- [Moderator] It is my pleasure to introduce Doctor Lang today. Doctor Lang is a national and international expert and pioneer in the application of hypnosis. She is also the founder of Comfort Talk. She has held faculty positions in Stanford, Iowa and Harvard and she's been in practice
for over 30 years. She has abundant government research funding, she has over 150 publications and she has received the Ernest Hilgard Achievement Award for a lifetime of published experimental work. So please welcome Doctor Lang today.
(audience applauds) - [Elvira] Well thank you very much. I'm really delighted to be here and share with you some coping strategies. When we were originally thinking what should the title be, the original title
was about resilience and stress management in IR which is for patients and at the same time for staff because as you will see they are just very, very much interrelated. Now all this work started back when I was at Stanford and at the VA in Palo Alto
and there was a young Vietnam veteran who was very difficult to even get on the table and he needed a repeat change of his intestinal tube and it was this huge production with tons of drugs and it would really delay the whole day and that's where I saw the first time
how some imagery process or hypnosis process or whatever you wanna call it could make a difference. So I said hmm, very, very interesting but is this gonna work for other people and where is this all gonna lead to,
does it work also within a team without making extra issues of their own? So I set up a research program surrounding that which I then took to Iowa and also to the Beth Israel Deaconess in Boston which ultimately then led to me founding the company.
And after pretty much NIH and DOD spent about 5.2 million on all the clinical trials we did we can say yes it works and yes we can train teams in it, but then there comes the moment where you have to jump into the ice cold water and say, okay you're gonna leave this
high paying job at the Harvard teaching hospital as division chief and you set up your own company. So (laughs) that's my disclosure, and we now focus on training frontline medical staff and a lot of insight I'm gonna share with you here today comes from this activity.
I also do receive royalties on two books I've written.
Now, to become resilient and manage stress if you're in IR this is not something you can do by taking a 20 minute meditation break for yourself and typically by the time you're done with your day, your weekend,
you're coming home and there's a life too so just focusing on yourself and working really hard on meditation may not do the trick because there are other people around you who very much determine how your day goes. And we've published just last year in the JVIR
where we looked, well what happens if a patient walks in the door and they have this really negative affect. I'm getting more and more intrigued by the whole issue of mood contagion and if you look at that the people who come in like that, they actually
have more adverse events, they get about three times the amount of drugs and if you just look at anxious people it's those persons who come in and they look at you with these big, fearful eyes and they tell you I'm gonna die today,
how is that going to affect you? They are gonna experience more pain and above all, their procedures are gonna take much, much longer. The good news though is, what we've found out in this IR room with the multiple players
where there is one person feeding off the stress of the other it is enough to actually just relax one person and with that you can break this cycle. Yeah and then we have relatives that may make some pertinent remarks there
and there was actually a pretty cute study done by a NICU team where they randomized and had a simulated relative say something as kind as, oh if I would have known that you're doing here like third world medicine I would have brought my relative somewhere else.
Just something that pushes all your buttons and they found out that this whole team suddenly couldn't work as well anymore. Now it's not that easy to change what other people do but, you know, you're within this whole setup,
you may be the manager of your division or you have a manager whom you have to report to and there's a lot of other things that goes through your head. I mean this morning you heard about MACRA is in full swing, payment big time depends on it
and the satisfaction ratings and yes, you do wanna retain your staff because you need to have happy staff otherwise your patient's not gonna be happy either.
So what I thought is perhaps to just look a little bit
around and think a little bit of what happens when you are in a situation let's say, where you do feel comfortable, where things kind of go their usual ways and what do you do then, what are your coping mechanisms in that?
