The Science Behind Coaching as a Treatment Option
How a Transformative Care Model Will Change Health Care As We Know It
- Sports has already figured out how important coaching is. Executive management has figured out how important coaching is. We need to apply it to health now.
- New studies show that patient pain levels and functional status improve dramatically with just a coaching model alone.
- A transformative care model: where you integrate coaching and patient training with treatment, using a team of medical professionals, a health coach, and technology.
- Additional studies demonstrate what happens when you integrate health coaching into routine care, estimating the reduction in healthcare cost would be at least 50%.
- Patient-centered care is really where it’s at. How do we create a system with healthcare providers with care that really transforms patients and provides the care they need to actually get better long term?
As patients, we feel so powerless sometimes. We’re at the mercy of our doctors. We’re at the mercy of our insurance company. A health coach can help us realize that we have what’s called “self-efficacy.” We gain a sense of control over our pain, and we engage in our own care in a vitally powerful way. When we engage in our care and gain that control, it’s really empowering. We understand that, “I am responsible for myself, and I have the ability to improve my pain.“
About Dr. James Fricton
Dr. James Fricton has over thirty years of experience in clinical care, research, and teaching in the field of chronic pain, temporomandibular disorders (TMJ), and health informatics. He completed his Doctor of Dental Surgery degree and postgraduate studies in Computer Science from the University of Iowa. He also completed a Master’s Degree in Oral Biology at UCLA School of Dentistry and an Anesthesiology and Pain Management Residency at UCLA Medical Center. After his research in clinical training at UCLA, he joined the faculty at the University of Minnesota.
Dr. Fricton is a senior researcher, pain specialist, and a member of the HealthPartners Institute for Education and Research. He is currently the President of the International Myopain Society; and has been on the board of the American Pain Society and the American Academy of Orofacial Pain. He is an avid researcher, teacher, author with five books, and over 150 publications and abstracts.
This is a guy who is actually doing the research and doing the work. He maintains an active private practise for patients with TMJ, orofacial head and neck pain, in Plymouth and Saint Paul, Minnesota.
Links & Resources
- Preventing Chronic Pain: A Human Systems Approach on Coursera.
- Below you will find both a full transcript and video of the episode, with the studies mentioned in the show linked in the transcript.
- Hackshaw, Kevin V., et al. “A pilot study of health and wellness coaching for fibromyalgia.” BMC musculoskeletal disorders 17.1 (2016): 457.
- Curtis, Rebecca, and Joel O’Beso. “Pain management coaching: The missing link in the care of individuals living with chronic pain.” Journal of Applied Biobehavioral Research 22.4 (2017): e12082.
- Margolius, David, et al. “Health coaching to improve hypertension treatment in a low-income, minority population.” The Annals of Family Medicine 10.3 (2012): 199-205.
- Iles, Ross, et al. “Telephone coaching can increase activity levels for people with non-chronic low back pain: a randomised trial.” Journal of physiotherapy 57.4 (2011): 231-238.
- Leahey, Tricia M., and Rena R. Wing. “A randomized controlled pilot study testing three types of health coaches for obesity treatment: Professional, peer, and mentor.” Obesity 21.5 (2013): 928-934.
- Moskowitz, David, et al. “Peer coaching to improve diabetes self-management: which patients benefit most?.” Journal of general internal medicine 28.7 (2013): 938-942.
You are listening to the Fibromyalgia Podcast with Tami Stackelhouse, Episode 7.
Welcome to the Fibromyalgia Podcast! I’m Tami Stackelhouse, your Coach.
Today I’m going to be interviewing Dr. James Fricton about coaching, about the science behind it, and what he has seen as a pain specialist and researcher in his own practice, on the benefits of coaching. We’re going to be talking about the research. We’re going to be talking about the science. We’re going to be talking about the benefits you can see as a patient, in your own life.
At the end of this interview, I’m also going to be sharing a recap and a little bit more details on one of the studies Dr. Fricton mentions in his interview. I hope you stick around after the interview to hear some of those more specific details.
There will be some things I won’t be able to link to because, of course, in this episode Dr. Fricton is talking about a few things that are still in process; a few studies that haven’t been published yet. A few of the programs he is working on are not available to the general public, they are only available to providers. Everything I can link to, I will. Just know that if something hasn’t been linked to, most likely it’s not publicly available.
[01:23] TS — Now, let me introduce today’s guest. Dr. James Fricton has over thirty years of experience in clinical care, research, and teaching in the field of chronic pain, temporomandibular disorders (TMJ), and health informatics. He completed his Doctor of Dental Surgery degree and postgraduate studies in Computer Science from the University of Iowa. He also completed a Master’s Degree in Oral Biology at UCLA School of Dentistry and an Anesthesiology and Pain Management Residency at UCLA Medical Center. After his research in clinical training at UCLA, he joined the faculty at the University of Minnesota.
Dr. Fricton is a senior researcher, pain specialist, and a member of the HealthPartners Institute for Education and Research. He is currently the President of the International Myopain Society; and has been on the board of the American Pain Society and the American Academy of Orofacial Pain. He is an avid researcher, teacher, author with five books, and over 150 publications and abstracts.
This is a guy who is actually doing the research and doing the work. He maintains an active private practise for patients with TMJ, orofacial head and neck pain, in Plymouth and Saint Paul, Minnesota. He will actually talk a little bit about the patients that he’s seen and the results that he’s seen, as part of this interview.
[01:49] TS — Welcome and thanks so much for doing this interview with me. I’m excited to have you share some information about health coaching, what you’ve seen in your practice and some of the research that is currently being done. So thank you so much for being here.
