A. Marc Gillinov, MD

The traditional paradigm for cardiac care has emphasized the use of technology to treat disease. Our focus on technologies such as echocardiography, advanced imaging instrumentation, and cardiac catheterization mirrors the preoccupation of society as a whole with technologic advances.

Attention has only recently been given to the patient’s emotional experience and how this might relate to outcomes, recovery, and healing. An expanded paradigm of cardiac care incorporates pain relief, emotional support, spiritual healing, and a caring environment. These elements of patient-centered care aim to relieve stress and anxiety in order to achieve a better clinical outcome.

PATIENT-CENTERED CARE

The importance of patient-centered care is illustrated by the results of a 2007 survey in which 41% of patients cited elements of the patient experience as factors that most influenced their choice of hospital.¹ Accepted wisdom on patient choice has historically centered on medical factors such as clinical reputation, physician recommendations, and hospital location, each of which was cited by 18% to 21% of the patients surveyed. Elements of the patient experience cited in the study include stress-reducing factors such as the appearance of the room, ease of scheduling, an environment that supports family needs, convenience and comfort of common areas, on-time performance, and simple registration procedures.

Székely et al² found in a 4-year followup study that high levels of preoperative anxiety predicted greater mortality and cardiovascular morbidity following cardiac surgery. In a study by Tully et al,³ preoperative anxiety was also predictive of hospital readmission following cardiac surgery. Preoperative stress and anxiety are reliable predictors of postoperative distress.⁴

The variety and relative efficacy of interventions to reduce stress and anxiety are not well studied. Voss et al⁵ showed that cardiac surgery patients who were played soothing music experienced significantly reduced anxiety, pain, pain distress, and length of hospital stay. One Cleveland Clinic study of massage therapy, however, was unable to demonstrate a statistically significant therapeutic benefit, despite patient satisfaction with the therapy.⁶

THE ADVENT OF HEALING SERVICES

Identifying patients who exhibit significant preoperative stress and providing, as part of an expanded cardiac care paradigm, emotional care both pre- and postoperatively may ameliorate clinical outcomes. As such, the Heart and Vascular Institute at the Cleveland Clinic formed a healing services division, based on the concept that healing is more than simply physical recovery from a particular procedure. The division’s mission statement is: “To enhance the patient experience by promoting healing through a comprehensive set of coordinated services addressing the holistic needs of the patient.”

A healing services menu is offered to each patient (Table). Referral for these services can come from the patient, family, physicians, or nurses. Of the first 898 patients admitted for heart surgery who were offered healing services on the third or fourth postoperative day, 582 chose one or more of the services (average, 2.7 interventions; total interventions, 1,514), most frequently spiritual or holistic nursing care. Ninety-three percent of these patients felt the services were helpful, and 90% said that they would recommend them to others. A personal connection between the patient and family and caregivers fosters feelings of a healing partnership that lessens stress and anxiety.

At the Cleveland Clinic, healing services are now integrated with standard services to enhance the cardiac care paradigm. Our standard medical services focus on areas of communication and pain control, both of which affect anxiety and stress. The need for enhanced communication is significant: 75% of patients admitted to a Chicago hospital were unable to name a single doctor assigned to their care, and of the remaining 25%, only 40% of responders were correct.⁷

It is worth noting that communicating more information to a patient is not necessarily better. Patients given detailed preoperative information about their disease and the potential complications of their cardiac surgery had levels of preoperative, perioperative, and postoperative stress, anxiety, and depression similar to those who received routine medical information.^8,9 On the other hand, patients desire information about their postoperative plan of care while they are experiencing it, and value communication with physicians, nurses, healing services personnel, and other caregivers when it is presented in a calm and forthright manner. Communications should emphasize that the entire clinical team is there to help the patient get better.

THE FIFTH VITAL SIGN

Pain control is an aspect of care that was long ignored. The goal of the pain control task force at the Cleveland Clinic is the development of effective, efficient, and compassionate pain management.

