Podcast: Treating the whole patient all at once

Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri … the Show-Me State. During the first two years that we produced this podcast, we focused entirely on how School of Medicine doctors, researchers and trainees responded to the COVID-19 pandemic. Now, as the pandemic, we hope, is receding just a little, we also are reporting on some of the other research, lifesaving and just plain cool work being done at the School of Medicine. In this episode: lifestyle medicine. The Washington University Living Well Center is one of the first in the country to apply lifestyle medicine in people with musculoskeletal problems — that is, problems involving the muscles, bones, ligaments and tendons. Dr. Devyani Hunt is the center’s medical director.

Devyani Hunt, MD: There are a few, actually a good number, of centers like this that focus on obesity medicine or cancer or diabetes, actually even cardiovascular disease. However, on the musculoskeletal side of things, we are probably one of the first that brings all of this together in an intensive, interdisciplinary program.

Dryden: The idea is to use techniques from counseling to physical therapy, from dietary changes to massage, to make it more likely a person will have a successful outcome when treated for a problem with the bones, the muscles or other connective tissue. Problems like a bad back, an arthritic hip or a painful knee. The idea was launched almost a decade ago by one of Hunt’s mentors, former Washington University physical medicine and rehabilitation specialist Dr. Heidi Prather, who helped design the concepts for the Living Well Center based on the idea that if a person is scheduled to, say, have a hip replacement, but he or she also is a smoker, the specialists at the center might be able to work to help that person kick the habit prior to surgery. The reason is that it’s known that quitting smoking makes it more likely the surgery will be successful. And Devyani Hunt says the developing field of lifestyle medicine attempts to address the root causes of medical problems by focusing on lifestyle choices that affect health.

Hunt: Patients who come to the center have a combination of musculoskeletal conditions and comorbidities. Our team — which is comprised of a physiatrist, a dietitian, psychologist, rehabilitation counselor, massage therapist, acupuncturist, physician assistant — they actually apply the six pillars of lifestyle medicine to address these issues. So those pillars include using food as medicine; exercise as medicine; really addressing any sleep issues, which we know can be the foundation of good health; managing stress and addressing anxiety and depression, which can kind of be confounded in people that have pain. Behavioral health is another pillar, and that is focused on managing stress and then also supporting relationships in the community. And that’s why we have such a beautiful gathering area, where we have a teaching kitchen as well as a community space because we know that the literature will tell us that if we don’t do it as a whole and as a community, it just doesn’t sit in, and people don’t have ability to move forward as well.

Dryden: Specialists like Deyani Hunt help people adjust their behavior in ways that might lower inflammation in the body or assist in losing weight or better control diabetes. All of those things make it more likely that patients either will have a better outcome after surgery or perhaps even avoid surgery altogether.

(audio of Hunt at an appointment with a patient)

Dryden: One of Hunt’s patients is a man named Zach Wood. His route to the Living Well Center began in an emergency room. He has a rare autoimmune disease known as mixed connective tissue disease, a fact that eventually got him referred to Washington University specialists who then referred him to the Living Well Center.

Wood: My left side was having severe symptoms, and so they took me into the ER, and I was admitted immediately. They imaged it, so they were like, “You need back surgery, but not emergency spinal surgery.” And then I was told by the spinal surgeon, “You don’t have a spinal problem. You probably should go see a hip surgeon.” Saw the hip surgeon, and he’s like, “OK, here’s your problem: musculoskeletal problem. And we know that it’s impacted by this rare autoimmune disease that you have, so let’s talk about how we might approach it.” And so a nonsurgical option was great for me, and I had the good fortune of being referred here from that hip surgeon.

Dryden: So is the goal to avoid surgery altogether or to get your body ready for a hip surgery in the future?

Wood: Yes. Both/and. I think that, yeah, initially, I thought it might be preparatory, and now I feel like it’s preventative, and I am pretty confident in the work that has been done through the coordinated efforts of the Living Well Center.

