Welcome back to the Healing Pain Podcast with James Maskell
We’re placing a spotlight under chronic pain group visits. As a loyal follower of the show, you know that we tackle and raise awareness around some of the biggest and most important topics and issues affecting pain science, pain care and chronic disease. Our guest is passionate about a single solution to the biggest challenges facing healthcare and how it can eliminate the chronic disease, escalating costs, practitioner shortages, quality care affordability access, practitioner burnout, loneliness, and the physical and mental health conditions we see now. That solution is the healthcare system that functions from a group visit model. Our guest is my good friend, James Maskell.
James is the host of a podcast and a show called the Functional Forum, which has become the world’s largest integrative medicine community. He’s on a mission to create structures necessary to evolve humanity beyond chronic disease, including chronic pain. He lectures internationally and has been featured on TEDx, TEDMED, the Huffington Post, and is also the Founder of Knew Health, a payer solution for chronic disease reversal. In this episode, James will provide you with the guide to creating and structuring group visits including how they originated, what they are, how to run them, how to avoid pitfalls and overcome challenges. Also, best practices for launching and facilitating a group visit, as well as online and digital tools for ongoing support. James will also discuss his book on the episode, which is called The Community Cure. It’s an excellent resource if you’re interested in group visits, how to structure them and how to get reimbursed for them. You can download that book by going to www.TheCommunityCure.com. I highly recommend you download it and grab your copy. Let’s begin and let’s learn all about group visits with James Maskell.
Watch the episode here:
How To Create A Chronic Pain Support Group With James Maskell
James, thank you for joining me. I’m excited to talk to you.
It’s great to be here with you, Joe. Thanks for having me.
I know you’re going to start talking about the concept of loneliness and isolation. It’s an important topic nowadays, and especially important for people who struggle with chronic pain and the practitioners who treat them. Tell us why we should all be concerned and interested in loneliness.
The first thing is for a lot of practitioners that are interested in getting to the root cause of chronic illness that loneliness and social isolation is the biggest driver of all-cause mortality, more than nutrition, smoking, the cigarettes or alcohol. Everyone knows it, but no one has any plan to do anything about it. It’s this understanding and it’s this systemic issue that people don’t like to think that there’s any solution for it. Over the last few years in my work in functional medicine, I’ve had the opportunity to bear witness to an elegant solution for curing and solving loneliness that’s applicable to regular people who want to get themselves well. Particularly health professionals that are looking to build structures to be able to get to the root cause of chronic disease. Chronic pain is even much more right in that zone. It’s a super important topic and I’m super excited to be sharing some of what I’ve had an opportunity to see over the last few years.
When you say the root cause, everyone’s antenna goes up. Especially people on the functional and natural medicine space and they say, “Root causes have leaky gut, have a nutrition imbalance or they’re not eating healthy fats.” You’re saying that below that root cause is another root cause of isolation. How did you become interested in this?
There are a lot of reasons why I got there. I’m outing myself and my book, Joe. In coming out of the closet as a kid that grew up in a commune, so I didn’t talk about it because it was weird for a long time. In fact, I was bullied at school. I remember being thirteen and venturing, “I grew up in a commune,” and all the kids making fun of me. I didn’t talk about it for a long time. That was the way that I was brought up for the first few years. I was always aware that the world wasn’t quite like that. Over the last several years, I’ve been involved in functional medicine. The goal in the last decade has been to get as many doctors run conventional medicine and help them understand this root cause approach functional medicine and shift doctors across. It’s part one of the master plans. We’re moving into part two, which is we’ve got to make that care available to everyone, even the poorest and most vulnerable people.
In 2013, I first came up with the idea of a functional medicine group visit. I was intrigued because, in the back of my mind with functional medicine, it was always like, “Are we only going to get rich people better? Are we only going to solve the problems that people can who can afford to pay?” I grew up in the UK. They’ve got a single-payer healthcare system there. That basically means no one’s going to get it because you’re competing with free. I was looking for ways that this kind of medicine, this root cause approach to get some more people, so I was fascinated about it. In 2015, I did my TEDx Talk and I talked about this group visit concepts, but I hadn’t caught light because it’s new for practitioners. First of all, we have privacy and there are a lot of things inside the system that focuses on doing care one-on-one like billing and all that thing.