The fifth vital sign, one that escapes the electronic medical record, can be addressed by this question: “How are you feeling?” Treating pain will reduce stress and anxiety. Before surgery, pain management priorities are discussed with patients, and at each daily encounter the goal is to set, refine, and exceed expectations for pain control through discussion and frequent pain assessments.

Reducing anxiety and stress is the goal of both standard care services and healing services, resulting in more satisfied patients with better clinical outcomes.

CASE: “YOU AND THE TEAM MADE ME GET OUTOF BED AND MOVE FORWARD”

Bobbi is a 78-year-old woman who was initially recovering well following cardiac surgery, including valve surgery, but had to return to the intensive care unit, which is difficult for patients. She was subsequently returned to the floor but was reluctant to walk and progressed slowly, despite normal electrocardiogram, radiographs, and blood panel results. We discovered that her husband was in hospice care in another state, causing Bobbi anxiety as she expressed concern over being her husband’s caregiver while being weakened physically herself. She was fearful of moving forward and her recovery stalled.

The primary care nurse referred her to the healing services team. The healing services team provided support for her anxiety and stress, and reviewed options for managing her husband’s care. She participated in Reiki, spiritual support, and social work services. During her admission her husband died, so the team provided appropriate support.

When asked about her experience upon leavingthe hospital, Bobbi did not mention her surgeon or the success of her heart valve procedure, but commented instead on the healing services team that enabled her to get through the experience.

The traditional paradigm for cardiac care has emphasized the use of technology to treat disease. Our focus on technologies such as echocardiography, advanced imaging instrumentation, and cardiac catheterization mirrors the preoccupation of society as a whole with technologic advances.

Attention has only recently been given to the patient’s emotional experience and how this might relate to outcomes, recovery, and healing. An expanded paradigm of cardiac care incorporates pain relief, emotional support, spiritual healing, and a caring environment. These elements of patient-centered care aim to relieve stress and anxiety in order to achieve a better clinical outcome.

PATIENT-CENTERED CARE

The importance of patient-centered care is illustrated by the results of a 2007 survey in which 41% of patients cited elements of the patient experience as factors that most influenced their choice of hospital.¹ Accepted wisdom on patient choice has historically centered on medical factors such as clinical reputation, physician recommendations, and hospital location, each of which was cited by 18% to 21% of the patients surveyed. Elements of the patient experience cited in the study include stress-reducing factors such as the appearance of the room, ease of scheduling, an environment that supports family needs, convenience and comfort of common areas, on-time performance, and simple registration procedures.

Székely et al² found in a 4-year followup study that high levels of preoperative anxiety predicted greater mortality and cardiovascular morbidity following cardiac surgery. In a study by Tully et al,³ preoperative anxiety was also predictive of hospital readmission following cardiac surgery. Preoperative stress and anxiety are reliable predictors of postoperative distress.⁴

The variety and relative efficacy of interventions to reduce stress and anxiety are not well studied. Voss et al⁵ showed that cardiac surgery patients who were played soothing music experienced significantly reduced anxiety, pain, pain distress, and length of hospital stay. One Cleveland Clinic study of massage therapy, however, was unable to demonstrate a statistically significant therapeutic benefit, despite patient satisfaction with the therapy.⁶

THE ADVENT OF HEALING SERVICES

Identifying patients who exhibit significant preoperative stress and providing, as part of an expanded cardiac care paradigm, emotional care both pre- and postoperatively may ameliorate clinical outcomes. As such, the Heart and Vascular Institute at the Cleveland Clinic formed a healing services division, based on the concept that healing is more than simply physical recovery from a particular procedure. The division’s mission statement is: “To enhance the patient experience by promoting healing through a comprehensive set of coordinated services addressing the holistic needs of the patient.”

A healing services menu is offered to each patient (Table). Referral for these services can come from the patient, family, physicians, or nurses. Of the first 898 patients admitted for heart surgery who were offered healing services on the third or fourth postoperative day, 582 chose one or more of the services (average, 2.7 interventions; total interventions, 1,514), most frequently spiritual or holistic nursing care. Ninety-three percent of these patients felt the services were helpful, and 90% said that they would recommend them to others. A personal connection between the patient and family and caregivers fosters feelings of a healing partnership that lessens stress and anxiety.

