Monthly Archives: November 2012

Embracing Clark Griswald: Battling Depression and Anxiety During the Holidays

The holidays can be a time of great joy and family togetherness.  For many, however, the weeks between Thanksgiving and New Years can be a time of great stress and even depression.  The holiday season can be very busy and often involves parties, shopping, financial stress and stretching already strained relationships.   In 1985, the New York Times published an article on dealing with holiday stress.  Even though it is a bit dated, much of what is said in this piece rings true today.  Much of the depression seen during holiday times is caused by the creation of unrealistic expectations.  Too many of us strive for the Norman Rockwell painting of the “perfect family Christmas”; however, if you are a fan of Chevy Chase, you may remember the movie Christmas Vacation.  For most of us, our holiday times are more consistent with the Griswald Family Christmas.  Coping with holiday stress is much more manageable if you plan correctly, set limits and realistic expectations.

The Mayo clinic has provided tips for dealing with stress and depression during the holidays.  I have explored those that I think are most important to achieve holiday bliss.

1. Acknowledge your feelings:  Embrace the fact that the holidays are going to be a stressful time.  Admit that family and other guests may be a bit taxing.  Certainly, if you have lost a loved one or friend recently make sure to take time to deal with those feelings.  Take time to cry and grieve –you do not have to be happy just because its Christmas.

2. Reach out:  Feelings of loneliness are common during the holidays.  You do not have to deal with these feelings in isolation.  Seek out friends, family, church groups and others.  Volunteer activities during the holidays can help you feel engaged and less isolated.

3. Be Realistic:  Although traditions and rituals are important, times change as children become adults and families move to different geographic regions.  Pick important traditions and be flexible.  Remember, Cousin Eddie could show up at any time.  There is no such thing as the “perfect Christmas”.  (Reference the Griswalds).

4. Set aside differences:  The holidays are probably not the best time to work through major relationship difficulties.  Save these discussions for a later date.  Make the most of the holiday time together and overlook the things that normally can be upsetting and strain relationships.

5. Stick to a budget:  The worst thing that a family can do is to outspend their budget over the holidays.  The credit card bills will arrive in January and they still have to be paid.  Setting a realistic budget will minimize financial stress.  Alternatives to extravagant gifts include homemade gifts or charitable donations in a person’s name.

6.  Plan ahead:  Understanding what your holiday obligations look like will help with advance planning.  Set aside days for decorating, baking, shopping and cooking.  By creating a calendar of activities, you do not get overwhelmed by a long list of tasks that hit you all at once.

7. Continue Healthy habits:  The holidays should not be an excuse to “let the wheels come off”.  Stick to your normal exercise routine and work to minimize binge eating at parties.
Eat healthy snacks prior to going to holiday parties.

8. Learn to say no:  Although it is often difficult to decline invitations for parties, social activities or service projects during the holidays, you must know your limits.  Over-extending yourself and allowing no time for rest will only worsen anxiety and depression during the holidays.

9. Take time for YOU:  Taking 15 minutes alone during particularly busy holiday times is essential to maintaining your sanity!  5 minute meditation, reading a book in a quiet room or just sitting quietly is important during the hectic holiday season.

10.  Seek Professional Help if needed:  If you have feelings of anxiety or depression that become overwhelming–if you cannot sleep or have feelings of helplessness or thoughts of suicide, seek professional help.  Counselors and therapists can often provide strategies to help you better cope with the stress of the holiday season.

The holidays can be very stressful.  For those with underlying anxiety, depression or stress, the holiday season can exacerbate these emotions.  Remember, there is no such thing as the “perfect family Christmas”.  Just as in the Griswald Family Christmas portrayed in Christmas Vacation, family  holiday gatherings are full of unexpected surprises –everybody has a cousin Eddie.  The key is to have realistic expectations, have strategies to manage stress and conflict and take time to relax.

Medical Agape: Honoring Patients, Caregivers and the Concept of Selfless Love

The term Agape can be defined and interpreted as selfless love.  Although the concept of agape has biblical and religious connotations, it has also been invoked by both ancient Greek and modern philosophers as well.   Modern scholar Thomas Jay Oord defined agape as “an intentional response to promote well-being when responding to that which has generated ill-being.”  As we reflect on our many blessings during this holiday season, I began to think about the role caregivers play in the lives of our patients.  “Caregiver” is an all-encompassing term and may include hospital staff, support personnel as well as home health nurses and family.  The job of a caregiver is tireless.  Caregivers give not only their time but give their heart and soul.  To help and support a patient suffering with a chronic disease or terminal illness requires selfless love.  No one understands the role of a caregiver better than a patient.  As I was reflecting on this subject last night, I began relaxing with my online copy of the New York Times and came across a wonderful article from a familiar writer that moved me to tears.  When I was done reading the piece, I understood what agape was all about and realized just how brave and selfless our patients can be when facing terrible disease.