In 2019, I had the opportunity to go to the Cleveland Clinic, which is the bastion where functional medicine is being delivered inside a major medical institution. I saw the model that they come up with which was before you see Dr. Hyman any of the five functional medicine doctors that you have there, you have to go through a ten-week, two hours a week training called Functioning for Life. Not only do you get introduced to a new peer group of people that want to reverse their chronic illness, but you get trained by health coaches, dieticians, and PAs, who teach you self-efficacy. How do you take care of yourself? Nutrition, sleep, stress management, all of these different things and the results were so spectacular and transformational that I realized, “This is it. This is going to be the signal to the market that this is the way that we do chronic disease care.” I reached out to my whole community and said, “I want to speak to anyone who’s doing any group care.” I turned it into a podcast series and that’s what led to this book.
If you look back over the decades of pain care and pain management back in the ‘70s and ‘80s, there was more group work, especially in hospitals. As the decline of medicine and reimbursement happened, group visits fell by the wayside as far as chronic pain management goes. Can you talk about the loneliness aspect with regard to pain and group visits?
One of the most interesting word that I’ve come across in my learning is the word, biopsychosocial. That’s a way of understanding chronic pain. It is seen as a biopsychosocial disease issue but if we look at all chronic illnesses, it has biopsychosocial elements. The thing about group visits is you are able to not only understand it as a biopsychosocial cause, but you can actually deliver a service that is biopsychosocial in nature. There’s a click-click. Lonely people’s pain scores are higher than people who are well connected. People’s success with pain medication or any pain modalities is better when they’re better connected. If we know that, we have to do something about it.
These pain group visits are exciting because one, you’re recreating community. You’re introducing people who have chronic pain to each other. You’re introducing them to people who used to have chronic pain but and now are way better through some of the modalities. Also, you’re setting up a structure where people can do the fundamentals of health creation, sleep, rest and have some accountability. More than that, specifically with pain, think about the modalities that you want to give to people in chronic pain. Let’s say acupuncture. That’s unaffordable in a one-on-one situation at scale, but imagine a group of twenty people sitting around and having acupuncture done by one acupuncturist in an hour and a half session. Suddenly the cost of that acupuncturist can be divided by all these people. They could be having ear acupuncture while they’re having a conversation, and you have this incredible synergistic effect where the barriers to entry for these integrated modalities go down and that’s exciting to me. There are a lot of reasons why the future of pain management is a biopsychosocial delivery system like group visits.
That word biopsychosocial is music to everyone’s ears. We’ve been talking about that for a few years and starting to focus on the bio, psychological and social aspects, which we know are untouched in our healthcare system, and perhaps globally with regard to all types of chronic disease. Let’s talk about a couple of different columns that are supporting all this. Let’s talk about the financial column first. Why should a hospital administrator, insurance company, and someone who’s managing a busy practice zoom in on this as part of their care?
The word that best describes group visits is elegant because it’s an elegant solution to a lot of different problems. Typically, group visits start as a resource constraint. In the Cleveland Clinic, they had a waiting list of 2,000 people and they were like, “We can’t catch up with this. What are we going to do?” Look at Terry Wahls. Her protocol takes over. She’s got thousands of people that want it and she’s like, “What do we do?” Dr. Shilpa Saxena, who’s the functional medicine group visit guru who’s like, “I’ve got sixteen diabetes patients, why don’t we put them all in a group?” It starts off as a resource constraint. If you’re involved in medicine where you are involved in a resource constraint, it can be an elegant solution to scaling up.
I did a talk in the UK in the National Health Service single-payer system. It’s one big resource constraint. With the Conservative government winning, it’s going to be even more constrained, so there’s even more back pressure to do something different. In America, a lot more organizations are interested in making money than saving money. Hospital systems and practices. The reason why group visits are so elegant is because it is also good at making money because you have a situation where you could provide a model.
It’s 90 minutes and two providers, one billable provider like a physician or physician’s assistant, and one non-billable provider like a health coach. You could be having 16 to 20 people in that one hour and a half billing them all a 99213 for a fifteen-minute visit, but they’re all getting a 90-minute visit. The insurance companies like it because they’re only billing for a fifteen-minute visit when you’re giving a 90-minute visit. Ultimately, you’re making money because you’re building twenty people at the same time.