So I'm just watching something very interesting, there is three ladies in the third row and one of them took her arm up and the next one did exactly the same and you're looking at me somewhat astonished and scared. (audience laughs)
But this is something people to tend to do when they're in rapport. We do this very, very intuitively and you may perhaps even look a little bit around of how you're sitting there, the two ladies there who have their arms just like perfectly folded
in the right way, I mean one of them is completely not watching what her neighbor does because she's doing her iPhone but both of them are having their hands exactly in the same way. So you know while you're sitting there it's kinda of like a little spooky thing
of what we do when we feel safe and comfortable we do tend to match the body positions of others. So now, okay you gotta work now. So I would like now every second person of you to get up, if you don't have a partner look behind you, every second person gets up and you're gonna be
playing yourself and the person who remains sitting is going to be your patient in the waiting room. Okay, it's work time, yeah yeah work time. Little stretch time, so find yourself a patient victim and the idea is that your patient has been waiting patiently for getting their PICC line
and you had all these emergencies come in and they've already been in the waiting room for over an hour and now you got this neuro case being wheeled in and you're gonna explain now this is gonna take at least another hour, you can't even say how long it's gonna take,
and your patient is allowed to misbehave. So let's go, see how this works. Just keep talking to them, I mean you do, you've got that lingo down all the time. (audience chatters) Alright, and now just kind of freeze in
the body position you have. How much matching is going on right now? (audience chatters) So number one, your patient is kind of sitting and you are, many of you, standing. So you're right on top of them
and there's actually some research that shows that if you sit down, people think you spent more time with them. So, if now you all sit down and this may feel a little unnatural, match whatever your patient's doing. If they do that, you can do that a little bit.
If they do that, you can be a little copying it. The whole thing they tell you in medical school about this open positive section and never raise your voice, does not work. You do want to match, that is like the big secret. So you match a little bit in the beginning.
Now the idea is not that both of you are screaming at the end, but you just follow it a little bit. Oh really, you have to wait long and then you go and go down. If on the other hand your patient is deeply depressed, oh I can't do that, and then you say, ah and then
take your breath up. Okay I'll give you two minutes to continue your conversation with your unwilling patient. So also if your patient has their legs crossed you cross them, if they don't have the legs crossed you uncross yours.
Just do what they do and then the patients you can try to stay nasty but see what happens in trying to stay nasty or unhelpful if the other person matches you.
Alright so now if there's still a bit of disbelief in, oh let's just look a bit how it can normally look,
and how you might be able to change it, there we go.
I mean I just thought I'll show you that second clip, how natural it can actually look to cross one's arms but then she opened it up and it's very hard to then not follow along, so that's how you sometimes can save the day
in a fast way. Now dealing with pain and that's something I think that gets to all of us emotionally, I mean we are gonna be poking people and there's certain things of how we feel about
what the patient should be experiencing. We've done several large clinical trials so we had the opportunity to look at the standard of care groups of those where patients could get as many drugs as they wanted and if I were to ask you, just by show of hands,
what do you think hurts the most? Okay angiography? Large core breast biopsy? Tumor embos? Okay well it's kind of like, what I thought too. However if you plot onto this graph
on the X axis is the time zero you wheel a patient into the room and on the Y axis is their self reported pain. We ask them like every end of 15 minutes, by the way we don't say how bad is your pain, we say what is your comfort level on a scale
of zero to 10, no pain at all and worst possible, and zero no anxiety at all, 10 worst possible. And what you find out is, I mean there are these three curves going up over time and the blue line is the tumor embos, the red one is the angio renal and the yellow
is the breast biopsies, there's really no difference. And furthermore when we dug deeper into this data not only is this increase in pain over time, this trend relatively independent of how hard you poke somebody, but also independent of how many drugs they get.
Actually there's a somewhat inverse relationship between the amount of drugs people get and how much pain they experience over time that is sent. And the question is why is that the case? So from nature we are used to always assume the worst
and similar curve applies, although with some differences for anxiety but there's an increase in anxiety over time in the case under standard of care and I think it goes all down, that's one explanation (mumbles), he's a surgeon in (mumbles) uses,
he says, you know, hundreds and thousands of years our ancestors, let's say who walks through the Savannah and one behind hears a little noise and says, oh this could be a tiger, perhaps I should look around and do something about it and the other one says it's just the wind it's not a big deal.
