Category Archives: Emotional Health

The Land of Oz: Engaging Viewers or Selling Snake Oil?

Dr Mehmet Oz, also known by many as America’s Doctor, is a very influential face within American medicine.  An accomplished cardiac surgeon and Columbia University faculty member, Dr Oz has impressive academic credentials.  However, in the last year, Dr Oz has received significant criticism for claims he has made about non traditional medical treatments on his nationally syndicated television show where he has called many of them “revolutionary” or “miracle cures”–many of his statements are without scientific merit and have no basis in traditional evidence based medicine.  Much of this culminated with his voluntary testimony in front of the US Congress this past summer.  During the hearing, Dr Oz was blasted for making sensationalized, misleading statements.  While I believe Dr Oz genuinely cares about helping others improve their health, I do think that he used poor judgement when speaking about these non traditional treatments.

This week, a study in the British Medical Journal (BMJ) examined the claims that have been made by Dr Oz and The Doctors syndicated television shows.  In the study, investigators randomly chose 40 episodes of each program and then attempted to find medical evidence for claims made about 80 separate treatments.  What they found was astonishing–only 50% of the therapies had either a study or case report to support the claims that were made by the television doctors.  More concerning was the fact that of the 80 recommendations from the Dr Oz Show, the data supported the claims only 46%.  In fact, nearly 15% of the time the best available evidence actually contradicted the claims that were made by Dr Oz on his show.  The Doctors television program did slightly better with evidence supporting their recommendations 64% of the time.   The investigators concluded that most recommendations from medical talk shows lacked adequate evidence to support their use and that television doctors do not provide adequate information on each treatment and do not disclose any potential conflict of interest.

This particular study has significant implications for both patients and physicians.  As physicians we are constantly confronted by patients who come into to the office to discuss treatments that they may have heard about on television.  We must not only be aware of these therapies but we also have to better educate patients and help them decide if any of the “Dr Oz treatments” are right for them and their disease process. Patients are bombarded with medical recommendations from television which are commonly sensationalized and oversold by television doctors and other well known personalities.  We must caution patients that when phrases such as “miracle cure” and “revolutionary treatment” are used on television when a particular disease or medical problem is discussed that the advice given is more than likely too good to be true.

As a physician that regularly appears on television to provide insight and commentary for medical stories and new medical developments, I am always careful to provide information that is based in fact.  Media personalities have a responsibility to report the truth–when giving opinion, we must be clear that we are in fact, making a statement of opinion that is based on fact and the best available medical evidence.  As physician journalist, I have an even greater responsibility to choose my words carefully–it is part of the American culture that TV appearances give on camera experts increased credibility and believability. While I believe that Dr Oz as well as the physicians who appear on The Doctors syndicated shows have the best of intentions, I do think that their zeal for ratings and viewers may lead to making less than accurate claims.  These shows have great potential–they bring medical issues to the forefront and actually help to engage patients in their own medical care.  We know that patient engagement is critical to improving outcomes–and these types of shows can play an important role.  Rather than reporting on non traditional therapies that have not been studied by randomized controlled clinical trials, television doctors such as Mehmet Oz could make a much larger impact by focusing on ways to prevent disease and reduce obesity among his viewers.  For now, viewers must continue to question medical claims made by Dr Oz and other television doctors.  And physicians who play prominent roles in the media must choose their words carefully and ensure that accurate, data driven information is provided to viewers–leave the snake oil at home.

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Experimenting with The Emotional Impact of Facebook: New Issues Surrounding Social (Cyber) Studies Without Specific Consent

Facebook, twitter and other social media platforms have become a hotbed of data for marketers, business and product development experts.  In addition, social media has created a new way to observe and investigate some of the intricacies of human behavior and social interaction.  Last week, a study conducted using Facebook users as subjects was published in the Proceedings of the National Academy of Sciences and reported this weekend by the Wall Street Journal as well as the New York Times.  This study, while interesting, has raised a new debate on the ethics of using social media users in social experiments without their consent.  While Facebook claims that they have all rights to perform such experiments under their terms of engagement–that all users sign when they create a Facebook account, many Facebook loyalists are upset and feel as though they have been manipulated and violated.

As an academically trained Cardiologist at Duke University and now faculty at the University of North Carolina, I have had a great deal of experience in medical research throughout my career.  There are basic principles and rules that must be applied when designing and conducting any investigation involving human subjects.  All scientific research on human beings requires informed consent.  In the University setting, we have Institutional Review Boards that provide oversight to any human experimentation–these boards function to protect the rights, safety and privacy of patient subjects.  When researchers manipulate variables and look to examine results, patients can be affected–either positively or negatively.  There has been a great deal of outrage over the recently published Facebook experiment.  Many debate whether or not Facebook has crossed ethical lines by performing a study involving manipulating variables without the consent of the user.  While the attorneys at Facebook will argue that its users give blanket consent to research under their terms of service– I believe that the rules that all of us must follow in any type of human experiment should apply.  Social media and networking is now a part of everyday life and spans all age groups–all of us are affected in some way.