A lot of the work can be done by non-billable providers, like the health coach who’s facilitating a conversation after delivering some content and facilitating a conversation while the billable provider is taking people aside. Taking a moment to do their vitals or whatever is necessary to do the insurance billable part on those two ends. The exciting thing for your community is what I’m seeing is this is lowering the barriers to entry for your community to deliver functional medicine. Some of the practitioners are not licensed to practice medicine and therefore, they have a different scope. Getting people in a room and talking about nutrition, sleep, exercise or otherwise not much can go wrong. Teaching people how to meditate and doing it slightly wrong is zero downsides compared to giving people the wrong medication. It’s good for people who want to make money and for organizations that want to save money. That’s why it’s such an elegant delivery system.
There are practitioners reading this and they’ve been on a one-on-one environment or maybe perhaps a fast-paced environment where they’re seeing one patient every eight minutes. How do they start to shift their mindset and start to cultivate some groups in their clinic?
One thing that is a root cause that is not honored and this is what my first book was about. That eight-minute production line can become an issue of moral failure for the practitioner on moral function because you don’t see people get better. You don’t have an opportunity to listen to them. A lot of practitioners are saying sorry in their head over and over again, “Sorry I don’t have more time to get into this issue with you that I can see is the cause,” or, “Sorry I’m late because I did take an extra few minutes with the person ahead of time.” Your fighting off fires all day. Ultimately in the group, you’re able to sit around.
A lot of the functional medicine doctors that have been on this production line for a long time that even take one group session a week is good for their mental health. They’re able to sit there, answer questions and see people being vulnerable with each other. Imagine being in a group and seeing your patients tell other patients things they’ve never told you because they never had the time or they don’t trust you enough to do it. The power of peer-to-peer medicine is so powerful. We may have been doing patients a huge disservice by not doing it. In fact, further isolating them when what they need is connection.
My friend, Kelly Brogan, who’s doing the hardest thing to do in medicine, which is to wean people off psychotropic medication. There’s nothing harder than that. She’s moved to completely to group model and she said that the key to her care, and I would imagine this is the key to your care to is, how do we send the body a signal of safety? How do we have the parasympathetic kick in and how they have the sympathetic turndown? What she said and discovered through her work was, “Nothing sends the signal of safety quicker and more effectively than the community.” In that context, we have to think about delivering this inside the system.
A group can take some pressure off a practitioner because the practitioner may be facilitating and leading the group. As the group is going over the course of one visit or multiple visits, there’s an exchange of information that happens from patient to patient. That takes some stress off the practitioner. It’s a peer-to-peer model, which is enriching for the patient and it can be cost-effective. What about someone like patients or people who have pain who may be reading this and say, “My conditions unique and I need one-on-one care, I’m not sure if this group is for me?”
I’m glad you asked that. Feeling like your condition is unique is profoundly isolating. You may be right but you’re probably wrong. One of the reasons why group visits haven’t taken off and become the standard of care is initially people can be resistant to it. They’re like, “No. I don’t want a group. I need this kind of care.” What we see in almost every situation is once people do it, they’re like, “This person is exactly me. Not only are they me but they’ve got results by doing some of the things that we’re talking about here.” In the group, we’re not going to talk about mindfulness. We’re going to do some mindfulness in the group because we got 90 minutes, we might as well spend ten minutes doing it.
I went to a group in Oakland, California called Open Source Wellness. It’s ethnically and socioeconomically diverse. We did the healthy behaviors there. We exercised in this group. Thirty of us together didn’t feel exercise, but got the heart going. We did a mindfulness exercise and meditated. For those people, finding other people like you who have had similar conditions, pains and root causes can be satisfying. Likely, you’re the only person in your family or maybe even in your workgroup that has the things that you have, but you’re probably not the only person. The best place to find those other people is in the pain clinic.
These can happen in person and live groups. Can you talk to us about the evolution of online and some digital tools that are important for practitioners to maybe start to look at if they’re entertaining? Are they doing this 100% online or can it be a hybrid too? You have the first visit in person and move into an online group.
I would say that online groups are bleeding edge. There’s not enough data one way or another to say, “Does it work?” Because we’re only getting started on it. Typically, if you’re billing insurance, people have to be in the insurance billable location. If you’re charging cash in your practice, that’s one of the reasons why there’s so much more innovation in America than in the UK. There’s a bigger cash market. In the cash market, people can do different things. We’ve seen for instance in the health coaching world or online nutrition, there have been people doing online groups quite successfully even some of the new technology. There are some electronic health record systems that are specifically for coaches and nutritionists that have an online group functionality within them and have even a place where patients can communicate with each other inside the portal.