You can see that being a little paranoid over time still probably translates into higher longevity and the ability to create offspring so we are all deriving from the somewhat more paranoid people that particularly, in a setting of ambiguity, we assume it's hurting
or it's bad or it's dangerous to us and it's a protective mechanism of the subconscious. That is going to happen. Furthermore, once there had been one painful stimulus then all subsequent stimuli are going to be interpreted as being painful or even more painful
and there have been studies done where they hook people up to a machine with little flashing lights and the first time they got a little shock and the next time just the little lights were flashing and they experiencing more and more pain with the little lights flashing even though
there weren't any more shocks. So that's what you have to deal with and this is what we all know. If you do a case that's over in 15 minutes it's not that big a deal. It's like you're in hour number one,
where you now are number two or in hour number three. That's when certainly everybody can get really, really stressed out. However, the good news is if right at the beginning you do something, you say to the patient something in words but also in your behavior
that reframes this experience this doesn't happen. And this is kind of the secret sauce, all you need to do is do something at the beginning, at time zero, and then you don't get this blue line on the standard of care where the pain keeps going up
over time, time, time, time. If you do some empathic attention the increase is not as steep but if you do some comforting words at the beginning, these are IR data in interventional radiology, you can go on for ever.
I mean it's just like a very different atmosphere in the room and very similar for anxiety. We've found similar responses in a trial we did with breast biopsies and tumor embolizations under standard of care pain to go up,
getting better if you give some empathic attention but anxiety dropping down very quickly while this patient is still on your table and actually even though the whole thing is called Comfort Talk you're gonna end up to talk much less
because the idea is to get that patient on autopilot as fast as you can, particularly in MRI. You wanna have them in there doing their own thing, having, as we shall say, their own experience while you can start to do all your paperwork
and your reconstructions and whatever you need to do.
We do use, particularly in interventional radiology we use a script
that somebody reads at the beginning of the case because not everybody has to work simultaneously at the beginning and we're reading this while the patient's prepped. I mean nobody stops, if we do large core breast biopsy we also do it while the patient's being compressed.
I mean nobody stops. So let's say perhaps nursing starts putting the blood pressure on, putting the probes on and all that, the technologist may start reading and then when those roles reverse the script allows that and somebody else reads.
If let's say you're in MRI, you just kind of may use some wording of it and you should theoretically be done by the time you walk the patient from the waiting room to the procedure room. Somebody's really claustrophobic you may need
to do a little bit more. But what I thought I'm gonna do with you, the basic of the script if somebody isn't too anxious takes you 90 seconds, we once timed it. If you wanna put in some extra provisions
like in IR that you wanna get somebody ready that there might be some potentially painful stimuli then you add a few of those what they can about, either mention some hot or cold pack and work on that and then if the patients already present with pain at the onset there's an extra little option for that.
If on the other hand they're really anxious and worried out of their senses there's another little piece and then at the end how we would reorient them. In that context it already has the explanation of what you do.
So the way this works, I'm gonna give you a little example of that, but what I'm gonna do is I'm gonna include what we call an insert. If you wanna do something special, you add a little thing in the middle and since this talk is about resilience
I thought to give you a little piece for if you need to get your confidence up like right at this moment. Either to walk in that waiting room to this patient who is already crying or you're walking in to your boss and you wanna have a salary increase
or let's say your chief of surgery who is throwing a tantrum in the hallway and you're gonna explain that this is not how it goes. So okay, and so basically what we would say to patients, well, and again there's a little confusion element
in the beginning, all we want to do is we want to help you so that you can help us so that we can help you to be more comfortable through this procedure. It's just a way of focused concentration like reading a book or watching a movie
or surfing the web and kind of forgetting where the time went and most people have this experience and, you know, you're fully in control of it. If it's a book you don't like you close it, same with TV you change the channel
and just use all the sounds and noises in the room to have your own experience and use only suggestions that are helpful for you. There are many ways to do this but there's a very simple way and on one you do just one thing, you look up and on two you do two things,
you slowly close your eyes and take a deep breath in, (inhales) and on three you do three things, breath out (exhales), relax your eyes and let your body float. That's right, just floating nice and safely, floating right through your chair or the table
and with each breath in take in strength and each breath out let go whatever is not helpful. Each breath in strength (inhales) and each breath out just let go whatever is not helpful. And just floating safe and comfortably like in a bath, the lake, or a hot tub.