This recent report is no surprise–We have known that Facebook and other social media outlets have gathered data on users for years.  Google and Yahoo have certainly utilized data obtained from individuals search preferences in order to promote advertising of certain goods and services on their homepages.  In fact, Facebook has an entire data science team that is given the job of collecting and analyzing data from nearly 800 million users worldwide.

In the latest investigation, researchers set out to determine if the content of posts on a user’s newsfeed could influence mood.  For one week in January 2012, the accounts of over 600K randomly selected users were manipulated by the research team.  According to Facebook executives,  the identities of the individuals in the study group were blinded and no personal information was shared. What they found was impressive–users whose news feeds were flooded with more negative postings tended to produce more negative content themselves and those users whose newsfeeds were  flooded with positive and inspiring news predominantly produced more positive content themselves.  Previous research in the area of emotional contagion seemed to indicate that in order to pass on a mood or emotion, in person contact and non verbal cues are required.  After conducting the Facebook experiment, the authors concluded that now emotion and mood can be passed on in an online environment without any in person contact at all.  Moreover, emotions shared on social networks can provide a system for large scale spread to millions simply as a result of negative or positive posts by others.   While this information is interesting and potentially quite useful to the both the business and scientific communities, this utilization of human subjects as “emotional guinea pigs” without informed consent has created outrage among many throughout the internet.  Manipulating the emotions of Facebook users within the framework of this experiment has been seen as an abuse of trust by many who are engaged in social networking and calls into questions the ethics of social experimentation via online platforms.

Beyond the ethical considerations that this type of investigation raises, I believe that this study actually may provide a very important message to those of us who utilize social media in medicine.  Social media is a powerful tool that allows us to communicate ideas, describe new technology and treatments and disseminate information.  This communication can be quite broad and the audience can be rather diverse–patients, colleagues and industry leaders.  As physicians, our voices can be heard well beyond our respective institutions and social media allows us to reach broadly.  Because of this reach, and the power of social and involves We must remain positive and hopeful.  Our words can greatly influence the outlook of those who read our blogs, follow us on twitter and check our Facebook postings.  We must inform, discuss and improve awareness.  We must remain positive in order to continue to inspire those who look to us for their care.

The issues raised by the recent Facebook study will need to be addressed.  Going forward, social media users, as well as those that manage major online networks such as facebook, twitter and YouTube (and others) must decide how and when to conduct social networking experiments in a way that provides both useful data and also protects the privacy and rights of those involved in the experiment itself.

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Finding Success AND Happiness in Medicine? Where Is The Holy Grail?

Medicine is a very rewarding career.  However, recent changes in the healthcare system have made the practice of business much more cumbersome and job satisfaction rates among physicians is at an all time low.  Fear over the unknown and how Obamacare may affect our ability to effectively and efficiently care for out patients has significantly contributed to the general unease in the medical community.  Most physicians are highly driven, highly successful individuals.  Much of my professional happiness (and I expect other healthcare providers feel the same way) is derived from developing relationships with my patients and achieving excellent clinical outcomes.  However, balancing success and happiness in medicine is now more challenging than ever.  More time is now devoted to additional government mandated paperwork, arguing with insurers and managing escalating overhead costs.  All told, these tasks begin to take away time normally devoted to patient care.

This week, in the online magazine Inc.com, I read an article discussing tips for ensuring BOTH happiness and success.  As I read through the piece, I began to reflect on my own balance of success and happiness–How can these two goals can be readily achieved TOGETHER?  Although primarily directed at the executive/business professional, much of the content is very applicable to medicine.  In today’s medical landscape, the most successful physicians have embraced the concept of the Physician Executive–developing a business skill set that allows one to be fastidious with a spreadsheet while also providing exceptional patient care.  I have addressed this concept in several previous blogs–now more than ever, it is critical for physicians to think like business people in order to navigate the changes that are being implemented on a daily basis.  Although much of our new executive-like tasks certainly take time away from patients, if we are able to find the right balance we can still find happiness and fulfillment in our jobs.  As stated in the Inc.com piece, in order to achieve both goals we must think in unique ways–try to do things differently and find out work works best for YOU.