[04:33] JF — It’s my pleasure Tami. It’s great to share some of the experiences we’ve had and how important coaching is to pain patients, but I think to the future of healthcare also. So, thanks for all the wonderful work you’re doing.
[04:48] TS — Thanks, thanks so much. What I would love to start with—and I don’t even know the answer to this, so I am excited to actually hear what you have to say about this—how did coaching first come into your life? How did you become aware of coaching and become such a fan of coaching? Because every conference I’ve ever seen you at, any time I’ve ever talked to you, I always hear you talking about the benefits of coaching, and I’m curious to know how that all started.
[05:11] JF — Well, it goes back to the days of learning to be a pain specialist. I realized, as I did more research and had more clinical experience with patients, I realized that it’s not necessarily about the treatments I provided, but it’s about that relationship I have with patients. When I used a lot of self management strategies—teaching them, coaching them, and training them to make the changes they need to do to get better—patients would improve dramatically. From that point of view, I thought coaching was really important until I realized that…. Karen Lawson, the director of the Health Coaching program at the University of Minnesota… We were involved in activities together, including grant research and I realized not only how important coaching is, but how important it is to develop coach training programs to be able to have enough coaches to provide that care for the patients that need it.
[06:23] JF — Coaching is a very unique profession. You have to be passionate, understanding, and empathetic. The people that I have met within the coaching field, have been just amazing, so far. I’m really sold on health coaching. I think it’s really the answer to the healthcare system—to try and make it more patient-centered, which is the most important transition we need to make.
[06:48] TS — Absolutely, I totally agree with that. Were you trained in coaching at all? Or did you just look at what it was that you were doing with your patients that made the difference; and those were things you naturally did?
[07:02] JF — Well, I was trained as a pain specialist, but when I was in my residency program and anesthesiology and pain management, I realized that it is these patient-centered factors that were very important. And that was many, many years ago. At the same time I was learning acupuncture. One of the things they do with acupuncture… They don’t just stand there; they talk to you. They coach you on the changes you need to make, and that is something that is in ancient history. What I have been doing with my patients since that, and back into the 70s, is to really focus on teaching the patients what they need to do. It started with acupuncture, originally, as a pain specialty. However, it’s very difficult to incorporate coaching within a pain management practice because you don’t get reimbursed for it.
[08:02] JF — More recently, one of the things we’ve been doing is working with the health plans to try and get reimbursed for preventive medicine counseling, which is really preventing chronic pain, addiction, disability, and ongoing dependency on the healthcare system by a coaching model. I have been successful in working with the healthcare plans making this a sort of transition that needs to happen in the healthcare system. We need to focus on preventing chronic pain and addiction instead of simply treating pain conditions and having relatively short-term relief.
[08:38] TS — Absolutely, I totally agree with that. I think you touched on something that is a big frustration for a lot of patients. We go to our doctors and we’ll hear things like, “you need to change your diet” or “diet and exercise” are two of the things heard most often. But we’re not getting enough help on how to actually make those changes. Especially when you have something like fibromyalgia, it’s like, “Okay, I’m supposed to eat better, but I don’t have the energy to go grocery shopping.” Or, “I don’t have the energy to cook, so how do I actually do this?” Right? I think that is the magic of having someone come alongside of you and help you strategize and figure out the actual implementation of the things we know we should do.
[09:30] JF — Yes, that’s so important because what we find in our routine clinical practices is that we provide treatment, physical therapy, exercise, medication prescriptions, etc.; but we don’t have a lot of time in our schedule to sit down and really explain to our patients, to do more coaching, not even teaching them. I go through a lot of self-care with my patients, but it’s really about that coaching process; it’s different than training people what to do. It’s really reinforcing that self-determination, that engagement, empowerment. How do you develop that relationship with patients, to really make sure they feel empowered to achieve their own goals, that are self-determined?
[10:12] JF — So, some of those characteristics of coaching—positive psychology, self-regulation, self-evaluation, and mindfulness—are things that are critical to teach, but it takes time to do that. And it takes somebody to really work with on a regular basis to achieve that. I have found so many benefits of the health coaching model, not only with me coaching my patients, but also having health coaches work with me in that context also.
[10:43] TS — Definitely. I know for me, one of the big things was having somebody who, first of all, I knew well enough and who knew me well enough that I couldn’t just gloss over stuff. You have to have a deep enough relationship, that they knew the right things to ask. They knew when you were like “yeah it was fine” when it really wasn’t. And, then, the other piece is having somebody to troubleshoot with: “I really wanted to do this thing but I wasn’t able to follow through on it. So, how do I make better choices next time?” And be able to have that dialogue and troubleshooting and brainstorming to help me get to where I wanted to go.
[11:32] JF — Yes, there are so many changes we need to make within pain management. The big three we work with patients are really 1) posture, 2) reducing repetitive strain, and 3) exercise: stretching, conditioning, strengthening. Those three things. Sports has already figured this out—how important coaching is. Executive management has figured it out—how important coaching is. We need to apply it to health now.
[11:57] JF — We need to create what we call a “transformative care model.” That’s a model where you integrate training a patient and coaching with treatment, using a team with a health coach and technology. Technology is particularly helpful because it can do a lot of the training, the teaching that needs to be done. But it’s really that relationship with the health coach that allows them to really implement those changes that they need to make within their life that reduce the causes of the pain. It’s great to do the treatments. Treatments work fine. But if you reduce the causes, you’ll have this much more long-term effect and outcomes. Some of the studies on health coaching have been very remarkable in supporting that. I know one of the things we wanted to talk about was some of the research associated with coaching.