At the Cleveland Clinic, healing services are now integrated with standard services to enhance the cardiac care paradigm. Our standard medical services focus on areas of communication and pain control, both of which affect anxiety and stress. The need for enhanced communication is significant: 75% of patients admitted to a Chicago hospital were unable to name a single doctor assigned to their care, and of the remaining 25%, only 40% of responders were correct.⁷

It is worth noting that communicating more information to a patient is not necessarily better. Patients given detailed preoperative information about their disease and the potential complications of their cardiac surgery had levels of preoperative, perioperative, and postoperative stress, anxiety, and depression similar to those who received routine medical information.^8,9 On the other hand, patients desire information about their postoperative plan of care while they are experiencing it, and value communication with physicians, nurses, healing services personnel, and other caregivers when it is presented in a calm and forthright manner. Communications should emphasize that the entire clinical team is there to help the patient get better.

THE FIFTH VITAL SIGN

Pain control is an aspect of care that was long ignored. The goal of the pain control task force at the Cleveland Clinic is the development of effective, efficient, and compassionate pain management.

The fifth vital sign, one that escapes the electronic medical record, can be addressed by this question: “How are you feeling?” Treating pain will reduce stress and anxiety. Before surgery, pain management priorities are discussed with patients, and at each daily encounter the goal is to set, refine, and exceed expectations for pain control through discussion and frequent pain assessments.

Reducing anxiety and stress is the goal of both standard care services and healing services, resulting in more satisfied patients with better clinical outcomes.

CASE: “YOU AND THE TEAM MADE ME GET OUTOF BED AND MOVE FORWARD”

Bobbi is a 78-year-old woman who was initially recovering well following cardiac surgery, including valve surgery, but had to return to the intensive care unit, which is difficult for patients. She was subsequently returned to the floor but was reluctant to walk and progressed slowly, despite normal electrocardiogram, radiographs, and blood panel results. We discovered that her husband was in hospice care in another state, causing Bobbi anxiety as she expressed concern over being her husband’s caregiver while being weakened physically herself. She was fearful of moving forward and her recovery stalled.

The primary care nurse referred her to the healing services team. The healing services team provided support for her anxiety and stress, and reviewed options for managing her husband’s care. She participated in Reiki, spiritual support, and social work services. During her admission her husband died, so the team provided appropriate support.

When asked about her experience upon leavingthe hospital, Bobbi did not mention her surgeon or the success of her heart valve procedure, but commented instead on the healing services team that enabled her to get through the experience.

The traditional paradigm for cardiac care has emphasized the use of technology to treat disease. Our focus on technologies such as echocardiography, advanced imaging instrumentation, and cardiac catheterization mirrors the preoccupation of society as a whole with technologic advances.

Attention has only recently been given to the patient’s emotional experience and how this might relate to outcomes, recovery, and healing. An expanded paradigm of cardiac care incorporates pain relief, emotional support, spiritual healing, and a caring environment. These elements of patient-centered care aim to relieve stress and anxiety in order to achieve a better clinical outcome.

PATIENT-CENTERED CARE

The importance of patient-centered care is illustrated by the results of a 2007 survey in which 41% of patients cited elements of the patient experience as factors that most influenced their choice of hospital.¹ Accepted wisdom on patient choice has historically centered on medical factors such as clinical reputation, physician recommendations, and hospital location, each of which was cited by 18% to 21% of the patients surveyed. Elements of the patient experience cited in the study include stress-reducing factors such as the appearance of the room, ease of scheduling, an environment that supports family needs, convenience and comfort of common areas, on-time performance, and simple registration procedures.