In the article, author Steve Tobak explores six unique ways that one can develop BOTH a successful career and enjoy a happy life–believe it or not, they do not have to be mutually exclusive.  Here is my take on how each of these suggestions (that were created by Mr Tobak) can apply to those of us who have made our careers in medicine and healthcare:

1. Develop real relationships:  In the end, relationships matter.  In medicine, the most important relationship is that with our patients.  Understanding patients feelings, their families and their preferences improves our ability to care for them.  Celebrating their successes and their family milestones provides me with great happiness.

2. Groom yourself:  No, I don’t mean comb your hair–Try new things.  Engage in other activities as time allows.  Make sure that you make time for family outings and that you try skydiving–or horseback riding–whatever it is that interests you–give it a whirl.  It may change the way you look at your work and your life.  Ultimately, exposure to new things can make us all better leaders and provide more opportunities for success at work.

3. Do Nothing:  Medicine can be incredibly hectic.  Running between hospitals and clinics.  Hustling to see a new consult or dictate another note–all of this “noise” can take away from happiness.  Every single day, just take a few minutes to do nothing.  Sit quietly and listen to your own thoughts…meditate.  Even a brief respite can make you more effective and ultimately improve your mood.

4. Work for a great company:  Whether you own your own practice (a rarity in today’s medical world) or work for a university or hospital, make sure you believe in the mission of the organization.  Be involved and try to influence policy.  If you work in an organization that recognizes and appreciates your efforts, your job satisfaction will improve.  If you do not, you may need to consider taking a risk and making a change.

5. Do one thing at a time:  This seems like an impossibility for physicians today (guilty as charged).  However, if you are able to make a list and prioritize–focus on one or two tasks at a time–you will see the fruits of your labor.  Crossing a task off the list gives us a feeling of accomplishment and completion which can add to overall happiness and satisfaction.  Trying to chip away at several things at once can often result in no task done well.  In medicine, it may be that you spend a half day a week on administrative work–take time to separate yourself from clinical work and catch up on the rest.

6.  Be good to yourself:  As physicians we expect nothing but the best out of ourselves–we are often very critical of our own decisions and clinical outcomes.  In the current healthcare market  (world of Obamacare reform) there is much we cannot control.  We must remember to remain centered and remain “in the present” in order to achieve happiness.  Although providing perfect care is a noble goal–it is not attainable.  Be reasonable with expectations–always provide the very best of yourself to your patients and be satisfied with the fact that you do.

Happiness is critical to a successful and fulfilling career.  With sweeping changes in healthcare, many physicians are finding it more difficult to balance both success and happiness.  By applying these 6 unique principles and looking at the “big picture” it is my hope that all of us can continue to serve our patients, continue productive successful careers and remain satisfied and happy throughout our professional and personal lives.  If we are able to achieve the right balance then everyone–patients, family and YOU–will ultimately reap the benefits of a long and HAPPY career in healthcare.

Nurses Show Us the Way: The Simple Beauty of Connecting in Healthcare

In today’s healthcare environment, we are all driven to see more patients in less time and do more with less support.  Obviously most of this is financially motivated–the delivery of medical care had unfortunately become more of a business than an art.  As more physician groups are now owned by hospital systems, the “bean counters” and administrators are now crafting the rules of engagement.  Physicians no longer have the luxury of time for a leisurely patient visit.  No longer do we have the time to routinely ask about the grandkids and the most recent trip that our favorite patients have taken in their retirement.  Ultimately, it is the patient who suffers.  Those who are ill and those who love them often need more than pills, blood tests, IV fluids and heart monitors–they need support and genuine caring.  These patients and families need a doctor or other healthcare provider  to sit on the edge of the bed and unhurriedly listen to their concerns –to simply chat for a bit.  Unfortunately, this is no longer the norm.  Luckily, we have dedicated caregivers on the front lines in our hospitals who can often fill the gap–nurses.

I was moved last week as I read a wonderful article in the New York Times by Sarah Horstmann.  In the essay, Ms Horstmann (a practicing Registered Nurse) describes her special connection to a few patients and their families on the orthopedic unit in which she works.  Ms Horstman chronicles her struggle with remaining objective and professional in her role as nurse when she becomes emotionally invested in her patients.  She paints a picture of an engaged and caring nurse who is able to put everything on the line for her patients.  Her internal struggles with “crossing the line” in her care for the patient is one that we all as healthcare providers have faced at one time or another.  However, she handles her feelings and her patients with absolute grace.  We can ALL learn a great deal from Ms Horstmann.  We should all strive to feel and care as deeply as she does.  Our patients and the care we will provide them will certainly benefit greatly.