[12:53] TS — Yes. Exactly. I definitely want to get into that. I think a lot of people… they don’t really understand that.
You use the word transformative—which I think is perfect because we are not just managing something that you have. We’re actually trying to change it, to transform it. Transform you and your life and let you be able to live the life that you want to live, rather than just treading water somewhere.
Many people don’t understand the science, and there is actually science behind this! So, I would love to dig in to some of those studies. I know you have a couple in particular that you want to share. So, why don’t you go ahead and do that.
[13:34] JF — Well, I know the one we had talked about was the study by Hackshaw was published in 2016 in theBiomedicalCentral Journal. That looked at pain patients, particularly fibromyalgia patients—which are a unique subset of chronic pain patients because of the generalized central sensitization that occurs to make you sensitive everywhere within your body, as well as fatigue and difficulty sleeping, stiffness; are many of the characteristics.
[14:09] JF — They did a model. They had a case series of nine patients. They found that just coaching alone, without a lot of training, just that relationship with a patient to encourage setting goals, achieving the goals in life style changes, like diet and sleep, relaxation, stretching and exercise, which are critical in fibromyalgia. They found that the pain level as well as the functional status, both improved by between 32-44% with just a coaching model alone.
[14:45] JF — There’ve been a couple other studies that have been pretty remarkable also. I know I mentioned Becky Curtis’ study, that was published in the Journal of Applied Biobehavioral Research. That study had a series of 51 patients that they studied with, again, a coaching model. They found about 50-75% reduction in the pain level within that study over a period of about six months or so. However, interestingly enough, within the first two or three weeks there wasn’t a lot of change. So, it is really this coching over time that is really the key element within that study.
[15:33] TS — Absolutely. One of the things I know from the study they did with fibromyalgia is that those numbers you shared… They actually followed the patients for a year. They worked with a coach for a year and then they also checked with them a year after they finished coaching. I think that’s actually where some of those numbers are coming from is two years after they started. So, a year coaching and then a year without coaching. Which is really quite impressive, because a lot of treatment options that you see, you might get benefit while you’re doing it, but to have those same kind of results a full year after you have finished your treatment, I think is something that we should really be taking notice of.
[16:22] JF — That’s why we reinforce this whole idea of a transformative care model because it doesn’t just provide treatment to give some short-term or mild effect. The systematic reviews of pain treatment have demonstrated that they do work pretty much universally. All pain treatments work, generally, but it’s only about 10-20% above placebo. Often, those results, for instance, chiropractic, physiotherapy, some of the medications, are short-term results.
[16:53] JF — When you then, also, provide that training within a team of health coaching, over time… the results are much, much more effective. And some of the clinical trials and the systematic reviews on exercise, like yoga therapy, mindfulness, stress reduction, meditation, and coaching have all demonstrated within randomized clinical trials that they work long-term. That’s where we need to really focus our energy within the healthcare system. It’s: how do we implement these changes as part of routine care?
[17:33] TS — Absolutely. One of the things that I noted about the fibromyalgia study that you didn’t mention, that I think our listeners will be particularly interested in is: in that year after they worked with a coach—so, in the year after they finished, when they weren’t working with a coach—the healthcare utilization (the number of doctor visits) went down by 86%. They went from seeing the doctor 11 times in a year down to an average of one and a half times in a year. Which means money saved for the patient.
[18:11] JF — Well, and that’s why the health plans have really focused a lot on how do we incorporate health coaching into routine care? Because pain patients on the average cost anywhere from $10,000-$40,000 per year. We did some estimation of what happens when you integrate health coaching into routine care, that we would estimate the cost reduction would be at least 50%, and this study was even more than that. There are a couple other studies that have demonstrated that significant improvement within the healthcare cost and healthcare utilization.
[18:49] JF — I mean, it makes sense. If you teach the patients to reduce their causes and gain them a sense of control over their pain, they are going to rely more on their own empowerment and engagement in those activities that make them feel better. It’s just a natural thing to have happen, and it’s the coach that really facilitates that change over time.
[18:11] TS — Exactly. I think most of us, as patients… I know I was there when I was diagnosed. I would end up in a flare and I would think what did I do this time?!? I would have no connection between the things that happened to me or the things I did and what I was feeling at any given moment. That was a huge piece that my coach helped me with, was being able to make those connections.
[19:37] TS — Now I am at a place where I know: “Okay, May is going to be a crazy month for me. It’s Awareness Day. I’ve got four trips during May.” So these are the things I am going to have to do to make sure I don’t end up in a flare. I’ll tell you guys right now, I fully expect to go through May with no pain. But there will be a whole lot of stuff I do that you won’t see. That’s all stuff I learned.
[20:02] JF — Exactly. I mean that’s the whole bottom line. Once the patients realize that they have what’s called “self-efficacy”, that they have a sense of control over their pain—more than just taking medication, pills, or going in to receive some type of passive therapy or injections. When they gain that control it’s really an empowerment. It says basically, “I really am responsible for myself, and I have the ability to improve my pain.”
[20:36] JF — Now, everybody has pain conditions: back pain, shoulder pain, neck pain, fibromyalgia. Some are more severe than others. We all need to learn these skills of how the pain is telling us something; it’s teaching us something. It’s telling us “Oh! There’s a problem right here.” We need to figure out what we are doing that may contribute to it, and how do we best reduce that over time. How do we prevent it from becoming aggravated over time. You do a great job with that within your program.