Székely et al² found in a 4-year followup study that high levels of preoperative anxiety predicted greater mortality and cardiovascular morbidity following cardiac surgery. In a study by Tully et al,³ preoperative anxiety was also predictive of hospital readmission following cardiac surgery. Preoperative stress and anxiety are reliable predictors of postoperative distress.⁴

The variety and relative efficacy of interventions to reduce stress and anxiety are not well studied. Voss et al⁵ showed that cardiac surgery patients who were played soothing music experienced significantly reduced anxiety, pain, pain distress, and length of hospital stay. One Cleveland Clinic study of massage therapy, however, was unable to demonstrate a statistically significant therapeutic benefit, despite patient satisfaction with the therapy.⁶

THE ADVENT OF HEALING SERVICES

Identifying patients who exhibit significant preoperative stress and providing, as part of an expanded cardiac care paradigm, emotional care both pre- and postoperatively may ameliorate clinical outcomes. As such, the Heart and Vascular Institute at the Cleveland Clinic formed a healing services division, based on the concept that healing is more than simply physical recovery from a particular procedure. The division’s mission statement is: “To enhance the patient experience by promoting healing through a comprehensive set of coordinated services addressing the holistic needs of the patient.”

A healing services menu is offered to each patient (Table). Referral for these services can come from the patient, family, physicians, or nurses. Of the first 898 patients admitted for heart surgery who were offered healing services on the third or fourth postoperative day, 582 chose one or more of the services (average, 2.7 interventions; total interventions, 1,514), most frequently spiritual or holistic nursing care. Ninety-three percent of these patients felt the services were helpful, and 90% said that they would recommend them to others. A personal connection between the patient and family and caregivers fosters feelings of a healing partnership that lessens stress and anxiety.

At the Cleveland Clinic, healing services are now integrated with standard services to enhance the cardiac care paradigm. Our standard medical services focus on areas of communication and pain control, both of which affect anxiety and stress. The need for enhanced communication is significant: 75% of patients admitted to a Chicago hospital were unable to name a single doctor assigned to their care, and of the remaining 25%, only 40% of responders were correct.⁷

It is worth noting that communicating more information to a patient is not necessarily better. Patients given detailed preoperative information about their disease and the potential complications of their cardiac surgery had levels of preoperative, perioperative, and postoperative stress, anxiety, and depression similar to those who received routine medical information.^8,9 On the other hand, patients desire information about their postoperative plan of care while they are experiencing it, and value communication with physicians, nurses, healing services personnel, and other caregivers when it is presented in a calm and forthright manner. Communications should emphasize that the entire clinical team is there to help the patient get better.

THE FIFTH VITAL SIGN

Pain control is an aspect of care that was long ignored. The goal of the pain control task force at the Cleveland Clinic is the development of effective, efficient, and compassionate pain management.

The fifth vital sign, one that escapes the electronic medical record, can be addressed by this question: “How are you feeling?” Treating pain will reduce stress and anxiety. Before surgery, pain management priorities are discussed with patients, and at each daily encounter the goal is to set, refine, and exceed expectations for pain control through discussion and frequent pain assessments.

Reducing anxiety and stress is the goal of both standard care services and healing services, resulting in more satisfied patients with better clinical outcomes.

CASE: “YOU AND THE TEAM MADE ME GET OUTOF BED AND MOVE FORWARD”

Bobbi is a 78-year-old woman who was initially recovering well following cardiac surgery, including valve surgery, but had to return to the intensive care unit, which is difficult for patients. She was subsequently returned to the floor but was reluctant to walk and progressed slowly, despite normal electrocardiogram, radiographs, and blood panel results. We discovered that her husband was in hospice care in another state, causing Bobbi anxiety as she expressed concern over being her husband’s caregiver while being weakened physically herself. She was fearful of moving forward and her recovery stalled.

The primary care nurse referred her to the healing services team. The healing services team provided support for her anxiety and stress, and reviewed options for managing her husband’s care. She participated in Reiki, spiritual support, and social work services. During her admission her husband died, so the team provided appropriate support.

When asked about her experience upon leavingthe hospital, Bobbi did not mention her surgeon or the success of her heart valve procedure, but commented instead on the healing services team that enabled her to get through the experience.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.