 10-year-old-self, on the mound, runners on base—definitive high stress! —also telling himself to breathe.
Part of “radical redesign”?
Think of these bruising, whole-system challenges. Over-medication of our youth and of our seniors. Chronic stress and burnout in multiple populations. The sucking sounds of the opioid crisis and of medical cost escalation that suppress investment in the community health. The Benson-Henry mindfulness program’s outcomes may reasonably be asserted, or postulated, to help us with each.
In his powerful plenary to the Institute for Healthcare Improvement two years ago, the Institute’s co-founder Don Berwick, MD, MPP, opined that “the pursuit of health, the creation of health, may require something even bolder [than interprofessionalism, accountable care and the Triple Aim]. The redesign we need may be even more radical than we have imagined.”
The Benson-Henry team has teed this solution up for us. It’s time to start flocking around these outcomes, and the research teams’ recommendations.