Hunt: Zach has been fantastic to work with. He is actually the perfect example of a patient that can really benefit from this interdisciplinary approach.

Dryden: Again, the center’s medical director, Dr. Devyani Hunt.

Hunt: So, Zach came to me, actually, from one of my hip colleagues. He had a hip problem that turned out to not quite be a surgical issue but needed a little bit more of a kind of whole-body approach. His underlying issue, even though he has a hip disorder, general connective tissue disorder, general inflammation, things of that nature. So if we can address those things from the perspective of decreasing inflammation, of really understanding the impact of a connective tissue problem and how using multiple disciplines such as acupuncture and massage can make a huge difference in decreasing pain, which then improves function. So he’s been able to take advantage of all of the disciplines within the Living Well Center. And when a patient like Zach comes in, it’s almost like all these lightbulbs and excitement go off because we know that we can make an impactful difference in their life. And one of the first things that we did with Zach was to have him talk to our behavioral health counselor to set some goals and do kind of a deep dive into where he is and where he wants to be and how to get there. And so once we have that, then we plug in all the different disciplines that could be helpful. He was also able to work closely with our registered dietitian, Nartana Mehta, and her approach is a little bit unique in dietary counseling as she really focuses on the impact of inflammation and how to decrease inflammation. One of her first sessions she does with patients is to talk about the microbiome and how that actually can be very powerful in decreasing inflammation and really improving health overall.

Dryden: In his individual case, one of the things he told me was that he came thinking he was getting his body prepared to have surgery, and he has since decided, well, no, he can be maintained and improved without having to have the operation. How common is something like that when a patient comes to you?

Hunt: That’s a great point. I have actually talked to my surgical colleagues about this. So as you know, we are in the orthopedic department, orthopedic surgery department, and one of our main goals is to optimize people to surgery. And you would think that when patients come in and tell us their goals, that we would know are they going to be on the side of optimizing to surgery or possibly optimizing away to surgery? And you think that would be a pretty black-and-white question. However, as time has gone on, it actually turns into a little bit of a gray place because yes, if you have to have surgery, people want to be able to be optimized to it. But if you’re getting so good that you don’t need surgery, then the actual goal changes, and we have been able to optimize patients away from surgery.

Dryden: You’re in the Department of Orthopaedic Surgery, but it’s really combining expertise from all sorts of areas of the School of Medicine and the hospitals. Do you have a count on how many departments are actually involved?

Hunt: We’ve been reaching out and have collaborated with a good number of them. I’m not sure if I actually do have a count for you, but I can give you a few of the examples. Some of our collaborations include the Care Clinic, which is the COVID clinic for long-haulers and associated issues. We’ve been able to collaborate with them. We actually have a post-COVID track, where patients who come in again with a musculoskeletal problem associated with long-term COVID complications. The most common is fatigue, joint pains and such. We also are collaborating with the young-onset colorectal cancer group. We collaborate with the breast-cancer group as well. Cancer survivorship is one of our tracks. Another great collaboration has been with our partners in physical therapy and massage program at Barnes-Jewish in the STAR facility. They’ve been instrumental in pushing forward some of these opportunities that aren’t always readily available. And it’s been instrumental in allowing patients to kind of move forward with some of their musculoskeletal issues.

Dryden: And again, I know every patient is different, but when a patient comes through the door at the Living Well Center, what’s the goal?