In my experience in medicine, it is the nurses that often lead the way for all of us. I have particular poignant memories from my training of nurses on the hospice care unit at University of Virginia hospital   These nurses set a remarkable example of compassion and connection.  I have been forever impacted by witnessing true caring–crying, grieving and comforting dying patients and their families.

As a whole I have found that many nurses go beyond what the physician is able to do in short encounters.  Nurses spend the time required to get to know the patient–their fears, their thoughts about disease, their thoughts about their own mortality.  Nurses understand family dynamics and can help in managing difficult family situations.  Nurses make sure that above all, the patient comes first–no matter what the consequences.  The very best nurses that I have worked with over the years are ADVOCATES for those who are too scared or too debilitated to advocate for themselves.  Many times early in my career, I did not pay attention or listen to the lessons that were all around me on the hospital wards.  However, as I approach mid-career I am much more attune to these very same lessons that I may have missed earlier.  There is much gained when we watch and listen to others who are caring for the same patient–maybe in a different role–but caring for our common patient nonetheless.  I now realize that nurses have “shown me the way” many times and for that I am truly grateful.

In my opinion, emotional investment and developing patient connections can improve care and assist patients and families with acceptance and with eventual grieving and loss.  I believe developing bonds with patients is a wonderful expression of love for another human being and is completely acceptable in medicine–as long as we are able to remain objective when critical clinical decision making is required. In medicine we strive to provide excellent care for all patients but every now and again there are special patients that we develop emotional bonds with.  Just as in everyday life, there are certain people that you are able to connect with in a spiritual way–whether they are co-workers, colleagues, friends or significant others.  We must stop and appreciate the way in which nurses provide care–we can learn a great deal from them and ultimately provide more “connected” care for our patients.  So, next time you are in the hospital, find a nurse.  He or she will likely be haggard from running from room to room, and it is likely that they have not stopped to eat lunch.  Thank them for caring for our patients.  Thank them for showing us all how to provide better care for our patients.  Then, stop in and say hello to your patient–sit on the edge of the bed and take time to simply just chat.


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Better Health Care for America’s War Heroes: Its Time to Get Serious About Providing Mental Health Services to Veterans

Today I am blogging because I am angry.  Like many Americans, I am saddened by the deaths of twelve innocent people in Washington DC this week.  My emotions have been difficult to reconcile over the last 48 hours.  Often, blogging can be therapeutic for me–today this is particularly true.  Typically, my musings are less than 750 words in length–please forgive me but today I may have to go a bit longer…

The tragic events that occurred at the Naval Shipyard in Washington, DC on Monday have forced all of us to reflect and many of us have begun asking very specific questions:  why did this happen? how could this happen? and, most importantly, could this have been prevented?  As details have emerged, it has become apparent that the alleged gunman Aaron Alexis was suffering from significant mental illness.  The reports of his symptoms suggest psychotic features such as those seen in patients with schizophrenia.  As the investigation continues, it appears that the gunman was a veteran (navy reservist) and had sought mental health counselling and care from the VA hospital system.  Unfortunately, the “system” failed him—failed those who were killed in the Naval Shipyard shooting– and ultimately has failed all of us. Our veterans deserve better.  The VA healthcare system is a proud institution with a rapidly increasing number of patients as the wars of the last 10 years continue to produce ailing servicemen and women in need of care.

Mental health care in the VA system has been identified as a major weakness by those in the VA administrative offices in Washington DC as early as the end of the Iraqi war.  As reported on National Public Radio (NPR) in 2012, the VA has not been keeping up with mental health demands.  In response to the increasing number of veterans entering the mental health system, the inspector general made it a priority to improve mental health services and decrease wait times for veterans requesting help.  In the last five years, the number of veterans requesting mental health services has increased by 33%.  In response, the VA appropriately approved increased funding and beefed up standards for patient evaluation and management.  However, it has become apparent that the ways in which the VA measures itself against a “standard” is rather dysfunctional.

In a hearing in Atlanta in July, 2011, Senator Patty Murray, Chair of the Senate Veteran’s Affiairs Committee, questioned the way in which the VA has been handling mental health care claims.   The Inspector general issued a report and admitted before the Congressional Committee that the VA had skewed the statistics in order to make wait times appear shorter than they really were.

In an opening statement, Senator Murray states:

“In the face of thousands of veterans committing suicide every year, and many more struggling to deal with various mental health issues, it is critically important that we do everything we can to make mental health care more accessible, timely, and impactful.  Any veteran who needs mental health services must be able to get that care rapidly, and as close to home as possible”.