Once again, cancer patient Dr Susan Gubar has amazed me with her moving, insightful and powerful writing.  Once again, because of her, I have been forced to look inward and examine my own attitudes and behaviors.  Once again, I have learned a great deal from a patient I have never met.  Luckily, Dr Gubar has chosen to share her many gifts and her insights about the condition of “being a patient” through her writing.  This week in the New York Times, Dr Gubar published a piece on Caregivers.  Like many patients with debilitating disease, Dr Gubar has had challenges during her treatment that have required assistance from others.  When admitted to the hospital, Dr Gubar and countless other patients are assisted by tireless nurses, nursing assistants, orderlies, unit secretaries, volunteers and other personnel.  Many of these positions are not well paid but are essential to providing excellent patient care.  When patients such as Dr Gubar come into the hospital or are moved to a recovery room or hospital ward after a procedure, they are often lonely, hurting, frightened and confused.  How the caregivers respond can determine the entire quality of the hospital stay and can often ease the pain and suffering associated with disease.  A gentle touch, a soft voice or a song can make the difference between an intolerable night of pain and insomnia and a restful evening in the company of a new friend.

As physicians, we often get caught up in our own schedules and in our own sense of self importance.  We expect certain things to happen behind the scenes on the hospital wards, in the operating rooms, in the office and at the switchboard. Too often, we overlook just how these “little things” (which in reality are NOT little things) impact our patient and their disease.  As providers, we can learn a great many things from the way in which our support staff treat our patients.  When a frightened patient comes back from surgery and a nurses assistant spends hours holding her hand and quietly talking to her through the night to ease her fear and pain–this is medical agape.  This selfless action is often just as important as the skill with which the scalpel was wielded in the operating room.  Everyone has a role to play in the care of the patient.  Sometimes, the most important role is not that of physician.

Patients are significantly impacted by how they are treated by everyone involved in a healthcare system.  From the way the phone is answered, to the way a phlebotomist draws blood to the way in which a nurses assistant helps with a bath–all of these are opportunities to show medical agape.  As we go through our daily routines at work we may not realize that even the most routine job activities may make a huge difference in the lives of our patients–a gentle touch, a short conversation, a smile–all of these may ease pain and suffering, if only for a moment.  I am on call for the holiday weekend.  Initially, I may have grumbled and felt sorry for myself for having to work.  Now, I see it as an opportunity to make a difference in my patients and an opportunity to honor my support staff.  Because of the insights provided to me by Dr Gubar, I am going to try to notice these “little things” more.  I am going to thank the hospital staff for their tireless efforts and I am going to spend more time focusing on providing BOTH outstanding care and selfless love as I make rounds this weekend and in the days, weeks and years to come.

Eat, Drink, Be Merry AND Exercise: Minimizing The Impact Of The Thanksgiving Day Feast

Tomorrow is Thanksgiving Day.  It is a time in the US where we reflect on the blessings we have had in the previous year and gather together to  celebrate family, friends and football.  First declared a holiday by President Abraham Lincoln in 1863, Thanksgiving Day tradition centers around food and decadent culinary indulgences.  In 2012, over 280 million turkeys (or about 7 billion pounds) have been sold for Thanksgiving amounting to $3 billion dollars of sales.  91% of Americans eat turkey on Thanksgiving.  The US produced 750 million pounds of cranberries this year and nearly 20% of all cranberries consumed in the US are eaten on Thanksgiving Day.

The average American will consume over 5000 calories in one Thanksgiving meal.  Most Americans will gain 1-5 pounds during the holiday and many are never able to get these pounds back off.  Over the years, this excess weight accumulates and contributes to the obesity epidemic in the US today.  Most diners do not engage in any physical activity either before or after the meal.  A single serving of turkey or stuffing or pie can contain 500 calories each.  Many families celebrate the meal with wine and other alcoholic beverages as well.  In fact, data from the CDC shows that more alcohol is consumed in the US on the night before Thanksgiving than any other holiday (including New Years Eve, St Patrick’s Day or Christmas).  Alcohol contains lots of “empty calories” and can significantly contribute to holiday weight gain.