[21:10] TS — Thank you. There’s a reason my first book was called Take Back Your Life! As patients, we do feel so powerless sometimes. We feel we’re at the mercy of our doctors. We’re at the mercy of our insurance company. I have a friend with fibromyalgia who was just denied a shoulder surgery. You know that her shoulder condition doesn’t necessarily have anything to do with her fibromyalgia, but it’s a trigger for her pain.
[21:41] TS — We feel this real sense of powerlessness many, many times. I think everything we can do to take back that power—to take back control of our lives and of our health—I think puts us in a much better situation, especially with everything that is happening right now with pain medication. If that’s the main thing you’re relying on, and that gets taken away… For those of you who are listening who haven’t followed me on Facebook, Oregon was just voting on limiting opioid pain medication to only 90 days period for fibromyalgia patients. I have never met a fibromyalgia patient who could get their pain under control in 90 days. I don’t think opioids are necessarily the best way to go—I think there’s lots of other options—but I think when we’re taking that away for a population, it becomes very dangerous.
[22:35] JF — And that’s the thing that’s very important. You have to give the patient a variety of different tools. Self-management is clearly the most important one, but many different treatments—whether it’s sometimes chiropractic manipulation, physiotherapy, medications, including opioids, in some situations. I have several patients on long-term opioids because that works. That is just one more tool to put in your toolbox to manage a pain condition, particularly fibromyalgia. Now, it is true that opioids do increase sensitization of pain over time, but there are ways to use opioids in such a way to prevent that from happening.
[23:15] JF — This is why we believe strongly in this transformative care model. Where you integrate treatment with training. You don’t do one or the other; you do them both together. We’ve developed a program called the PACT program. It’s the Personalized Activated Care and Training program. It integrates both treatment and training together. It relies on technology to do several things:
[23:42] JF — 1) Is risk assessment to identify: what are those factors that drive chronic pain, that happen to be in your life?
2) It does risk reduction training. So, once you have identified the risk factors for driving chronic pain, then you can train yourself in reducing those specific factors. It uses the concept of micro-learning. It’s on the computer but it’s five-minute lessons on the critical elements that you need to know about that particular risk factor. Like diet or how to get a good night’s sleep every night, or how to sit properly if you’re sitting ALL day long. We evaluate about 36 different risk factors, put them in micro-learning tools, but learning them online is not the answer.
[24:34] JF — That certainly gives you the information but it’s the coaching over time.
3) Within the program the coach uses telehealth—preventive medicine counseling—to work with patients over the phone. It can do video conferencing, like we are doing right now, also, if they want, but phone seems to be the choice for communication. The coaches work with [patients] over a period of six months or more, with calls every two weeks or so to really connect with the patients, develop that coaching relationship, help them set goals, purpose in life, how to achieve specific changes in lifestyle factors, relationships, all the things that cause stress and increase pain over time can really be coached, in terms of the changes.
[25:23] JF — So the program has been very successful. We did a randomized clinical trial with that compared to usual self care. So, you did treatment plus usual self-care or treatment plus the PACT program. Those patients in the PACT program not only had higher levels of satisfaction with the care, but they were able to change pretty much every outcome measure we looked at from self-efficacy, to functional interference, to pain levels. It was really an eye opener in terms of results.
[25:56] TS — I know you have stressed on multiple occasions, that the PACT program is a health coaching program with an online training component, not an online training program with a health coaching component. Do you want to talk about the difference a little bit there? I know you kind of did because of the value of coaching.
[26:16] JF — Yes, that’s an important fact to realize. There are a lot of online programs to learn about these specific risk factors for all kinds of chronic conditions. They have high engagement, but they do not necessarily help a person change the lifestyle that they have. It takes that engagement, that empowerment, that working relationship, that therapeutic effect of a relationship, to coach you through the changes you need to make that is really the critical element that makes it successful. It was clear within our study and many of these studies we are commenting on, that it’s that relationship with a coach that really gave them the energy and the insight and the self efficacy to really make the changes they need to get better.
[27:10] TS — Perfect. There’s one quote I wanted to mention [in particular]. I’m actually going to read that here. This is from a study that was done on blood pressure, talking about the difference working with a coach made literally on a patient’s blood pressure. This was Dr. Bodenheimer, who was the key researcher. He said: “The more calls between a coach and a patient, the better the patient’s blood pressure. It’s almost like a medicine. If you increase the dose of coaching, you get a better result.” [Health Coaching Dramatically Lowers Patients’ Systolic Blood Pressure]
[27:45] TS — I love that quote because I really do see coaching as a treatment option, not just like talking to a friend or something nice to do. We are actually helping you have less pain and live a better life and have more energy and all of those things. We see this again and again, whether we’re talking weight loss studies—there was one study where they compared peers and mentors to a professional coach, and the professional coach got them an order of magnitude more results: more weight lost, lost it faster. They also did this with diabetes, looking at A1C numbers, and seeing those lowering the more [patients] worked with a coach. So, we do see this over and over again in multiple places and lots of different conditions.
[28:37] JF — Well, there’s another study that’s interesting by Iles, in the Journal of Physiotherapy that’s interesting, published in 2011. They randomized clinical trial with physical therapy alone for back pain. Then, they combined physical therapy with health coaching. They found within that model, again, there’s not much difference within the first 2-4 weeks or so, but within 12 weeks—only three months—there’s a significant difference in functioning within the group that had both physiotherapy and health coaching together. Then, long-term they had a much more significant effect both in functioning, as well as a sense of self-efficacy and expectation that they are going to continue to get better. So, combining the two—physiotherapy with health coaching, treatment with training and health coaching—is really the key factors that I think is going to drive the most, best long-term success.