That's right, and just with your eyes open or your eyes closed just focus on where you imagine yourself being now, what is it like? What do you see around, what do you hear, how does it feel like?
And you can make this your safe and comfortable place, you can always return to and play a trick on this whole procedure because your body has to here but you can be anywhere where you would rather be. And right now you may just focus on the moment
where everything just works out perfectly. One of these magic moments where everything comes together. You might have worked for it a long time or it just comes like a pot of gold at the end of a rainbow, and there you say, yes this is it
and it may be a private moment or a public achievement. While you're right in that just look a bit around a look at the colors that might permeate the scene and you can make these your colors so that whenever you need to get again into this state of confidence and peace and success
you just need to think of this color or you might get a pen or a pair of socks or just something to remind you of it. Or for some it may be a sound around, perhaps a song so that every time, at a moment's notice you need to get back into that state
you just think of the song or hum it for yourself. Or perhaps you enjoy just the way things feel and you can, you know, touch your thumb and forefinger together or you can do a very discrete, just curl your toes and then anytime you need it to get back in a state of confidence,
resourcefulness and brilliance all you need to do is just think of the color or the sound or of this movement that you gave yourself as a symbol. And now this was quite a lot to assimilate because sometimes in the conscious mind we have our own thoughts about whether subconsciously
we're assimilating all that into some new learning and while consciously there are all these logic things that go through one's mind, subconsciously one really knows how to move forward and which aspects to use and to learn. And now you can again gently float back
up over yourself and perhaps count backwards from three, like at three you can relax your eyes again and on two, start opening up your eyes and on one feel absolutely refreshed and delighted and ready to go on with the day
and you can even wiggle a little bit after in your room and go around and be all alert again, ready for the day to continue. Okay everybody back in the room. It got really quiet, very quiet.
So that was the deluxe version, that had the extra insert for the confidence. By the way, anyone of you who liked the color the best to remember? Or the sound? Or the movement, you can think a little bit
about how that works. You're really nice and quiet now. (audience laughs) It's amazing, you can have that in the IR suite where suddenly everybody just does their thing. Pretty good huh?
So and now I'm just gonna show you another video where we'll, just as an example how to go about the tips because you can't get anesthesia at four in the afternoon. That's when script reading really comes in handy, okay.
Leave that a bit for later. While we were doing all the work in interventional radiology
we were asked to train a private practice MRI team north of Boston because they further wanted to reduce their claustrophobia rate and that's how we got into this whole issue of using Comfort Talk in the MRI setting
and what we are finding out now more and more is that patients who are claustrophobic it's PTSD. So for the one's of you who are doing nursing and are called in there, that's what it is. The situation, in one way shape or the other reminds them of past trauma.
There is now a fair amount of trauma exposure therapy, particularly these veterans who are coming back from the various wars where they go to the psychologist's office and they are re-introduced to the setting and this is reframed and then the hope is that they walk out of the office and feel better.
