Practice Spotlight: Michael Jeremiah, MD
Lifestyle Medicine in action in a rural, Family Practice residency program.
Michael Jeremiah, M.D. has been working to blaze a trail in the application and teaching of lifestyle medicine in a Family Practice residency setting. He is also proving that lifestyle medicine can be implemented in a challenging setting and with challenging patients.
He currently serves as the medical director of the Carilion Clinic Family Medicine Residency Program in Roanoke, Virginia, where he has served on the faculty since 1995. He is also an Associate Professor at the VTC School of Medicine. Their group cares for approximately 11,000 patients between two practices and covers the full scope of patients from birth to death. Ob/Gyn and full-spectrum hospital services are part of their training and services. The patient payer mix is approximately 35% Medicaid, 15% uninsured, and a quarter each of Medicare and commercial insurances.
Dr. Jeremiah says:
“I would describe myself as a relatively recent student and practitioner of lifestyle medicine. I've always had an interest in behavior and how to find ways to improve the skills of our residents in helping their patients to facilitate lasting change. This interest, along with a strong family history of heart disease, set the stage for my introduction to lifestyle medicine.”
“In 2004, a psychology colleague had been asking our residents to read The China Study by T Colin Campbell. My wife and I read the book along with Diet For A New America by John Robbins and our perspectives on nutrition and the food industry were forever changed. I became a strict vegetarian and personally experienced the benefits that so many others have of weight loss and improvements in cholesterol. Around that same time I met John Kelly on a return plane trip and learned about the start of ACLM and the community of people dedicated to tackle the roots of chronic disease in this country.”
Journey in Lifestyle Medicine
Early on Dr. Jeremiah attended a CHIP training program with Hans Diehl in Rockford, Illinois with three of his colleagues and coworkers. The rest of the team attending this conference included another family practice physician, the group's lead nurse, and an administrative support person. They set about to put into practice what they had learned and conducted a CHIP intervention program for patients with type II diabetes at one of their centers, seeing significant improvements in fasting blood sugar, weight loss, and lipid levels. This program was paid for with funds from a foundation grant and conducted in partnership with John Kelly, MD (ACLM’s founding President). It was done as a study, particularly looking to see if patients still got good results even if they got the program for free. They found the cost did not change the good results typically received from the CHIP program.
Dr. Jeremiah has created and coordinates a rotation in Lifestyle Medicine for the residents. This is an elective that is usually done by those who choose it in the third year of residency and is four weeks in duration. Sometimes they will participate in an ongoing CHIP program, sometimes they will participate with long-term CHIP groups, and sometimes they will work on clarifying how they plan to apply the competencies of lifestyle medicine they have developed internally. Dr. Jeremiah also conducts lifestyle medicine workshops on a regular basis for all of the residents.
The residency has conducted two regional lifestyle medicine conferences with speakers including T Colin Campbell, Caldwell Esselstyn, Hans Diehl, John Kelly, and Neal Barnard.
Dr. Jeremiah and colleagues have worked with representatives from three other family medicine residency programs around the country to create an initial set of lifestyle medicine competencies for family practice training programs. These collaborators include: Wayne Dysinger at Loma Linda University, George Guthrie at the Florida Hospital family residency program, and Kathleen Jones who was with a family practice residency in Colorado. He presented the work on these competencies at the annual meeting of the American College of Preventive Medicine February, 2010 and has submitted a paper for publication on these competencies to “Family Medicine”. Dr. Jeremiah notes that currently in the Family Practice world organizational structure there are only clinical categories of "preventive” and “nutrition” but not what we would understand to be a comprehensive and practical understanding of lifestyle medicine.
His latest venture is pursuing training in health coaching. He recently completed the foundation training in integrative health coaching at Duke's Integrative Medicine Center. He believes there is much greater effectiveness from a “coaching” approach to lifestyle changes rather than approaches that rely too heavily on “advice” or “education.” What’s the difference? There are many differences, but some of the key points include: a truly nonjudgmental attitude, a patient-driven agenda, and very specific goal setting processes.