[29:42] TS — I totally agree. I know that there have been lots of times when I’ve worked with clients who, for whatever reason, did not have good provider on their team. Either they lived in an area where there weren’t a lot of options or whatever their reasons were, it’s hard. Even as awesome as coaching is, it’s hard for me to get them results without also having the other side. We really do need this collaborative team effort in helping patients get better.
[30:14] JF — So, what we have done with this PACT program is try to create a system—what we call a patient engagement portal system—that allows the provider, the physician, physical therapist, chiropractor, dentist, whoever is the treating physician, to be able to write that prescription for certain self-management training and coaching within the context of an office visit. We can quick-enroll somebody in a program like that, so that the coach is connecting to the patient. The coach calls the patient and begins that relationship. The patient goes through training at the same time. The system also allows the provider and the coach and the patient to track their progress over time as they continue to get better. Then, it has the risk assessment, risk reduction training, and interaction and connection with the health coaches.
[31:14] JF — It’s a model we believe could become part of routine care. And the best thing about it is that the health plans have been reimbursing it as part of preventative medicine services, so that it would be covered 100% without deductible, without copay. That’s one of the best things because financial limitations is one of the aspects of all of healthcare. If this can be something that could be incorporated within every health plan, I think it will be transformative, not just for the patient but for the whole healthcare system.
[31:51] TS — Right. That’s what I’ve seen too, in working with the doctors I know, is that it helps everybody involved. It obviously helps the patient. It helps the doctors because they’re seeing the patients get better and follow through on the instructions they are given. They are not having the same conversations over and over: I need you to do this, I need you to do this. It’s actually happening! It helps the healthcare system in general because it is overburdened and extra expensive. Ultimately, long term, it’s even helping our economy and government because, hopefully, we have more people who are functional, who aren’t on government assistance or can’t work. If we catch people earlier, the better results we have to be able to help them keep working.
[32:47] JF — It’s all about preventing chronic pain. Preventing addiction. Preventing disability. Preventing that ongoing dependency on the healthcare system. Healthcare is not just for acute problems but chronic problems too. But with every one of those chronic problems, they really need somebody to get within their lifestyle—not just have them drive a half-hour to go to the doctor and spend twenty minutes just talking about it. But somebody who’s actually going to call them within their lifestyle, interact with them, really to help make those changes that are needed. To me, that’s the beauty of health coaching, to really integrate the care, into the patient’s life.
[33:30] TS — I think a lot of times, as coaches, there are things we will see that your doctor isn’t aware of, simply because we’re interacting with you more frequently, we are getting into your life a little bit deeper. There have been several times where I have been able to give the doctor important feedback about patterns I see, or symptoms I see, that may not be coming up in visits. Which then allows them to treat the patient better, maybe diagnose things that were sliding under the radar, or more effective treatment options. It’s definitely all of us working together, for sure.
[34:09] JF — Yes, and the PACT program has the ability to do two things: One is to communicate directly to the physician or the provider who is providing the care and treatment. So, there’s a way to make notes and send confidential, secure HIPAA compliant emails back and forth. In addition to that, it also has the ability to really help the patient identify when there are some really specific red flags or complex mental health issues, whether it’s suicidal ideation, depression, abuse, addiction, and other things such as that, and to be able to connect with a health psychologist immediately on the same day as required, with discussion and consent with the patient or the client.
[34:58] JF — And so the ability to connect both of the professionals—as well as to health psychologists, as you need to—is also very important. So, the coach can actually be, to some extent, be the center of care within the patient’s lifestyle. They don’t necessarily do care coordination, but they can facilitate communication back and forth, because one of the difficult things about care, especially with complex chronic conditions, like chronic pain, is communicating with providers. So, it’s very true that the coach can play a significant role in improving the treatment also.
[35:35] TS — Absolutely. You brought up mental health, and this wasn’t one of the things I mentioned that we would talk about but I would love to ask you—because I know this is something a lot of patients aren’t really clear on—which is the difference between working with a coach and working with someone like a counselor or a psychologist. I’ve had clients who were working with me and a counselor or psychologist because it is very different. I was wondering if you would talk a little bit about that.
[36:06] JF — Yes, we have both coaches and health psychologists within our clinic because the coaches really help the patient make the changes they need to make within their lifestyles— whether it’s diet, sleep problems, posture, repetitive strain, etc, behavior changes specifically. Whereas the counselor really connects to get into deeper issues—for instance, past trauma—that really require some in-depth discussion, and the coach is not going to do that. I mean that is really the responsibility of the counselor and health psychologist within that. Both of them can be very helpful. But, nonetheless, I think it’s important to recognize when a patient needs more mental health support and care for those specific deeper issues.
[37:03] TS — Absolutely, as a coach that’s not stuff I’m trained to dig into. It’s not just past trauma. It’s also if you have severe anxiety, depression, even food issues—like working with a health coach on losing weight if you actually have an eating disorder—we’re not trained to handle that. Quite often people will need both for different areas. Just like you might need different providers. You might have a neurologist. You might have a rheumatologist. You might have your primary care… And all working together, hopefully.
[37:46] JF — Well, and that’s the key. That’s why having a patient engagement portal in addition to an electronic medical record is critical. The electronic medical record provides the very important medical data that you really need to understand that physical condition that the patient has, the medical condition. But what the patient engagement portal does is really allow communication between coaches, health psychologists, physicians and other health professionals.
[38:13] JF — In addition to that, it also provides the ability to bring family members—as we all know, family members and friends are critical support systems to really make the changes you need. If everybody in your life is eating poorly, you’re going to eat poorly. But if you can bring that knowledge and that coaching and energy to the people that you have in your life on a regular basis, it really helps make those transitions—the transformations—to occur much easier.