That's hard to do. However, when the patient shows up at your doorstep and is completely freaked out, they are in the trauma, they're in it, and all you can do is actually make it better because it is the setting where they are the very most motivated to improve it
and this is also why it kind of works. We had done a recent trial at Boston Medical Center, Tufts and Ohio State where we basically just look at what happens if you train a team in just changing their vocabulary a little bit, sometimes they would read a script
but most often not, what is gonna happen to the outcomes? And we didn't even insist that people would use the techniques, we said okay you get the training, do with it what you want but it kind of changes after you see how things work
that you are gonna see your results and then adaption becomes more. So we saw the incomplete and no show rates going down and a significant improvement in patient satisfaction and there's nothing that improves your stress level
more than if a patient comes and says, hey thank you very much you really helped me through that. Or they really express their appreciation. And we then moved on and did a randomized trial and I think that gets a bit back to the original slides I did
in you are not alone in this. You are in this environment of commercial pressures of patients who come in who are not coming and then what is happening to your practice base. The fascinating thing about this, and that was in Columbus, Ohio, that the trial,
we trained three teams in Comfort Talk and three teams we didn't and that was in one healthcare system of MRI and what had happened at time zero is a fascinating event which I call the adverse effects
that philanthropy can have. For those of you who have come from the Columbus area there is so much money out there, there are more wealthy people probably than in New York that don't show it, but there is a lot of richness, so for somebody to give a hundred million
to build a new tower for the hospital is not a big deal. So they build a new tower but then the competitor in town obviously couldn't let this go by and they also got this beautiful nine story newer tower. Obviously all of them having MRI.
Same thing happening in Boston. I mean it's amazing how many millions, hundred millions in philanthropy for new stuff and everybody has a new MRI. So now suddenly, and it was at time zero you have more scanners in an area than you have
patients to go around. And what happens, what we found is, and that's the blue line, the people who were trained in Comfort Talk, were able to keep their volume and the others lost volume. So even in big urban areas word gets around
of like where do people go or we see impact on no shows. Most no show are people are frequent offenders but in any event we saw that. So now obviously if you are working in an area where you have fewer and fewer patients showing up
your equipment utilization is going down. And keep in mind that the current regulations are you are supposed to have your equipment running 90% of time, that's what payment is based on, that CMS payment is based on. So if you see this line going down
and you work in a place like that you can count on your five fingers that somebody's gonna get fired making things even worse because that's how administrators really high up solve that situation. And what we have seen is that, in other settings
where we had trained people whose patients are happy and actually send that in, that's actually a very good insurance against being, quotation mark downsized and this is what happened with patient satisfaction. So once you stress out the personnel,
patient satisfaction is gonna go downhill and we had done that and seen that in a prior study too where, in that very first place that had hired us it was a joint venture of two hospitals for an outpatient facility and at the moment the reimbursement changed
to have more reimbursement hospital wise. They told everybody they'll get fired or transfer. That obviously did make a dip down in the patient satisfactions but then they came up again and at least throughout stayed longer than before training. I thought I'm gonna just share this
because that got published last week and our first author, who's actually at UCLA in economics, already has given three press interviews. So you might be hearing about that in the weeks to come. We trained a team at Duke and we looked at,
where do people waste, where does extra time go, where does extra expensive time go? And the two columns on the left side are the hospital based facilities and the two right columns are the free standing facilities.
Pre is before training, post is after training. Now the interesting thing is that in the hospital based places the amount of general anesthesia and conscious sedation didn't change because there are fixed slots, and every month, interestingly enough,
it's exactly the same. But that comes from the fact that places that don't have anesthesia and don't have sedation send them there until the slots are filled. But you might notice that green bar, the oral sedation went down, and particularly
disruptive motion. So the whole idea that you put somebody under general anesthesia and their breathe to you on command is not necessarily going to happen. If you look particularly at the freestanding places you've got a pretty big decrease in all these issues
that cost you extra time and run into money. So if you look at all, I think a paper that came out at Emory, what they call unanticipated events, I mean I don't call it unanticipated if a patient moves around, that's kind of life,
but if you look at those we found a drastic reduction but then also found even if you use Medicare reimbursement data quite a lot of more money. If you do 25,000 patients a year, and you make 12,800 times 25,000
that's nearly 300,000 for that you can keep some extra staff without anything else happening, or at least you can keep your structure intact or invest in new equipment. I think, since now we are all kind of really quiet,
I wasn't sure whether I would be showing you another video but I think you really need it with another great trick which is, if you're doing something and there's a repeat thing gonna happen again, some stimulus that's unpleasant,
and this actually really happened, the one we're playing now. Let's say you have the patient and let's say they're heavy and you know they take a breath in and they're gonna hit the equipment, which is kind of a bit scary for the patient,
or let's say you do a biopsy and you use the gun and it's gonna shoot all the time. So you have repeating, or you do a laser, you have a repeating stimulus coming, you can actually interestingly enough use that stimulus to make what we call an anchor.