Clinical Application
Clinically, practice involves direct patient care twice a week and precepting resident’s care 3 to 5 times a week. Every day they see many opportunities for both prevention and intervention of chronic disease with lifestyle approaches. While Dr. Jeremiah’s approach continues to develop, it generally includes the following:
• Assessing whether the patient is open to change (Where are they in the stages of change?)
• Asking questions to see how knowledgeable the patient is about the underlying causes of their chronic conditions.
• Maintaining a truly nonjudgmental approach. This being quite different from an “advice” or “shaming” approach, which is more typical but very ineffective.
• Working to increase lifestyle awareness with such things as food diaries, recommended reading, and other materials and handouts.
• Setting one or more specific goals as they are ready for them.
• And constantly looking for opportunities to provide support and reinforcement.
Administrative Application
Like most physicians, Dr. Jeremiah and his colleagues struggle with how to incorporate elements of lifestyle medicine into a typical 15 min. visit. They have the additional challenge of making sure that the residents are continuing to learn and grow in their knowledge and skills in the process of providing necessary medical care. They've also had to struggle with the fact that many of their patients are underinsured or completely uninsured and are often living on inexpensive and unhealthful foods. Some of the specific administrative things that have helped them deal some of these barriers include:
• A transition to a primary care medical home model has prompted a formal review of what they have been doing well and what needs improvement. A collaborative process of working with faculty, residents, staff, and administration to solve problems together has been very helpful. In his role as medical director this transition has taken a large amount of his focus for the past 18 months, but has been very productive.
• A medical record system that allows improved communication between the outpatient and inpatient settings, as well as bridging some of the divide between primary care and specialty providers has facilitated better coordination of care. They are able to look for improvement opportunities, especially after ER visits or hospitalizations. One EHR feature that they are finding particularly useful for lifestyle medicine is that part which allows direct electronic communication with patients. This allows them to ask questions and provide updates on their change goals. There is not much in the system that is structured specifically for lifestyle medicine, but Dr. Jeremiah is finding it quite helpful for tracking lifestyle changes and associated numbers.
• They now have "care coordinators." This is a new role for a specially trained nurse to call and meet with patients after hospitalizations and with patients with poorly controlled medical conditions. This nurse can work with patients to look for surmountable barriers to their healthcare and help them overcome them.
Pearls
So what are some “pearls” of wisdom learned in this process?:
• “Never assume you know why a person has been successful or not successful in making lasting changes. You must ask and learn.”
• “Our medical education system is biased to prescribed medications and/or do procedures.” This approach does not address the cause of the problem.
• Change occurs most effectively in a continuing relationship with a provider built on trust and caring.
• The only “universal” approach needed by all patients is that they need a good listener and encouragement. Beyond this there is no “one size fits all”. Some need structure, some need the power of a group, some need educational prescriptions, etc. Find what each individual needs.
• Patients like to know their numbers. For example, the “ABCs” of diabetes (hemoglobin A1C, blood pressure and BMI, cholesterol).
• "Check vitamin D levels!” Many people are deficient in vitamin D.
The Future
Plans for the next year include a third regional conference in lifestyle medicine to be held October 7 & 8, 2011. Dr. Jeremiah plans to implement health coaching approaches in his own patient care as well as into the education of their residents and students. He will continue to look for ways to enhance and expand the educational experiences in lifestyle medicine for those they teach. They also plan to create group visit processes that will rely heavily on lifestyle medicine principles.
Thank you Michael for your passion, efforts, and continued work in the development of lifestyle medicine. And thank-you for demonstrating that lifestyle medicine can, in fact, be implemented in less than ideal circumstances.
ACLM Disclaimer: Our Practice Spotlights are intended to provide examples of Lifestyle medicine in practice. We recognize that Lifestyle Medicine practices vary widely, and inclusion in Practice Spotlight is not intended to imply official endorsement of individuals or practices.