Hunt: The typical goal in a patient that comes to Living Well Center is a functional goal. So many patients, we’ll ask them, “What’s your main goal?” It’s actually one of our main questions. We have a slew of questions that we ask at our consultation. And I know that in some ways, that’s a little bit of a burden for patients as they come through, but it really allows us to understand what their goal is and allows us to know if they have the tools to be successful. A few of the questions that we also ask are patient-activation measures, resiliency. Are you ready to make a change is one of the main things that we want to gather from the first consultation. And so typical goals can be, “I want to be able to walk up the stairs with my grandchildren.” “I want to be able to hike a mile in Yosemite.” But then there’s also goals of, “I want to lose 30 pounds so that I can have surgery on my knee.” It could be, “I need to get my hemoglobin A1C under 7 so that I can optimize to a surgery on my foot.” We also have patients that come in with a goal of general health care, or health optimization is the track that we call it. And so that’s a patient that maybe has more of an exercise or activity goal, higher level, could be a triathlete that they have maybe a chronic knee problem that has not really been available to be addressed in a typical clinic. But when you put all of the disciplines together, and they get acupuncture and massage, and they also work on decreasing their inflammation with the food that they eat, then you start to see a difference.

Dryden: Some patients treated at the Living Well Center do have surgery, too. We spoke to Genny Watkins one morning not long ago while she was getting some postoperative physical therapy from physical therapist Matthew Foster. Not long ago, Watkins had a complicated operation on her lower leg that involved stabilizing her ankle and lengthening her Achilles tendon. Her surgeon, Dr. Jonathan Backus, had recommended she check out the Living Well Center before the operation and before the many weeks afterwards when she wouldn’t be able to put any weight on her leg.

(audio of Genny Watkins during an appointment in physical therapy)

Genny Watkins: I was going for several reasons. One is I wanted to lose some weight, so I knew that they could help me with some behavior modification. And they also promote a plant-based eating schedule or diet, if you will. And so I did that a couple times a week and found that very beneficial. And then also just the trauma of having surgery. I have a disability anyway, an incomplete spinal cord injury. So to be immobile for that period of time, I knew it was going to be very stressful, and so they helped me find a good psychologist and start that sort of treatment also before surgery. And then my BMI went down. I lost 12 pounds. I took a class, a Zoom class, with them on behavioral modification and met some other great people through the Living Well Center. So it really got me through a challenging surgery.

Dryden: The center’s medical director, Devyani Hunt, says that as a physical medicine and rehabilitation specialist, she’s often looking for connections. A bad hip might cause back pain. Weak muscles in one part of the body might lead to pain in another part. And she says the Living Well Center works to enhance overall health by focusing on connections, not just between muscles and pain, but between what a person eats and how that person feels, as well as how that person’s blood sugar levels might affect things like wound healing after an operation.

Hunt: The best thing about it is that we see change. We see patients improve, and we see this kind of transformation in their lives to a place where they are actually healthier and that they have the tools for long-term success. So, you know, we all went into medicine to help people. It sometimes gets a little bit frustrating when you can only offer them so much and that there’s no way to address the other barriers to their success. We want to see them before and actually give preventive care or actual health care and not sick care. As a provider, we get fulfillment in seeing that, but also in the camaraderie. So through COVID, of course, we all get siloed, even more than what we are usually. And having that ability to collaborate, having the physician assistant, Molly, next door to me, and the dietitian and the physical therapist and the massage therapist and the psychologist, all of them within walking distance, and just a slight knock on the door to discuss a patient or to collaborate or to be excited about an outcome, if you can share that in a day and really kind of rejoice in it, as a physician, I have so much more satisfaction. Burnout is real, and this really adds to our day-to-day enjoyment of what we do.

Dryden: Hunt is one of several health-care professionals involved at the Living Well Center, all with one goal: to provide personalized care so that people with orthopedic injuries, cancer survivors, long-COVID patients, and others can employ lifestyle medicine techniques — such as diets that lower inflammation and therapies that lower stress and get patients more involved in managing their own health — to improve outcomes. More than 800 patients have been treated at the center in recent years, and the data suggest that for many, the approach seems to be working.

“Show Me the Science” is a production of WashU Medicine Marketing and Communications. The goal of this project is to introduce you to the ground-breaking research, lifesaving, and just plain cool work being done by faculty staff and students at the School of Medicine. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thanks for tuning in. I’m Jim Dryden. Stay safe.