Remember when I did the little hypnosis script with you, where I asked you to think either of a color or a sound or of a movement to anchor that with something really pleasant, the same you can use a stimulus that happens to anchor the patient in either getting more relaxed
or use that as a sign to numb the area around even more. It sounds spooky but it works.
So let's look at this very last video we had about the heavy patient.
Alright, so you know in conclusion,
if you have a happy patient you're going to have a happy staff and the key ingredient really is this rapid rapport piece, to reframe the experience, avoid these negative suggestions and you can use a bit of this hypnotic language and it doesn't need to take extra time.
Thank you. (audience applauds)
Yes. - [Audience member] So we do lymph nodes integrity
inductions in the breast. They're extremely painful and patients come not prepared for a discussion about what's gonna happen to them. How would you give informed consent to let them know what's gonna happen
without giving them negative stimulus? - [Elvira] Well typically in those settings when you do your informed consent, whether it's something painful or where you potentially might kill somebody you still obviously have to describe what might happen
but what you're gonna do about it. Say, okay you know, and you explain what's happening, so say we'll be numbing up the skin and then we'll be injecting the material and you might feel that. Some people experience it as warm, some as hot,
some as a sense of tingling yeah, but the key thing is we want you to be comfortable and it's very, very important that you always tell me what is happening. If something, let's say your risk of killing somebody during your procedure, you say, and I've done
a fair amount of high risk cases. If, for example, while we're going through your heart and do that your heart stops we are going to resuscitate you and while we can never guarantee any outcomes I can promise you we will be doing everything known to mankind
to make this go well. I mean that is all I can promise so one can go somewhere deeper into that but I am open and some people in embolization say well, is it gonna hurt? I say well you know, different patients
experience it very different. The key thing is you are gonna let me know anytime how you feel like. I do not want you to be a hero, even if you say I do not want you to be a hero, still the hero is still in there,
I really want you to work with me and I'm gonna do whatever I can to make this a good experience for you. Which is, I mean it's honest, it's what you really want.
- [Audience member] How about children?
- [Elvira] Children, the beauty with children is that they have a very great imagination. I mean they are Batman, they are whatever they want to be and you can get them very quickly into their state. So for a kid, all you may need to do is,
oh what do you like to do? And then when they tell you what they like to do we use a little, how shall we say, ego strengthening piece in it. So for example, we do work a lot with Toronto Hospital for SickKids
and obviously what kids love there to do is play hockey, and so they go and play hockey and all the sounds there is your fans cheering you on and then they're gonna hit a goal and that kind of makes them really proud. What I may also add to that,
I've been thinking about this earlier to include in that is landscape in medicine is really, really shifting and what is happening that nursing and technologists, frontline staff are gonna be determining what is happening with patients.
We see this more and more, I mean doctors don't have really that much to say anymore and at Toronto Hospital for SickKids the nurse is running an absolutely landmark study. She's 11 patients away from 170 and this is gonna be the very first trial
that shows can you actually, if you decrease pre-operative anxiety, and that's kids who have cardiac ablations under general anesthesia, can the pre-intubation anxiety reduction, is that gonna result in better post operative behavior? Because there's a lot of research that you basically
create PTSD in these kids who come, they're in this environment the next time it's gonna be worse and worse. So she follows them up. But the other thing too is there always has been some thought about how much do patients
actually hear? When they are under, so with those kids we're actually also looking at not only a script at the onset but right before extubation. How is that gonna affect how they recover in recovery? What's it gonna do afterwards, what's it gonna do
for the whole safety? So I think particularly in kids, anesthesia is a problem because brain development can be affected depending on the age so we are very much into, hopefully soon, knowing exactly what is happening
in the pediatric population on a broad scale there.
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