Biologically, eating a decadent meal such as a typical American Thanksgiving Day feast has been shown to create measurable changes in blood levels of triglycerides (fats) and other hormones.  In addition, indulgent meals have also been shown to increase the stiffness of arteries throughout the body (such as the coronary arteries).  These biologic changes can put patients already at risk for heart attack and stroke at even greater risk for these events.  Luckily, exercise, even modest amounts, has been shown to quickly reverse these detrimental changes.

What strategies can we employ in order to proactively combat the holiday weight gain?  

1. Eat a hearty breakfast.  Many people will avoid eating all day long and focus on one decadent holiday meal.  By eating breakfast, you are able to temper your appetite and avoid overeating at the Thanksgiving meal.  In addition, the chef of the home should begin cooking the meal just after breakfast.  This reduces the nibbling and “sampling” that goes on during the cooking process.

2. Serve the holiday meal in the middle of the day.  By serving the large meal at midday, you are able to promote and create time for physical activity both before and after eating.  Eating later in the day can result in slower metabolism and accumulation of fat.  In addition, by eating earlier in the day, you are less likely to eat multiple large meals in the same day.

3. Portion control and a strategic approach to the buffet.  When approaching a large holiday meal, focus on choosing and eating the healthier foods first.  Fill up with vegetables and other more nutritious items.  Certainly, sample all of the holiday goodies but limit portion sizes when you do.  Avoid seconds–it is better to save the second plate for leftovers the next day.

4. Drink lots of water.  It is important to remain hydrated on Thanksgiving Day.  Drinking lots of water helps with the metabolism of your meal and also gives you a “full” feeling throughout the day so that you do not gorge and “pig out” when the time for the holiday meal arrives.

5. Start a new family tradition.  Incorporate exercise into your Thanksgiving Day.  Take a walk as a family before the meal and consider a second walk after the meal BEFORE sitting down for dessert.  Often, by exercising, we are able to reduce our appetite and curb hunger prior to the meal and dessert.

Thanksgiving is a day to celebrate our good fortune with friends and family.  However, it is also a time that many Americans over-indulge in both food and alcohol.  Holiday related bad habits can lead to obesity and obesity-related illness.  Certainly, it is important to enjoy the wonderful holiday
meal and the company of family and friends.  However, by incorporating healthy eating strategies and a little family exercise into the festivities we can all avoid the unwanted pounds and unneeded calories.

Think Like A CEO: Must-Have Skills For Business AND Medicine Today

Now, more than ever, the practice of medicine has become a business.  Traditional business skills and strategies are essential tools for success in both academic and private practice settings.  As I have mentioned several times before in previous blogs, physicians must now not only be fastidious with a stethoscope or scalpel but also be equally as adept with managing a spreadsheet.  The concept of the “physician executive” is garnering growing support in both academic and private practice circles.   Dr Pam Douglass, former president of the American College of Cardiology (ACC), has publicly stated that the development and training of the new physician executive must be a top priority of the organization going forward.  In fact, partnerships with the American College of Physician Executives and the ACC are underway.  

This weekend in the Wall Street Journal business section, journalist Ruth Mantell discusses what she terms “must-have skills” that are now necessary for success and advancement in the corporate world.  As I read the article, I reflected on how each of these highly sought after skills could be used to improve physician practice and ultimately, patient care.  Each of the skills discussed are essential to the success of a Physician Executive and I believe are “must-have skills” that we must provide to young doctors in training as we move into the next iteration of the US Healthcare system.  

1. Clear Communication:  Ms Mantell correctly identifies effective communication as a key component to success.  In medicine, we know that the ability to clearly communicate with patients improves outcomes.  Healthcare systems in the future will rely more on cooperative co-management of disease among various providers.  It will be very important to clearly and concisely communicate management plans for a particular patient among primary care physicians, specialists as well as mid-level providers.  As mhealth (mobile health) and the expansion of the e-patient (electronic patient) becomes more mainstream, the ability to communicate both face to face and via email, twitter and other social media outlets will become increasingly important.   Moreover, as groups integrate with hospital systems and begin to come to grips with Obamacare, communication with other healthcare professionals and healthcare industry executives is paramount.  Without the ability to clearly state your position on an issue or negotiate a contract or manage hospital system politics, a physician’s success in the future will be limited.  

