"Discontent is the first necessity of progress" - Thomas Edison
By ACLM Member Megan L. Grega, MD
Co-Founder, Chief Medical Officer Kellyn Foundation
Though I followed the traditional path into medicine by studying biochemistry, doing cancer research, attending an Ivy League medical school, and racking up all the required honors and certifications necessary to practice medicine in 21stcentury America, what I really wanted to be was a Shaman. The idea of caring for the physical, mental, emotional and spiritual health of a community was what drew me into medicine. Coming from a family of teachers and accountants, I had no idea what the logistics of medical practice entailed; but I knew that I wanted to spend my life as a healer. In medical school, much to the chagrin of the majority of my academic mentors, I decided to pursue Family Medicine as my career path, figuring it was the closest thing to a modern day shaman that can be found in healthcare today. I became a Board Certified Family Doc and have practiced in several settings over the past 17 years, including military medicine, hospital-employed practice, college health and community medicine.
In the early years of my career I rapidly became a relatively discontented clinician. Not in a grumpy, morose sort of way; but in a constantly asking “WHY NOT” kind of way. I loved my patients, and became increasingly frustrated with my inability to spend the time I felt necessary to support them in making lifestyle changes that would have a much bigger impact on their health and vitality than the prescriptions I was providing at every 10-15 minute follow-up visit. Childhood obesity has been an especially intense interest of mine. It is shocking to me that the percentage of overweight American children has more than tripled over the past three decades, along with an alarming decrease in their cardiovascular fitness and endurance, yet we remain relatively laissez-faire as a society about this emerging health crisis for our kids.
In my clinical practice I saw many children who were well on their way to a lifetime of chronic disease due to their weight and their lifestyle choices. I spoke with our hospital administrators about what services we could provide to change the health trajectory of these kids. Sadly, the answer was “Until they have a billable diagnosis like hypertension, diabetes or hyperlipidemia we cannot refer them for nutrition counseling or provide regular follow-up visits in our office other than their yearly health maintenance checks”. I addressed issues related to nutrition, sleep, exercise, screen time and social connection at every visit, but the infrequent contact resulted in little impact for most patients. My discontent was growing, and I realized in my quieter moments that I was habitually calculating how much longer I would need to work like this until I could retire and start doing the things I really wanted to do. I had a thriving clinic with wonderful colleagues and fantastic patients, but I could not envision practicing medicine in this manner for another 30 years (for those who empathize with this sentiment check out ZDoggMD’s rendition of “Once I was 7 years old”. It reminds me of my Penn Med “Spoof” days and definitely resonates with me).
Around this time my church had an opening for the Parish Health Nurse position. In a radically atypical move for me, I decided to apply for it. I think I completely freaked out the leadership committee with my dreams of yoga classes in the church common rooms, leading walks with parishioners and instituting cooking classes, chronic disease management lectures and blood pressure checks, in addition to the traditional role of visiting congregants in the hospital and making home visits to those recently discharged or homebound. Not surprisingly, I was not selected for the position; but the process of taking the leap to apply and realizing I was willing to decrease my income dramatically in order to try to find a way to practice medicine under a different paradigm was powerful for me. As the business tycoon Dhirubhai Ambani once said, “If you don’t build your dream, someone else will hire you to build theirs.” I decided it was time to start building a career I didn’t need to take a vacation from.
I resigned from my hospital-employed practice and set out to create the type of intervention programs to which I had wanted to refer my patients. Along with my talented business partner, Eric Ruth, I started Kellyn Foundation (www.kellyn.org), a 501(c)3 non-profit, to focus on child and family wellness, allowing me to implement lifestyle medicine initiatives and provide counseling services to my patients in a longitudinal way. The billing codes and reimbursement models did not exist to support those services at that time, causing us to create the programming we wanted to provide outside of the traditional medical clinic model.
In 2008 we started an intervention program for families struggling with overweight/obesity issues, especially in children, involving an immersion period of 8-10 weeks of intensive intervention that included frequent individual/family physician visits for screening and goal-setting, a structured exercise program, group nutrition sessions and an online daily lifestyle survey. After the initial immersion period there was a maintenance phase that included bi-monthly physician follow-up, continued participation in structured exercise and continued online daily lifestyle surveys. The program was funded as a self-pay program with a sliding scale fee, and was supported by a small amount of grant money for the initial year. The program was successful clinically, but had difficulty with sustainability due to the lack of insurance reimbursement. After approximately three years, we scaled the intervention program into two family medicine residencies in our area. The initiative was partially supported by grants, and also by being an educational tool for the residency programs, utilizing resident clinics as the physician visit component. The intervention was a success in teaching the family medicine residents about behavioral therapy and lifestyle medicine counseling, and even in influencing some of the residents’ own lifestyle choices. End-of-year evaluation comments from the residents like, “I spend more time in counseling kids, teens and whole families about lifestyle modification now. I personally am making better choices about screen time vs. activity time and I have tried to integrate the ideas of hara hachi bu into my eating,” and “This program helped me remember why I went into family medicine,” convinced us we were on the right track.