[38:45] TS — Absolutely. I totally agree.
What do you see for the future of chronic pain and fibromyalgia? When you look five to ten years into the future, what do you see?
[38:59] JF — Well, that’s a good question. I’m a researcher and a clinician, pain specialist, so I’m always trying to come up with ideas that will really help patients. That’s the bottom line. How do we best help patients over time?
So, what I see happening… Right now, we’ve developed the PACT program. There are other platforms out there that are evolving. I believe using technology—and the Institute of Medicine, in 2011, recognized the importance of that. They stated that coaching is critically needed within healthcare. But, also, the use of apps, cell phone apps, patient engagement platforms, website training, and things like that need to be integrated together. So, I see in about five years or so—especially with the excitement that the health plans have within the programs such as the PACT program and the importance of coaching—that I believe that nearly every clinic, particularly pain management clinics, are going to have multiple coaches that are involved in managing their patients over time. I think that is going to be one of the critical shifts that occur.
[40:17] JF — Now, what that means, basically, is the healthcare system is going to continue to move towards what we call patient-centered care versus treatment or provider-centered care. Patient-centered care is all about the patient. How do we create a system with healthcare providers with care that really transforms that patient and really provides the care they need to actually get better long term? So, patient-centered care is really where it’s at, and I think that within five years—and every provider I talk to agrees with me to some degree—that patient-centered care is really the goal. And that’s to achieve what’s called “The Triple Aim.” Are you familiar with The Triple Aim?
[41:06] TS — I don’t think I’ve heard that.
JF — That’s the Institute for Healthcare Improvement’s goal for the healthcare system. So, 1) the first aim is to engage the patient. 2) The second aim is to improve those long-term outcomes. 3) The third aim is to reduce long-term healthcare costs.
[41:34] TS — Yes. I could of just about guessed those. I mean, I’m glad they’ve identified that because those are the problems I see. Those are the problems most people see. So, I think that’s awesome they have chosen the same things we would. So, A+. Perfect!
What research are you particularly excited about at the moment? I know you’ve got some things you’re working on, but, whether it’s yours or somebody else’s, what things are you excited about?
[42:01] JF — Well, we’re doing several things, and the focus is really on preventing chronic pain, addiction, disability, etc., and ongoing dependency on the healthcare system. So, we have a campaign we’re doing right now on preventing chronic pain. We’ve worked with several national and international organizations, including the International Myopain Society and the International Association for the Study of Pain—and we’re working with some other groups too—to engage them within a movement in 2020: to make the year of 2020 the “Year of Preventing Chronic Pain”. Now, with that, there are several initiatives—both research, as well as training initiatives—for providers that really help in making this a significant success.
[42:51] JF — One of them is a course that is online, a course that we offer here that a group of my pain specialist put together. A course on Preventing Chronic Pain: A Human Systems Approach. That’s on Coursera.org that’s available.
[43:11] TS — Just to jump in here really quick, I will have that for those of you who are listening to this, that will be in the show notes; so just go to FibromyalgiaPodcast.com/7 and I’ll have links to all of these studies, but also, specifically, this Coursera course. I took it back in 2015, and, in spite of being a coach for six years at that point, I still learned a lot. There’s really a lot of good information in there. So, for those of you who are interested in really learning new ways to manage your pain, or just interested in the science behind pain, there’s a lot of that too. I highly recommend it and it will be in the show notes. Okay. Continue.
[43:51] JF — That’s good. And, in addition to that training program, we also have training for health professionals. Although that was designed for health professionals also, half the people taking it were patients, and 93% said it had changed their life. So, we’re really impressed with that. Providing good, scientific, sound, information about pain, what causes pain conditions and how do you prevent it, is very useful information.
[44:21] JF — We have two more courses that are skills courses for health professionals to really learn about transformative care. One is through the Institute for Healthcare Excellence, and they provide a one-day skills course on patient communication and implementing transformative care for pain conditions for any health professional. It’s a very good skills course. It’s a small group, 20-25 health professionals getting together to really discuss how you do this on a routine basis. AND, most importantly, is how to get reimbursed for it.
[44:56] JF — And, then, we also have a course through the International Myopain Society, it’s a one-day skills course on pain management skills. This is for any health professional, from physicians to chiropractors to physiotherapists to dentists and others, to learn the basic skills behind pain management.
[45:18] JF — In addition to coaching and the whole training programs, what should the health professional do to examine the patient, identify joint limited range of motion, neck limited range of motion, back limited range of motion, tenderness, trigger points, fibromyalgia, how do you diagnose those, basically. We have some experts who have been in the pain management field for years with the International Myopain Society who will be teaching that.
[45:51] JF — We’re also developing a curriculum course that is online for health professional schools, to integrate within their curriculum on transformative care for pain management. So, that’s a little bit more longer-term but we are hoping to have it done by 2020. If health professional schools, medical schools, dental schools, chiropractic schools, etc., want to incorporate this into their curriculum, it can be done.
[46:18] TS — That’s fantastic, because there’s not that much that’s really being taught, I don’t believe, on these more long-term chronic pain conditions and managing chronic pain as opposed to just managing acute pain. I think that’s really critical for equipping our providers to-be.
[46:39] JF — Well, and also, we are doing a few other things, too. For instance, developing some consumer-based information about transformative care. So, what happens when you have a pain condition? It’s kind of like a reality tv show…
TS — “A day in the life of a pain patient” kind of thing?