2. Personal Branding:  Again, Ms Mantell points out that online presence is an important part of how one is perceived in business today.  As I have previously blogged, management of one’s online presence is critical to using social media effectively.  Effective use of social media in medicine results in increased patient and physician engagement.  As patients increasingly go to the internet to obtain medical information and to choose providers and healthcare systems, it is vital that physicians and healthcare systems alike carefully plan and manage their online reputations.  Patients are now using Twitter to connect and discuss specific disease states.  Often they are recommending (or not recommending) particular providers or hospitals.  Proactive approaches to personal and system branding are critical to success.  Physicians must develop an online personality and manage it effectively.  Remaining active on Twitter, Facebook and creation of an interactive, frequently updated website is an important part of branding.  

3. Flexibility:  With enormous changes in the US healthcare system on the horizon, physicians and healthcare systems must remain flexible and embrace new technologies in order to remain competitive.  Physicians must develop contingency plans in advance of government mandates and regulation in order to be prepared to respond quickly and in a way that makes good sense for patients, one’s practice and the healthcare system as a whole.  No longer will “digging in your heels” and sticking to the status quo be a viable option.  Success will come through compromise and negotiation.  Having the ability to react to new mandates with a plan ready to implement will insure success and will keep you ahead of the curve.  Healthcare reform is here to stay.  What will define success and its impact on patient care in the US is the way in which the physician community responds.  We must remain advocates for our patients and ensure that no matter what “system” we are forced to work in, that we always put the needs of the patient first.  

4. Productivity Improvement:  Ms Mantell correctly describes the fact that in business today, workers are asked to do more in less time with less support.  Nowhere is that more true than in medicine.  Decreasing reimbursement, increasing pressures to see more patients in less time and contain costs by eliminating support are stretching physicians thin.  In the future, physicians who are able to develop strategies to become more productive will have higher success rates.  Utilization of newer technologies, online tools and electronic applications will likely provide the mechanism for improved productivity.  

Medicine is now a business. Ms Mantell’s article in the WSJ is a timely reminder of what we can all do to prepare for the practice of medicine in the future.  Healthcare reform and skyrocketing healthcare costs have forced physicians and healthcare systems to work together and find new ways to provide superior care.  Just as in business, there are new “must-have skills” that will separate successful physicians from the rest as we move into a new era in medicine.  Providing excellent patient care should remain the central focus of every provider.  However, understanding how to navigate the financial and regulatory challenges in healthcare are vital.  As we educate tomorrow’s physicians to be kind, compassionate and competent, we must also train them to become effective physician executives as they enter the brave new world.  

“Play it Again Sam”: As Time (And Life) Goes By

One of the most memorable scenes from the classic Humphrey Bogart movie Casablanca is when Ingrid Bergman turns to the piano player and says “Play it again, Sam”  and the talented barroom performer begins to sing “As Time Goes By”.

(Image via YouTube)

For many of us, time is not a REAL issue.  Certainly there are deadlines to meet, appointments to keep and pressures to get more done is less time.  If anything, we rush around in our daily lives competing with the clock.  The worst that can happen is that a deadline is missed, a deal falls through or we lose a big account.   For others, Time is the most precious commodity.  Chronic diseases such as cancer and heart disease can come with a stopwatch.  Certain cancers are very aggressive and have very limited survival times from diagnosis even with the best of therapies.  Patients with end stage heart disease and serious congestive heart failure also face limited timelines.  Individual perception of time varies greatly and is often dependent on both environmental/situational factors as well as one’s personality.

This week in the New York Times, author and cancer patient Susan Gubar explores her feelings of living with cancer’s timeline.  Dr. Gubar gives us all pause to think about how chronically ill patients think about the concept of time and how we all can work to better enjoy the “now” rather than worry so much about the “tomorrow”.  In addition, the ways in which our patients measure time may be very different from our own.  As Dr Gubar relates, time may pass too slowly during cycles of chemotherapy or too quickly when facing one’s own mortality.  As physicians, we must learn to better understand how our patients measure time.  It may be measured in years, or it may be measured in the intervals between hospitalizations.  Time, is in fact, a precious gift given to everyone in varying amounts.

Research has indicated that people do not perceive time objectively.  Children feel that time passes far too slowly as they rapidly experience new and interesting things throughout their early years.  By contrast, older adults feel that time moves far too quickly and they tend to cherish and savor each experience whether novel or mundane–especially when faced with the inevitability of their own mortality.