As I mentioned above, during the hearing data was presented that seemed to indicate that most patients were receiving timely mental health care and referrals–the standard is that any patient requesting mental health services is contacted within 24 hours and an appointment is scheduled within 14 days.  However, upon closer inspection, it was determined that the way in which the VA tracked this data was flawed.  They only counted the time until an appointment was scheduled.  Real data from veterans in mental health referral situations shows that the average wait for mental health services in the VA system is actually 50 days.  In some centers (Seattle, for instance) the average wait is nearly 80 days!  Mental health requests will continue to increase as more brave soldiers return from battle.  Those who have served must be afforded with easily accessible, timely healthcare.  Certainly, in the case of naval shipyard shooting suspect Aaron Alexis, better access to more comprehensive mental health care may have made a difference and this week’s tragedy could have been averted.

Senator Murray, after the Atlanta hearings in 2011, issued a summary statement that we should take notice of again today:

“This report confirms what we have long been hearing, that our veterans are waiting far too long to get the mental health care they so desperately need. It is deeply disturbing and demands action from the VA. This report shows the huge gulf between the time VA says it takes to get veterans mental health care and the reality of how long it actually takes veterans to get seen at facilities across the country…this report clearly shows that the VA is failing to meet their own mandates for timeliness. Clearly the VA scheduling system needs a major overhaul.  The VA also needs to get serious about hiring new mental health professionals in every corner of the country.”

The Senator goes on to say  “…the VA is failing many of those who have been brave enough to seek care. It is hard enough to get veterans into the VA system to receive mental health care. Once a veteran takes the step to reach out for help we need to knock down every potential barrier to care”

It is clear that we must do more.  Large agencies such as the VA must eliminate the bundles of red tape that those seeking mental health evaluation and assistance must navigate.  Every single day there are multiple suicides among veterans.  Although money has been allocated for hiring new mental health professionals, a report issued as recently as February 2013 indicated that although roughly 1900 new mental health professional positions have been created, they are not yet filled.  In fact, other previously approved vacant positions have yet to be backfilled.  Our veterans continue to suffer.

When are we going to get serious about providing timely access to mental health services?  Now, more than ever, we have been given a solemn wake up call.  Shall we wait for another mass shooting rampage before we seriously attack the problem?  Do we continue to tolerate those that manipulate data to meet predefined metrics or do we say ENOUGH!  We need action NOW to prevent future tragedies.  The VA system was created to SERVE those who have SERVED.  It is time to live up to that lofty charge and provide prompt mental health care services to those who need it.  Hopefully, with time, those who are grieving losses at the Naval shipyard will heal–lets honor the memory of the fallen by working to provide better mental health services in the US today.

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Underestimating The Impact of “Waiting for Godot” (and A Doctor’s Call)

In Samuel Beckett’s play, two vagrants pass the time of the day by waiting for another man named Godot–a person that they have never met.  The wait becomes intolerable at times and the men argue, philosophize and even go as far as to contemplate suicide in order to “pass the time.”  It is estimated that Americans spend roughly 37 billion hours waiting in lines each year.  Waiting in lines can have a negative emotional toll–just as in Beckett’s play–as we stand in line, many of us have a nagging sensation that our life is slipping away. Waiting can produce irritability, anger, anxiety, and boredom.

Unfortunately, healthcare is ubiquitous with waiting.  We wait for an appointment, we wait to be called to the exam room, we wait to hear the rattle in the door that signifies the arrival of the physician.  As patients, we all come to accept waiting as part of the ritual of medical care.  (and with the new Affordable Care Act I expect waiting will become even more commonplace).  However, some waits can be intolerable and can negatively affect our psyche–leading to sleeplessness, anxiety and even depression.  One of the biggest challenges facing healthcare providers is the ability to quickly and accurately disseminate tests results and information to patients.  Even in this era of electronic medical records, smartphones, twitter and facebook we still sometimes have to wait for an old fashioned phone call from our doctors.

This week in the New York Times, Dr. Mikkael Sekeres shares his own experience with waiting for news from a physician.   Dr Sekeres, an oncologist, often must return panicked phone calls from patients and families with serious diagnoses.  In his essay, Mikkael describes his emotions while waiting on his doctor to call him about an abnormal cardiac stress test.  As physicians, it is important that we read this piece and are able to understand the healing power of a simple phone call.  As with most things, the experience from the “other side” of the white coat is very different from what we may perceive about the patient experience.  Learning from our own experiences as patients will inevitably make us better caregivers in the end.

Today, physicians and other healthcare providers are asked to do more with less time.  With increasingly grueling inpatient and outpatient schedules, tasks such as returning phone calls often get delegated to others or pushed to the end of the day.  What may seem like a “low priority” activity to a busy physician may very well be a “game-changer” for the patient awaiting the buzz of his or her smartphone.  However, we must remember what is most important to a patient who is left waiting and worrying–information.  Information provides power and gives back control.  When we have information, we can start to make choices and begin to move forward.  Living in limbo is not a party–for many, limbo is purgatory.