I was working with a local pediatrician who was part of our practice accelerator here in Sacramento and we tried an eight-week hybrid group visit. We did the first two weeks in person so that people could get to know each other. We had a Facebook group for people to connect in between and weeks 3 through 7 were virtual. We came back together for week eight. I volunteered to be part of it because I wanted to experience it from a patient’s point of view. There are people in that group that I still count as friends and we were all connected at that point because it was to do with kids. It was a kids group. There are a lot of potentials there.
It’s not going to be a surprise to anyone to learn that virtual relationships are not the same as in-person relationships, but in the same way, I’m feeling reconnected to you, Joe. We see each other once or twice a year at conferences. If there’s a baseline of relationship that can be built in person it can be continued via Zoom. I’m not necessarily sure that you can spark new relationships that have the depth that is required to solve loneliness in a purely digital environment. I’m also open to innovation. If someone shows me they can do it, I’m totally in. I would say that people coming together around a specific issue that they’re having like Kelly Brogan’s Psych Med Reversal programs is the most likely place where you could create that because everyone’s one, similar in what they’re trying to do, and two, engaged into wanting it to be a success.
People who are highly motivated are interested in a specific niche topic and the practitioner has to become skilled at facilitating that group in person. If it’s online, you have to be even more skill to facilitate. You don’t hear someone’s tone of voice and you don’t necessarily see their face. If it’s a Facebook group, you could do a Facebook Live video too but it’s one-way communication and not two-way. You’re right. There’s a place for both and we’ll see technology will start to grow, advance and help people.
Imagine virtual reality as an example. Imagine you could probably have an online group visit a virtual reality room where people would be right there and you could get more of that. Even in this kind of environment, one of the things that you’re looking for in an in-person visit and this is why the two provider models is valuable is you are looking for subtle clues in people’s body language that either they’re getting it or that they’re disengaged. They’re sitting back and not engaged. Maybe they turn off the camera on the Zoom. That would be obvious. There are some examples of group visits plus remote patient monitoring. Remote patient monitoring became insurance billable. We’ve got some cutting-edge clinics that are 24/7 monitoring people in between and having a health coach monitor their vitals in between the groups. That’s pretty innovative.
That’s amazing to be able to monitor vitals and blood sugar. Can you tell us about some challenges that might pop up as a practitioner starts to implement this?
The first thing is most practitioners have been valued for their expertise for a long time. You’re an expert, you want to be an expert and you want to deliver that expertise to people. Some of the people that have come at the front of this like Dr. Brogan, Shilpa Saxena or Dr. Jeff Geller have started to realize that your expertise not necessarily what’s most valuable. The facilitation is valuable because what you want, especially what Dr. Geller said this so elegantly in the first podcast I recorded in the series, I did it with him. It was so awesome. I was like, “I’ve got do the book because this guy’s amazing.” He was saying, “I don’t live in the same zip code as these people that I’m serving. I don’t know what it’s like to be a Puerto Rican immigrant in the rough parts of Boston. I’m not going to stand there and tell them to do Tai Chi. I’m going to listen to them. I’m going to get them to ask questions. I’m not even going to come with a curriculum. I’m going to have them answer and solve their own problems.”
What he was doing there was dynamically solving the social determinants of health by getting a group together. Those groups have maintained. They started as diabetes groups twenty ago, but after several years, no one has diabetes because they’re also supporting each other to reverse it. What do they do for the next several years? It’s salsa dancing, gardening, trips and projects that they’re doing together. These guys still meet every week. It’s not being billed to insurance or a medical visit. It’s the re-emergence of the community.
They’re moving on to enjoy the things that life can bring and afford you when you reverse chronic disease and a chronic condition that can happen with functional medicine and this type of approach. I loved that you mentioned the social determinants of health against something that is rarely spoke about although this is starting to bubble up more and more. What can the average person do who only started to open up their view of groups? How do they find one, how they start to look for one? What can they do in that respect?