Patients with disease certainly have a different measure of time and individual perception may be affected by the nature of their disease.  A great analogy to help illustrate time perception as perceived by patients confined to a hospital for chemotherapy or other prolonged admissions for disease management is that of a long-haul airplane flight.  A direct flight from Los Angeles to Australia can average nearly 15 hours.  Rarely do we willingly confine ourselves to a single space for hours on end.  In the first few hours of a long haul flight, the time seems to pass relatively slowly.  We are, however, eventually distracted by those around us and the in flight meal and conversation with the flight attendants.  Time moves a bit more quickly as the next few hours pass.  As the flight stretches on, we may read and sleep in intervals and ultimately we are able to remember very few details of the “middle hours” of the flight.  In the time before landing, excitement builds and again time seems to slow down to a crawl.  When on a trip, we tend to remember nearly every detail about the activities in the cabin during boarding and takeoff and then again in the hours before touchdown and landing.  Patients that must deal with recurrent admissions for chemotherapy or congestive heart failure have reported similar experiences.  Many may measure time in hospital hours, or days or in blood draws or in intervals without pain.  It has been said that the good days “fly by” and time stands still when we are suffering.  As caregivers it is important to remember that what may seem like a “brief” 5 day admission for a course of chemotherapy or a “routine” procedure may be perceived as anything but that by our patients.  It’s all about one’s perspective.

Humans do not perceive time just as a clock ticks it away.  Most of the time we do not think of time as second to second and minute to minute.  Our perception of time is affected by environmental factors and this is particularly true for patients battling chronic disease.  The beauty of the practice of medicine is the lessons we learn from our patients.  Dr Gubar inspires us to take note of time; to cherish and respect time and to enjoy every minute–not as measured by a stopwatch but as measured in life experiences.  As physicians we must make sure that we are able to synchronize our own “clocks” with the patients that we treat.  Remaining sensitive to the subjective passage of time and how it affects both caregiver and patient will ultimately make us better and more effective both professionally and personally.  So, breathe deeply and quietly listen…”Play it again Sam.”

(Image via YouTube Frame Grab)

Practice Makes Perfect: Muscle Memory and “Brain Training” to Improve Patient Care

Certainly, when learning to play an instrument or perform a particular pose in yoga class, repetition and practice is important in order to succeed and ultimately to improve.  Athletes train their muscles to remember particular movements so that when in competition, they can perform at very high levels without even giving a thought to mechanics.   Similarly, a concert pianist or violinist are able to guide their hands along the keyboard or strings even under the pressures of playing at Carnegie Hall.  A recent article in the Wall Street Journal by Doug Lemov discussed the utility of rehearsing activities commonly performed at a particular job in order to free up the brain for other more complex tasks.  As the author suggests, there are limitless applications for this type of “brain-training” in business, medicine and other technically challenging professions.  

In medicine, the old adage of “see one, do one, teach one”  has been the standard for educating young medical students and physicians.  Much hands on experience is gained during the years of training in our current system.  As Mr Lemov describes in his WSJ article, practicing one task until it is nearly automatic allows us to devote more of our brainpower to other more complex tasks.  Practicing skills allows us to not only improve at a particular movement but more importantly helps us respond to a particular situation quickly, calmly and automatically.  This can be a life saving proposition in the practice of medicine, particularly in emergencies.  I suspect in medicine, we could improve upon the old adage and adapt it to “see one, do many, teach several” in order to apply these principles more fully.  

A recent article in the New York Times  described “brain training” techniques that are being marketed to children between the ages of 11 and 21.  Unlike traditional tutoring, these classes focus on brain exercises such as number recall, sequence memorization, and visual manipulation tasks in the face of distractions.  Similar to practicing repetitive mechanical tasks until they become second nature, “brain training” is designed to help students focus on complex mental tasks in the face of significant auditory and visual distractions.  The theory behind the process is that through the performance of mental exercises, we are able to sharpen and brighten the brain’s skills–similar to how a professional golfer may perfect his or her golf swing.  

I believe that the practice of medicine may very well benefit from incorporating these types of mechanical and cognitive practice sessions into physician education.  Today, medical centers are beginning to use simulators to train surgery residents to perform procedures.  Physicians in training should begin by utilizing simulators to develop muscle memory –then move to assisting and performing actual surgical procedures in order to perfect their skills.  Certainly, simulators do not replace the experience gained in the operating room but can improve safety and expose trainees to more opportunities to learn.  Additionally, physician-patient interactions could be simulated and practiced using actors as patients. Many medical schools are already using simulated patients to evaluate competency in patient interactions.    In my medical school training at Wake Forest University I benefited greatly from interacting with simulated patients.  Not only did I learn how to perform a history and physical exam  I was also given direct feedback from the patient–I learned the importance of making eye contact, expressing emotion and forming a connection with the patient in a short exam room interaction.   By putting even more emphasis on “practicing” these interpersonal interactions, physicians in training will be more prepared to handle complex situations such as delivery of bad news, angry families or other challenging patient interactions.  Most importantly, through a combination of both physical and mental “practice” we are able to perform at very high levels in very chaotic situations and environments such as the trauma suite in the Emergency Room or in the Operating Room.  