Given the mandates for electronic records and e-prescribing, why can’t we come up with a HIPAA compliant way to allow patients immediate access to test results?  This is a very difficult question to ponder.  There is no easy answer.  Doctors are not reimbursed for this type of work and yet physicians must justify every minute of their existence to the “bean counters” that follow them around electronically.  Assistants often answer patient calls for healthcare providers and are often ill-equipped to handle the questions that may arise when providing results or other medical information.  Many patients and practices have systems in place that allow a patient to log on to a secure website and look up results–however, how does the average patient interpret these results?  Will this create even more anxiety and worry?  There is no replacement for the doctor’s call–some situations must be handled by either a face to face visit or a personal phone call.  We must remember to imagine what waiting in purgatory must be like for our patients and make it a priority to provide timely results and information in order to ease their pain.  Even if Godot never shows his face…

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Connectivity, Email and Stress: Finding the Proper Balance for Success

Well, here I am.  Again.  On vacation and connected to the internet.  I must admit, I am addicted.  Twitter, blogging, and email.  I cannot seem to just let it go–not even for a week.  Email, in particular, seems to have taken a dominating role in all of our lives.  Constant hip checks for email downloads to our iphones have become an obsession.  As we speak, I am on a beautiful 4 hour train ride from Edinburgh to London (the same route that Harry Potter and his friends take from Hogwarts, no less).

This week on the website Inc.com, I came across an interesting article that explores the ways in which email is ruining our health.  A group of UK researchers decided to examine the effect of email on a group of workers.  Objective measures such as blood pressure, heart rate and cortisol levels were measured and the workers also kept a log of their work activities during the study period.  Results of the study indicated that a single email was no more stressful than taking a single phone call–however, an inbox full of a large amount of email produced a powerful stress reaction with elevations in cortisol, heart rate and blood pressure.  Interestingly, the study did find that the type of email received had a significant effect on stress.  Email that was received about current activities and contained time relevant information as well as emails that congratulated a “job well done” were not at all stressful.  in contrast, emails that were completely irrelevant and interrupted tasks were incredibly stressful and levels of cortisol, blood pressure and heart rate all spiked.  The lead researcher, Dr Tom Jackson, concluded that the email itself is not the issue–it is how the email is used that causes the problems with increased stress.  We are managing email in the  midst of phone calls, family time, and other in person meetings.  Often, responding to and filtering through email can be a distractor and take us away from more important tasks. Hence–email is stressing us all out.

As I mentioned, I am currently on “holiday” in the United Kingdom with my family.  I have tried very hard not to use email but I have failed miserably.  For me, the act of checking email twice a day has lowered my levels of anxiety about work.  However, when I stumbled upon certain email messages my levels of stress began to spike.  These were often emails that I could  do nothing about until I return to the states.  (As with most folks, feelings of loss of control and the inability to respond also create elevated levels of stress).  Luckily, I have my family with me on our tour through the UK to set me straight–instead of fretting over the emails and how to handle them, I was “convinced” to take a walk to Edinburgh castle and enjoyed a nice day in the sun (It may have been the only sunny day in Scotland this year).  My family and I had a wonderful day together in the castle.

I think that, in reality, one must find a balance between connectivity and relaxation.  For each person this balance is going to be different and based on individual personality traits.  I enjoy blogging and it is a very relaxing, stress reducing activity for me.  As I have mentioned in a previous blog, writing allows me to process my thoughts and share my feelings.  (Hence this blog is being written over the course of a four hour train ride).  For others, a completely disconnected holiday is the best course.  Whatever it may be, find your own balance.  Understand that email is an important tool for productivity and that it can be abused.  For me, I am learning what types of emails tend to elevate my own cortisol levels and will attempt to avoid these emails on future vacations.  Life work balance is essential to success and longevity–finding your own balance with email and connectivity is a critical component to this process.  With that, I am going to sign off and stare out the window at the beautiful Scottish wind blown sheep.

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The Blogging Patient and Cyberspace: Unlimited Possibilities for Improving Health and Battling Disease

Social media has opened a whole new world for patients.  Now, information about disease is readily accessible and available to everyone.  Certainly, there are issues with reliability and accuracy of internet sources and this can create uneasiness and misunderstanding for both physician and patient.  However, the internet can also provide many new therapeutic possibilities.  In particular, online support groups, twitter chats and blogging can provide a positive outlet for patients suffering with disease.  Today, I want to focus on one of these internet opportunities–the patient blog.  Recently, a online article on iHealth Beat explored this concept  of patient blogging and its benefits.