At the same time, Kellyn Foundation branched out into more population health lifestyle medicine initiatives in our community. We started KellynSchools which is a consecutive curriculum for 3rd, 4th and 5th grade students, teaching about eating “Real Food”, how to read nutrition labels, “Eating Out Survival Skills”, exercise, sleep and screen-time choices, and wrapping the curriculum around the “Garden as a Classroom” program that involves students in growing and savoring food from their own school garden. Kellyn staff members now visit over 8,500 students throughout nine school districts in our area annually, through individual classroom-based presentations; following the students over 3 years to teach them about making lifestyle choices that will lead to a healthier life. We mentor over 3,000 students annually in the garden program, taking them from seed to salad and sending home tomato and pepper plants that they have nurtured on their classroom windowsill to start their own gardens. It is immensely satisfying to hang out with a classroom of children who are eagerly devouring the mesclun mix, kale and spinach salad they have grown and asking for second helpings! I believe that by encouraging healthy lifestyle habits in the upcoming generation we can make great progress in stemming the tsunami of chronic disease currently looming over us, but the only successful way to encourage that change is through ongoing relationships with the kids and families.
A few years later we started KellynKitchens, a cooking/nutrition program provided in community locations like the YMCA and inner-city community centers or schools. This program involves children, families and seniors in preparing healthy meals from fresh, whole-food, plant-based ingredients and then enjoying the meal together while connecting as neighbors and friends. We often hear comments like, “This is surprisingly delicious” and “This tastes too good to be healthy”, demonstrating without a doubt that families enjoy healthy meals when they have the support to learn how to prepare them and have access to the necessary ingredients.
A more recent component of Kellyn’s programming is the “Eat Real Food” Mobile Market. During the growing season we bring a “healthy grocery store” on wheels stocked with fresh produce, healthy grains/bread, beans and other grocery staples into areas of food-insecurity in the Lehigh Valley. We visit 10 sites on a weekly basis, which allows the residents of these neighborhoods to count on us as a way to stock up on healthy groceries each week. We also provide cooking demonstrations, food sampling, recipes, nutrition education and chronic disease screening at these locations. During the 2016 season, the “Eat Real Food” Mobile Market sold over 6.5 tons of fresh produce in our local neighborhoods that do not have easy access to a grocery store. We accept the SNAP benefit card and are able to provide a matching incentive for local fruits and vegetables which allows our lower-income customers to receive $20 of fresh food for only $10. This program not only increases access to healthy food for our neighbors, it supports our local farmers in creating the sustainable food system we desperately need. We are very excited about a fruit and vegetable prescription program that launched in 2016 in collaboration with one of our local health systems, an excellent start towards adding produce to physician prescribing habits instead of only writing scripts for pills. Patients with chronic diseases like diabetes are given a prescription voucher for fresh fruits and vegetables from their regular clinician that can be redeemed at the “Eat Real Food” Mobile Market which visits their neighborhood, helping to make the healthy choice the easy choice for participants who will benefit greatly from the increased consumption of produce in their diet.
Kellyn’s home base is in the Llantrisant Retreat and Wellness Center (www.llantrisantretreat.com), a 100 year-old building along a creek, next to a rail-trail path. The Wellness Center offers therapeutic yoga and Pilates classes, nutrition/cooking classes, massage therapy, behavioral counseling, and workshops on lifestyle medicine topics. This fall we will open the Kellyn Café, a healthy, whole-food option for our students and neighbors. We have a thriving community of people who find support and encouragement at the Center every week; and I am hopeful that as our healthcare system evolves there will come a time when the services we offer are considered worthwhile investments from the insurance industry which will allow significantly more clients to access these programs. There are some positive signs in the reimbursement world now that face-to-face counseling time is more regularly accepted as a billable option, and with the growing momentum around the return on investment for various lifestyle medicine interventions such as the Ornish and CHIP Programs.
A recent JAMA article unequivocally demonstrated that diabetes, heart disease and neck/low back pain are the top three most expensive conditions to treat in the current traditional healthcare model, and that the cost of prescription medication for conditions like hypertension and hyperlipidemia are increasing at more than double the rate of total healthcare spending. These are all conditions that can benefit from a Lifestyle Medicine approach with better long-term outcomes and decreased costs. A Chinese proverb states, “If we do not change our direction, we are likely to end up where we are headed.” I am hopeful that we will wake up to where we are headed in our current medical model in time to change course. I truly believe that in Lifestyle Medicine we are on the right path, and I am grateful to have found the ACLM community. Having the opportunity to interact with so many like-minded clinicians through the College is very motivating and inspiring. You have all utilized your discontent with the status quo to make marvelous progress for the Lifestyle Medicine cause! Thank you for sharing the journey with me.