Practice makes perfect in sports, music and in medicine.  As medicine becomes more complex and more advanced technologies are made available, it is essential that physicians are able to become proficient and able to treat patients under pressure.  Moreover, the doctor-patient relationship is critical to success.  Physicians must constantly work to improve our ability to connect with patients.  Although practice may not always make us perfect,  practice will make us better physicians and ultimately help to improve patient outcomes.

Election Day Stress: Simple Tips For Minimizing the Negative Physical and Psychological Impacts

Tomorrow is election day. There is much at stake in this year’s election. Many agree that this may be the most significant presidential election in my lifetime and may very well determine the the future of the United States’ place in the world. That being said, this is not intended to be a political commentary, nor is it an endorsement of any one candidate. I will leave these important decisions to the reader.

This weekend, I came across an interesting article published in the European Psychopharmacology Journal that examined the psychological effects of election day on individuals participating in national elections. In the study, the investigators found that voting in national democratic elections created significant emotional and physical stress that could alter decision making capabilities. In this presidential election, more than any other I can remember, the country is polarized and most Americans are engaged and have a definite opinion–many of these opinions are emotionally charged.

The “fight or flight” stress response is an important adaptive mechanism for humans and other mammals. Cortisol, one of the most important stress hormones is produced in response to threat or in periods of physical or emotional stress. In the study, conducted in 2009 during national democratic elections in Israel, registered voters took a brief survey and had cortisol levels tested at baseline (both pre and post election) and immediately before approaching the ballot box to cast their votes. The cortisol levels were found to be three times baseline just prior to approaching the ballot box. In the survey conducted in association with the cortisol testing, investigators found that if a particular candidate is not popular in the polls and is unlikely to win that supporters have even higher levels of emotional stress and cortisol levels. As I examined this study, I began to wonder if part of the issue producing the excessive stress may be a perceived lack of control and the fact that the outcomes of the election process can have a profound effect on each individual’s daily life. Worries over fairness, fraud, and the political process itself are exacerbated by the way in which mainstream media attacks election coverage. Political ads and negative campaigning serve to further contribute to pre-election stress. To date, no study has looked at the rates of cardiovascular events during the days leading up to a national election, but I must guess that they may be significantly higher is susceptible patients. We know that other significant life stressors such as the loss of a spouse or loved one, or traumatic events are associated with increased risk for heart attack–its easy to assume that major political change may be as well.

So, what can each of us do to minimize the psychological impact of tomorrow’s election? Most importantly, understand what you can do and what things you have no control over. Understand what is important to you; family, friends, career and other interests. These will all exist even if your candidate loses the election.

What you can do to affect political change:

1. Participate and VOTE-if you do not vote tomorrow, your voice will not be heard. Remember, many lives have been lost over the years in order to ensure that every American has the right to cast a ballot on election day.

2. Campaign for your favorite candidate. Participate in fundraising efforts. Get involved in the grass roots efforts to get out the vote.

3. Write to elected officials. Let your viewpoints and opinions be expressed.

What things will not affect political change and will contribute to increased stress and anxiety during the election?

1. Constantly watch and read political coverage by the media. Certainly, it is important to remain informed, but don’t obsess with round the clock babble by popular political pundits.

2. Don’t’ agonize over the outcome. Although your candidate may not win the election, the life of the country will go on. Become or remain involved in your particular party in order to work for change in the next election

3. Don’t threaten to “abandon ship”. Moving to Canada and becoming an expatriate is never a viable option.

Tomorrow is a big day in the life of our country. Many important issues are on the table, including healthcare reform, foreign policy strategy and economic recovery at home. As US citizens we all have the right to vote. The election is a celebration of our freedom and of the men and women who have fought and died in wars to provide and protect that very freedom. Although change can be stressful and this particular presidential race is quite polarizing, make sure that you put election day in perspective. Control what you can control. Do not let the media, and the emotion of the process and the outcome negatively affect your physical and psychological health. Most importantly, get out and vote.