Just as commonly experienced in the climax and resolution phase of Greek tragedy, writing a blog about one’s experience as a patient can be cathartic.  Patients with chronic illnesses or with a new diagnosis are often confused, frightened and angry.  Numerous studies in the psychiatry literature have demonstrated that journaling or writing about one’s feelings and experiences can have a very positive effect on emotional health.  Journaling has been shown to have several other unexpected benefits as well.  In the age of the internet and social media, journaling is now called blogging.  Blogging can be a private posting (where only you  or those you approve can see) or can be made public for anyone to see.

Blogging can have many benefits that are very similar to journaling.   From a pure neuro-biological standpoint, while you are occupied with writing, the analytical left brain is engaged in the writing process.  This allows the right brain to be free to feel, emote and create.  In this setting, you are able to better understand yourself and the world around you.  Specifically, there are four distinct benefits that patients can receive from blogging that I believe are worth mentioning:

1. Blogging helps to clarify thoughts and feelings:  Often writing down our feelings provides a way for us to better organize our thoughts.  Blogging can help patients with terminal illnesses better understand their disease and how they are reacting or adjusting to the challenges of the diagnosis and/or therapy.

2. Blogging helps you to get to know yourself better:  Writing routinely will help you better understand what makes you happy and content.  Conversely, writing will also help you better understand what people and situations upset you.  This can be incredibly important when battling chronic disease.  It is important that you are able to spend more time doing the things that make you happy and are able to identify and avoid things that are upsetting.

3. Blogging helps you to reduce stress:  Patients who receive a diagnosis of a major illness or who suffer daily with the challenges of chronic disease often have a great deal of anger and resentment.  It is human nature to ask questions such as “why me?”.  Blogging about angry feelings can be a positive and therapeutic release of emotion.  It allows for the writer to return from the blog more centered and better equipped to deal with negative emotion

4. Blogging helps unlock your creativity:  Often we approach problem solving from a purely left brain analytical perspective.  This is how we are taught throughout our education to attack problems in math and science in school.  However, some problems are only solved through creativity and through the use of a more right brain approach.  Writing allows the right brain to creatively attack problems while the analytical side of the brain is occupied with the mechanics of the writing process.

I believe that blogging can be just as important as medication compliance in patients with chronic disease.  The diagnosis of a chronic disease can produce a great deal of stress and emotional angst.  Patients who are able to deal with negative feelings and emotions in a more positive way are better suited to tackling their health problems.  As mentioned above, blogging has many benefits on our emotional health.  By dealing with negative emotions and unlocking creativity, we are better able to deal with the realities of chronic disease and more effectively interact with friends and loved ones.  I encourage everyone–patient, physician, family member or friend–to begin to blog.  I expect that the health benefits of writing will be well worth the time in front of the computer screen and the insights that you may discover about yourself may be be life changing.


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Helping Patients Successfully Weigh Options: Effectively Discussing Risks and Benefits Prior to Procedures

Medicine is about balancing risk and benefit.  Certainly, as healthcare providers, we attempt to provide the best care for our patients based on available evidence.  Physicians often are seen as shepherds, helping to guide patients through disease and therapy.  As I have mentioned in previous blogs, ultimately medicine will be personalized and tailored to one’s particular genetic make-up.  However, the need for a clear discussion of treatment options with patients will remain a necessary and important part of the doctor patient relationship–even in the era of genomics.

Recently an article was published in the Archives of Internal Medicine that examined the way in which cardiologists communicated with patients prior to implantation of an Implantable Cardioverter Defibrillator (ICD).  As an Electrophysiologist who routinely performs ICD implantations, this particular study hit pretty close to home. The authors used patient focus groups to determine just how well each was informed prior to their respective procedures.  Researchers found that many patients felt inadequately prepared specifically for the emotional and psychological impacts of ICD therapy prior to proceeding with implantation.  Moreover, many patients felt that they did not fully understand the reason for the procedure or its possible complications.

For the most part, I think that procedurally based physicians do a fair job of explaining the technical aspects of the planned procedure and readily quote complication rates (as required by informed consent).  What we don’t do a great job of is making sure the patient actually understands the explanation or the risks.  Physicians who are procedurally focused often do not consider the long term emotional and psychological impacts that procedures such as ICD implants may have on the patient down the road.  As Electrophysiologists, we are aware that there is a growing body of evidence to support the significant psychosocial and emotional side effects for patients living with an ICD (mostly thanks to the outstanding work by colleagues such as Dr Sam Sears).  In the last decade, device recalls and lead failures have led to significant patient morbidity and mortality.  All of these complications come with a price–both physical and emotional.  

