Category Archives: Emotional Health

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.



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.


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.


Singing the Blues: Stress, Depression and Risk for Stroke

Depression is common in US adults over the age of 65.  As we age, we are faced with our own mortality and often lose family and friends to disease.   According to the CDC, over 80% of elderly adults have at least one chronic medical condition and nearly 50% have more than two.  Dealing with multiple prescription medicines, multiple doctor visits and treatments add stress to life.  Many seniors live on fixed incomes and financial pressures are often quite significant.  To make matters worse, seniors are often misdiagnosed and many medical professionals do not recognize depression in this age group.  Many physicians believe that feelings of sadness experienced by the elderly is just part of the natural aging process.  Older patients themselves do not even recognize that they are depressed and believe that their feelings are part of the natural aging process–they never seek help.

Just a few days ago, the AHA Journal Stroke published a study linking increased risk of fatal stroke in older Americans.  In the study, over 4000 adults in the Chicago area were followed and their level of psychological distress was measured using standardized, reliable assessments.  The results of the investigation demonstrated a statistically significant increase in both fatal and nonfatal stroke in patients who were depressed and had increased levels of psychosocial distress.  Clearly, there is an association between mental health and cardiovascular disease.  Prior studies in patients with congestive heart failure have also demonstrated negative outcomes in patients with untreated or concomitant depression.  In fact, in this newly published stroke study, a clear dose response relationship was seen between the level of psychological distress and stroke;  those with higher levels had a 2 fold incidence in fatal stroke and a 30% increase in incident stroke rate.As scientists, we are driven to demonstrate a cause-effect relationship when approach disease.   In order to treat a disease, we must target specific biologic connections.  However, the biology of the association between stroke and emotional distress is difficult to definitively determine and has yet to be proven.  Several biologically plausible hypotheses have been offered:

1.  Emotional distress and depression may create higher levels of stress hormones and inflammation that contribute to events.

2. Patient who are emotionally distressed and depressed may be more likely to be non compliant and unengaged in their own healthcare.  They may be more likely to live unhealthy lifestyles.

3. Emotional distress and depression may produce a hypercoagulable state where a patient is more likely to form a thrombus and experience a thrombotic event (embolic stroke).

The emotional well being of a patient can clearly have an impact on cardiovascular health.  As healthcare providers, we must diagnose and treat depression, anxiety and other mood disorders as part of routine care.  As cardiovascular healthcare professionals, we must develop relationships with mental health providers, counselors and psychiatrists so that we are able to refer our patients for specialized care when appropriate.  The link between emotional health and physical illness is real.  The heart-brain connection has been reported in the past and studies such as this one in the journal Stroke continue to emphasize the complexity of this association.  Elderly patients are at particularly high risk for the detrimental effects of psychological distress simply due to its high prevalence in this population.

As we enjoy the holiday season and move to the New Year, let’s all commit to providing comprehensive care for our patients.  Let us all strive to recognize signs of psychological distress and help our patients deal with their feelings in a productive, positive way.  Help our patients by recognizing financial strain and prescribing generic medications.  Make it clear to your older patients that depression and sadness is NOT a part of the aging process.  Help integrate care by communicating with primary care providers and other specialists in order better coordinate care for our patients.  Regardless of the specific biology of the association between emotional distress and cardiovascular disease and stroke, we can reduce risk by helping our patients to improve their own psychological health.


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.

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.

The Doctor Becomes The Patient: Lessons Learned From Wearing A Gown

Physicians are terrible patients. That fact is one of the few absolutes in medicine. I can remember developing an acute appendicitis as a medical student. I remember the fear, the uncertainty and the discomfort. I can remember wanting someone who was in charge to spend a little time in my room explaining things to me. I can remember the embarrassment I felt when a group of 6 student nurses paraded into my room with a senior staff nurse in order to learn how to put in a foley catheter. As physicians, we are used to being the person in control in the healthcare setting. When the doctor becomes the patient, all perceived control is surrendered. No longer do we wear the “magic white coat” and wave healing hands over patients. Our daily intake and output is recorded. We are shipped all over the hospital for tests in unflattering, often risque attire. Once the transition to patient is made, there is no going back. Nothing ever seems the same.

One of the most well published experts in this area is Columbia University psychiatrist Dr Robert Kitzman. In a 2008 New York Times article, Dr Kitzman provides insight and discusses the implications of the transition from physician to patient. Dr Kitzman, after losing family in the September 11th terrorist attacks began to suffer from depression and eventually became a patient himself. Once doctors become patients, many begin to recognize major flaws in the healthcare system that had previously gone unnoticed. What may seem to us like small inconveniences (long wait times, or uncomfortable office temperatures, or outdated magazines in the waiting room) become a really big deal when YOU are the patient. The process of transition from healthcare provider to patient can be quite eye opening; in fact, I believe that time spent as a patient should be part of medical education. Even though most physicians do their very best to show compassion, provide support and empathy, it is often not enough. Sometimes we must look through the eyes of those for which we care in order to better serve their needs.

Dr Eric Manheimer who is medical director at Bellevue Hospital Center, understands this better than most. In a moving piece written in 2011, he describes his own experience becoming a cancer patient. Diagnosed with throat cancer, Dr Manheimer details his personal struggles with becoming a patient. Fear, loneliness, hopelessness, anger and loss are common. These feelings can become overwhelming to patients with chronic illness or cancers. Through his experience as a patient, Dr Manheimer has been able to inspire other physicians to become more compassionate and better understand the condition of “being a patient”. In a follow up New York Times article from July 2012 he describes how he is a much more effective doctor. Not only is he able to relate to his patients as a physician, but now he is also able to relate to them as a fellow patient. By identifying with patients and developing a better understanding of the daily struggles patients face, Dr Manheimer suggests that we can ALL be better physicians.

There are many other stories like Drs Manheimer and Kitzman. Certainly, in the big scheme of things, my appendectomy was no big deal. However, the experience of becoming a patient can and should have lasting effects on healthcare providers. The very act of becoming a patient and facing an illness forces physicians to make personal choices in testing, treatments and risks. These decisions can change the course of one’s disease. Interestingly, an article in Archives of Internal Medicine from 2011, studied how these decisions differed when a doctor recommended a therapy for themselves versus another patient. In this particular study, physicians tended to choose treatments for themselves that involved higher risk for death. It is not easy to explain this difference but one can postulate that personal beliefs and values must play a greater role when choosing treatment options for one’s self as opposed to a patient.

Patients deserve our very best. As physicians, we must remember that the people we care for are often lonely, frightened and may feel as if their world is spinning out of control. Becoming a patient can open our eyes to the challenges of the ‘patient condition”. We must strive to provide better, more compassionate care to our patients. By “wearing a gown” providers may be able to better empathize with patients and ultimately ease the pain of living with disease.