It’s probably best to start to join a group that is most relevant to you. In the book, I gave some examples. My friend, Mickey Trescott, runs the Autoimmune Paleo groups. What she found is she valued the community of being in a group of people that understood that eating an autoimmune paleo diet was crucial to them keeping their autoimmune disease under control and eating the AIP diet was isolating. They’ve got these cooking groups. It’s autoimmune wellness. They have a listing of 50 groups countrywide. For cancer, there’s this group called HealingStrong. They’ve got over 100 chapters where people get together. Ultimately, some of the most important tools that we have at our disposal are things like Meetup.com, Eventbrite because people are going on to them looking for these groups. The first thing you could do is you could go to your doctor. If you have a specialty issue, give them a copy of the book and say, “You should start a group here because there are people like me that would probably join it. You can build the insurance and we can start this group here.” That’s how you’ll find like-minded people.
I want to share an incredible story that can give everyone hope that this is not only possible but we’re coming into the new decade. What can we do in the next decade to solve this problem? There’s a place near where I grew up in the UK called Frome. It’s a town and there are a few towns around it that have commended the area, and 116,000 people live in that area. One of the things that happened there a few years ago, they decided to tackle loneliness through the introduction of groups. The first thing they did for a year was to chart every group in that area of 116,000 people. They found 2,000 groups. It could be church, bereavement, work-out, men’s shed groups, every group there was. They whittled that down to 400 groups that were solid. They were happening every week, regular attendance, weren’t going to go away and been running for years, good organization, all different levels and they put it up on a website.
They hired a few health coaches in the local GP clinic that deals with these 116,000 people. One coach in each location, where if you were lonely or if it was determined that that was an issue that you would see them and they would connect you to help you find a group. These people would also take office hours in what they call Talking Cafes. They were places in the area that were cafes, where two hours a day, they would be somewhere every day in the area where you could go and meet with one of these people, go through the website, find a group that works for you and be introduced to it.
Not only five health coaches but 1,000 community connectors who are not medical in any way. They’re taxi drivers, hairdressers, people who work at bars. How do you know that they’re involved? They wear this green lanyard and they have a little green button on their shirt that they wear every day. If you see one of those people and you tell them, “I’m struggling. I need some help.” They’re not trained to do anything apart from sending people to the resources like the Talking Cafe or into the clinic to meet one of these people or to the website. It had such a profound effect on loneliness that hospital admissions were down 20%, say £3 million. There’s a great sense of well-being in the community. That’s a program that could be implemented in any city in America super easily. I intend to spend the next years facilitating and delivering that in different ways.
What those guys don’t know is the power of functional medicine principles delivered in a group but they’re finding out about it because they met me. What they have done successfully is to start the foundation for essentially a new health system built around health creation and salutogenesis. In my book, I argue that we need a separate system for chronic disease. Starting a whole separate system looks extremely cumbersome, tiring and it might cost a lot. It doesn’t cost a lot. It has a negative cost because it saves a lot. Frome is a perfect example. If you Google, ‘Frome Community,’ you’ll see there are articles about it in the US and UK media.
A 20% decrease in hospital admissions can be a huge impact on the local community, healthcare, things and healthcare finance. I’ve been speaking with James Maskell. He runs the Evolution of Medicine. His book is The Community Cure. Make sure you check it out. I want to thank James, for joining us. James, let us know where we can find you. What’s your website?
GoEvoMed.com is the practitioner website. You can find The Community Cure. It’s going to be free from January 14th to 18th. I’ve self-published this book, so everyone would have access to it for free. You can get on Amazon and you can download it. I give you permission, if you download it, to send it to your local GP, a local doctor. Send it to every anyone who matters in your community because ultimately, these ideas are too important to be held in some financial prison. I would say to everyone, please send this on, share the message because the future of healthcare is participatory. Everyone needs to know that they can participate.
We love the idea of sharing. I will talk to our community here on the show. Whether you’re a practitioner or someone who’s struggling with pain, make sure to share this out with your friends and family, whether it’s Facebook, Twitter, LinkedIn or wherever your people are hanging out. Make sure to grab the link to this episode, drop it in a Facebook group or maybe there are people in the community who are talking about this information. On behalf of James Maskell, thank you for being here.
- James Maskell
- Functional Forum
- Knew Health
- The Community Cure
- TEDx Talk
- Terry Wahls
- Dr. Shilpa Saxena
- Kelly Brogan
- Open Source Wellness
- Dr. Geller
- Autoimmune Paleo
About James Maskell
James Maskell is the podcast host of the Functional Forum, the world’s largest integrative medicine community. He is on a mission to create structures necessary to evolve humanity beyond chronic disease.
He lectures internationally and has been featured on TEDx, TEDMED and HuffPostLive and also founder of KNEW Health, a payer solution for chronic disease reversal.