Clearly, we are not doing enough when discussing a potential procedure with a patient.  I do not believe this is in any way limited to Electrophysiologists who are implanting ICDs.  I think that this study brings up an important issue for every physician to consider.  The results of these patient focus groups should cause us all to pause and evaluate our ability to communicate with our patients.  In my practice, I make a conscious effort to carefully explain the procedure, why it is indicated and what the potential side effects are to both patient and family.  But, after reading the Archives piece, I am left wondering, do I do enough?

Given the shortcomings that are illustrated in ICD consents in this survey, Where do we go from here?  I think that we must reevaluate the way in which we discuss procedures with our patients.  Certainly the principles of informed consent must continue to be documented for the lawyers of the world.  However, we must go beyond basic informed consent and make sure that we are able to provide a reasonable explanation of possible long term emotional and psychological side effects (as well as the immediate impact on our patient’s lives).  We must also do more than simply discuss the statistics and the potential for risk vs. benefit.  We must provide the patient the opportunity to ask questions and to explore with our patients how the implant of an ICD may impact their lives–both positively and negatively.  Only then, can we feel as though we have truly served as a guide for those we are charged with caring for.  After all, one of our most important jobs is to communicate options in a way that allows our patients to make the best treatment decisions for themselves and for their families over the long haul.

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Suffering in Silence: When Doctors Fail to Ask The Right Questions

Let me start by saying that I am by no means an expert in Medical Oncology and I have great respect for what my colleagues in this field are able to do for their patients and their families.  From my earliest days of Internal Medicine training at the University of Virginia, I can remember the oncologists as being some of the most caring and compassionate physicians around.  However, recently I came across a remarkable article in the New York Times that gave me great pause.  Author Suleika Jaouad has been chronicling her battle with cancer in a regular blog.  In this particular entry, she describes her experience with dealing with the sexual and reproductive side effects of her cancer and its therapy.  Ms Jaouad brings to light the fact that often physicians fail to ask the right questions at the right time of the patient in their care.  It is not for lack of attention or concern but more often due to a laser-like focus on the task at hand–battling the disease.  In addition, in medicine today, most physicians (other than urologists and gynecologists) do a poor job of discussing sexuality and sexual side effects of diseases or treatments.  In her blog, Ms Jaouad remarks that she found it very difficult to discuss sexuality related issues with her doctors or staff–the subject never really came up.  Thankfully, she had a support group of peers to turn to.

As a specialty physician, I often find myself focused on one disease or one aspect of my patients’ health.  Sometimes, patients are crying out for help and we do not even hear them because we are wearing “blinders” as if we are thoroughbreds in the Kentucky derby. Too many times, we see the finish line of the race and forget to provide the necessary encouragement (and support) to the patient along the way.  Certainly there are guidelines and proven therapies for specific diseases–we all strive to provide the very best care.  But, as evidenced by Ms Jaouad’s blog, we sometimes fall short simply because we “forget to ask”. Or worse, we fail to pause and provide an environment conducive to TWO WAY communication when interacting with our patients.

So, what is the lesson here?  I think that for starters, it is imperative to LISTEN to our patients.  I have blogged many times about the importance of developing a positive and productive doctor patient relationship.  As we all know from our personal lives, one of the most important aspects of a relationship is effective two way communication.  This is not always easy–patients may be intimidated by their disease or by their doctor–Doctors may be so preoccupied with their agenda for the day that they forget to pause for questions.  Either way, the opportunity for questions and attending to the needs that are important at the moment to the patient are lost.  A patient with a chronic or debilitating illness may have concerns that may not seem relevant to the overall treatment plan or disease battle to us as caregivers.  However,  addressing these concerns may make an enormous difference in the long run to the human being suffering with the disease.  As physicians, we are now under increased pressures for productivity and are asked to do more with less time–But we must remember to take a deep breath, and focus on what really matters.  More than anything, our patients need our care, compassion and concern.

I think that as healthcare professionals we must make it part of our routine to spend some time each visit making sure that the patient feels comfortable asking questions.  In order to facilitate this type of interaction AND ensure that our treatment goals are also met for the visit, we must make a real effort to incorporate time for questions into every visit.  In addition, we must remember that sexuality and sexual side effects of diseases and the treatments we prescribe are real and can have significant negative impacts.  We must do a better job of educating ourselves about these side effects and make a concerted effort to discuss them with our patients during routine office visits.  Although initial discussions may be a bit awkward for doctor or patient, it is important to open the door and invite communication to improve the lives of our patients who suffer with chronic disease.

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