JF — Exactly. Exactly. There are a lot of other programs, like the National Fibromyalgia and Chronic Pain Association, who will have regional sort of support groups for patients and I know you’re involved in that to some extent, also, which is very helpful for patients. And blogs, you’re involved in that, so some of the work you’re doing and Becky Curtis is doing. There’s quite a few health coaching programs around the country that I think are going to be very helpful in terms of providing enough support for patients, but also support for health professionals, to integrate health coaching into their routine care. That’s such a critical aspect to do.
[47:53] TS — Yeah, and that’s the challenge I think a lot of providers are having right now. If they are aware of the benefits of coaching, they’re a little bit at a loss for how to get their patients involved with that. Rather than just telling them over and over, “You need to work with a coach. You need to work with a coach.” I think all of these things are great.
Is there anything that you think we should be spending research money on that isn’t being done yet?
[48:25] JF — Well, next week, actually, I am speaking to the National Academy of Sciences on temporomandibular disorders. I think we do need to understand a little bit more about the underlying pathophysiology, pain clinics and pain conditions, and really how lifestyle factors play a significant role. How does diet play a role? For instance, we’re realizing that sugar, by itself, increases blood glucose level, then causes it to crash. That fluctuation increases inflammation. So, some of the mechanisms associated with lifestyle factors, I think are really important to study.
[49:10] JF — And, of course, I think randomized clinical trials that are pragmatic trials—which means they are part of normal clinical care, and we are evaluating the outcomes associated with that.
[49:24] JF — We have a couple studies that are in process: one with United Healthcare and Optimum, and another one that’s going to go forward, hopefully, from the National Institutes of Health, to do a multi-site randomized, pragmatic clinical trial to see: when you incorporate this into routine care, what kind of impact does it really have over time?
[49:45] JF — We just need so much more research on the health coaching model—even though there’s randomized clinical trials, and there’s a lot of case series out there—we need some more large scale studies to show the big impact it can have, not only on functional status and pain, but on healthcare utilization as you mentioned earlier.
[50:07] TS — Yes, absolutely, I totally agree. I can speak from my decade-plus of coaching patients what kind of outcomes the patients can see, but I have not seen as much, because it’s not who I am interacting with, the impact it’s having on practices or impacts it’s having on insurance. We need to see the whole picture here, for sure.
[50:37] JF — Yes. I mean, when you think about it, pain patients cost about $10,000-$40,000 per year, and at least 20%—more like up to 40%—of the population has pain conditions. That right there is the big elephant in the room of healthcare costs. By empowering and engaging patients, educating them on the changes, and supporting them with health coaches, it will have an amazing effect on the entire healthcare system. You started a tidal wave of change that hopefully is going to spread throughout the country.
TS — That’s perfect.
JF — Thanks so much for all your efforts.
[51:23] TS — Thank you so much.
You know my big dream is that we would change what happens when somebody is diagnosed with fibromyalgia. Right now, most fibromyalgia patients, when they are diagnosed, they’re essentially told, “Well, there’s no cure. We don’t really have much that even works. So, here’s a couple of things and good luck to you. Life won’t ever be the same again, and it kind of sucks to be you.” Nobody says it like that, but that’s kind of what we’re told.
My big dream is that, instead of all of that, it would be, “Okay, you have fibromyalgia, but it’s not a big deal. Here’s what we do…” Hopefully.
I will accept all of your five- and ten-year predictions and let’s make that change.
[52:13] JF — Alright, well, I agree with you. Let’s just move forward, and we just need more training programs, more coaches to really supply the need that is going to be growing dramatically.
TS — Absolutely, I agree. Any last minute thoughts you would like to share with folks who are listening?
[52:30] JF — Well, the most important thing is to realize that pain—pain conditions, whether it’s fibromyalgia or regional pain, like back pain, or neck pain, or headaches—are very manageable. I had a patient just the other day. She’s 34 years old. She had nine years of pain from the head down through her neck and shoulders, sharp, shooting pains back there. She went to all kinds of doctors, and had a variety of medications, physical therapy, chiropractic, and nothing went away. With some simple training of posture and stretching, as well as some treatments—I did a couple of treatments, injections within that area. I saw her one time, just once, and I saw her a month later. Within two weeks of that first visit, she had no pain and has had no pain since then. She said, “I don’t need you anymore, Dr. Fricton.” I said, “Fantastic! I’m happy to follow up sometime in the future, but right now you are on your own. You can self-manage this problem.” She was so delighted.
[53:43] JF — I had another gentleman, 81 years old. I was seeing his daughter and his wife for pain problems, and they were getting better. He was sitting over in the corner, and he came up to me after the visit; he said, “Maybe you can help me. I’ve had a headache everyday for the last 65 years of my life.” Since he was age 16. Within a couple of months, teaching him some basic principles of what he needs to do for that condition: stretching, posture, reducing some strain, forward head posture, plus some dietary changes, his headaches went down to once every two weeks. It was surprising because he was so angry. I said, “Why are you so angry?” He said, “Why didn’t someone tell me this 10 years, 20 years, 50 years ago?” I have that type of story over and over again with patients.
[54:50] JF — The most important thing to realize is that most pain conditions are very able to be managed by yourself.
[54:55] TS — For sure—and that’s the whole focus of this podcast folks. If you don’t believe that basic premise, then you should probably find yourself another podcast, because that’s what you’re going to hear over and over from me. It’s that you can feel better than you do right now. We’re not necessarily promising zero pain, but you can feel better. You Can!
Thank you, again, so much, Dr. Fricton, for being here and doing this interview and sharing your experience with us. I look forward to hearing more from you. You’re doing some exciting stuff.
[55:28] JF — Well, you are too, Tami. Thank you for the interview and the opportunity to share this information with others.
[55:37] TS — I hope you can see why I invited Dr. Fricton to join us here today. He is obviously a huge fan of coaching, because of what he’s seen it do in his patient’s lives, and in his practice. So much so, that he is actually changing his practice, working to change the healthcare system and insurance companies, to have coaching be more of an integrated part of our healthcare system. He wants to create that transformative care model, which I love, because it’s all about transforming your life.
[56:11] TS — Now, there’s one specific study that he mentioned. It’s the study on fibromyalgia and coaching. I wanted to talk a little bit more in-depth about that. He mentioned a couple of statistics, but I wanted you to hear the whole picture about that particular study.
[56:31] TS — This was done at Ohio State University in 2016. Again, as a quick reminder, all of these details are going to be available in today’s show notes. Just go to FibromyalgiaPodcast.com/7 for episode seven and you will see a link to this study and all of the details I’m about to give you.
[56:53] TS — In the fall of 2016, Ohio State University published this study. They had followed nine patients through one year of working with a coach and then for one year after they had stopped working with a coach. They actually followed them for two full years. Now, the numbers you are about to hear are from the end of that second year. This is one year after they stopped working with their coach.
[57:26] TS — This is what they found a year later: They discovered that patients were still seeing a 31% decrease in the severity of their pain. That means how bad their pain was. (For example, it may have gone from a 6 down to a 4, or something like that.) So, a significant decrease in the severity of their pain.
[57:54] TS — They also saw a 44% reduction in interference. What this means is that the impact their pain was having on their life—the amount that their pain interfered with these patients’ lives—was cut almost in half. That’s huge!
[58:15] TS — The other thing I mentioned about this study during the interview was that healthcare utilization was reduced by 86% overall. It was 70-something percent for rheumatology visits. I don’t remember specifically, but it was 86% in general. All of their doctor visits, their provider visits, were cut 86%. So, they went from eleven provider visits in one year down to an average of one and one-half visits. We get “half” visits because we’re diving by nine people.
[58:50] TS — Researchers doing this study estimated that the cost savings for the patient was somewhere around $900. Now, this varies a lot depending on your insurance coverage, how much your doctor charges, whether you have met your deductible, or you have a copay out of pocket, if you’re seeing a specialist. There are a lot of factors there. They just did this on an average of 9.5 visits at about $90 per visit, is right around $900 savings.
[59:24] TS — Another cool thing about this study is that they used the Revised Fibromyalgia Impact Questionnaire (FIQR). They used this to measure their results, in addition to looking at pain scores and the interference levels. This is important because this is the measuring stick that a lot of studies use to measure the impact fibromyalgia is having on their patients’ lives. This is the measuring stick they use for the FDA-approved medications, for instance.
[59:58] TS — So, to give you an idea of how BIG this is: they found that the FIQ score went up by 35%, meaning people felt better by 35%. To put that in perspective, Lyrica only increased the score by 17%, Cymbalta by 20%, and Savella by 32%. Now, I know many of you have tried these medications and found that they actually didn’t work for you at all—and that’s part of the problem with these. Yes, the people it helped, it helped an average of 17%, 20%, or 32%—but there were also a lot of people they didn’t help at all. Probably about half of the patients who try these medications find that they didn’t do anything for them.
[1:00:49] TS — Another thing I want to compare this to is a very common counseling and behavioral therapy which is ACT: Acceptance and Commitment Therapy. So, it’s all about accepting your illness and committing to changes. This only showed a 27% increase [in the FIQR score]. What this means is that coaching in this pilot study was proven to improve fibromyalgia symptoms more than any of the FDA-approved medications, and more than typical counseling and behavioral therapy. AND coaching is probably one of the treatment options your doctor hasn’t talked to you about! So, we want to make sure you know.
[1:01:38] TS — The other thing I want to mention is that the PACT program that Dr. Fricton talked about in this episode is not covered by insurance yet. It is something he is still working on. He told me after we ended the interview, that he’s still in meetings with them, still contracts that have yet to be signed. We’re close but we’re not quite there yet. It’s also not going to be covered by all insurance companies from the get-go. He has a couple of companies he is specifically working with and will expand from there.
[1:02:13] TS — But, just because this awesome program is available, doesn’t mean it will be available to you on your insurance. I want you to know that. And, it’s not that there’s anything wrong with the program. It’s a great program. In fact, many of my coaches are going to be coaches as part of this program. But, I do want you to know, because I don’t want you to wait. I don’t want you to have your symptoms to get worse while you are waiting for this to be covered under your insurance. There are lots and lots of coaches out there right now, ready to help you today. And, if you’re willing to allocate some funds to paying for this out of pocket, you can actually get the benefits of coaching NOW, without waiting. Just keep in mind that one of the benefits of coaching is that it will reduce your other healthcare costs. In other words, coaching does pay for itself.
[1:03:19] TS — In our next episode, Episode 8, I’m going to be discussing the unique type of coaching that I provide and teach to my coaches. I’m also going to tell you some tips, so if you are out there looking for a coach, you’ll know how to find a good one, and what to look for in terms of their experience and expertise, and also what to look for in terms of their programs and whether or not they can meet your specific needs and goals.
[1:03:50] In the meantime, if you already know you want to explore coaching as a way to reduce your pain and your symptoms, so you can get back to living the life you want to live, you can go to FibromyalgiaPodcast.com. We have a link there where you can schedule a complimentary consultation and we can discuss your options.
[1:04:10] If you have any questions or something you’d like me to talk about in future episodes, you can let me know through that website as well.
[1:04:21] I will see you back here next time where we talk about Fibromyalgia Coaching specifically, and I will see you then.
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