Category Archives: Emotional Health

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.

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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.

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Workplace Stress and Heart Attack: Finding the proper Work-Play Balance

Americans are workaholics.  Most of us work 40+ hours a week, bring work home on the weekends and take as little as 2-4 weeks of vacation including holidays.   As cleverly addressed in an essay in the New Yorker in 2006, life in Europe is quite different; 7-8 weeks of vacation time is the norm.   Europeans seem to value leisure more whereas Americans tend to emphasize earning and spending.  Much has been written about how certain habits at work can harm our overall health.  In US News and World Report in July, seven habits that were considered to be health harmful were examined. Habits identified included eating at your desk, lack of exercise, all night work sessions just to name a few.  Now add excessive workplace stress to the list.

I was listening to NPR this weekend and was intrigued by a story from the Lancet on the relationship of on the job stress and increased risk of heart attack.  In this study, a meta analysis from 13 European cohort studies was performed and included nearly 200 thousand patients.  The study demonstrated a 23% increase in risk for cardiovascular events in patients whose jobs were considered stressful as compared to those who did not report workplace pressure.  Based on this report, reducing stress in the workplace could potentially reduce heart attacks by 3-4%.  Certainly, this potential for reduction is not really comparable to the 20-30% reduction in events that is conferred by smoking cessation but it is not insignificant.

Traditionally, stress has been thought to contribute to cardiovascular events by increasing sympathetic tone and causing the abundant release of stress hormones such as adrenaline and cortisol.  These stress hormones may cause increased lipid (cholesterol) levels, increased tendencies for blood to clot and they may also promote the formation of atherosclerotic plaques in the arteries with subsequent vascular damage.   Blood pressure and heart rate are all increased in this state, all leading to increased demands by the heart and potential for ischemia (lack of blood flow to the heart muscle).  Stress management techniques have been studied in the past and have been shown to result in decreased cardiovascular events.  A survey by the American Psychological Association (APA) in 2011 found that 36% of workers included in the study had experienced stress on the job.  Interestingly, the study participants cited lack of opportunities for advancement (43%), heavy workload (43%) unrealistic job expectations (40%) and long hours (39% ) as major stressors at work.

Much of the American worker’s self worth is measured by elite job titles, driving luxury cars and owning a large home in a prestigious community.  In Europe, the worker measures himself by having the ability to take extended holidays with friends and family.  In fact, US workers often fail to take allotted vacation time.   This may be due to the fear of losing traction towards advancement in the workplace or out of fear of being replaced by co-workers who did not take time away.  The US certainly remains the land of opportunity but many US workers have lost sight of the real American dream–the freedom to use our time as we see fit.  To enjoy family, friends and the lives we have worked so hard to build.

Much can be learned from the value that the Europeans place on leisure.  These workers make time away with family a priority.  Some studies of worker efficiency and productivity have shown superior performance and less burnout and depression in employees who take time for vacation and leisure.  Coronary artery disease and sudden cardiac death are one of the leading causes of death in the US today (behind all types of cancers combined).  Certainly we can impact disease by eliminating smoking, eating well and exercising but we can also reduce events through better management of workplace stress.  Take time for family.  Take time to relax.  Return to work refreshed, re-energized and renewed.  Although workplace stress is an unavoidable reality in the US today, we must find ways mitigate stressors and this will ultimately improve both our productivity and overall quality of life.

Grief and Loss in Medicine: The Role of Physicians in Helping Families Find Closure

This week I blogged about screening tests for potentially life threatening ovarian and prostate cancers. As I thought about the impact of screening for disease, I reflected on the potential for poor outcomes and how these outcomes may impact families and loved ones. Unfortunately, death and dying is part of medicine. Patients and families must cope with extraordinary circumstances as they face life aggressive cancers, traumatic injuries and deadly disease. As physicians, we must try to help patients and families navigate through difficult times.Today, while reading the New York Times, I came across a very moving article addressing closure after the death of a family member.   In the piece, author and oncologist Dr Mikkael Sekeres describes a recently widowed spouse and her young children meeting with him after their husband/father’s death in order to find closure after his long battle with leukemia. Dr Sekeres’s story illustrates an important part of our job as physicians–the care of the family and loved ones.   Disease and death can strike suddenly and end quickly but can also persist over agonizing days, months and years.   In either case, many families need to process these events and find closure to their journey with disease.   I recently blogged about the recent publications demonstrating increased rates of depression and suicide in spouses of heart attack and sudden cardiac death patients.   Families with young children have particularly difficult times finding closure after the untimely death of a parent and spouse.

Harvard Professor J. William Wordencreated his “Tasks of Mourning” and these principles can provide a framework in which we can better understand and help the families of our patients cope with and process grief.

1. To Accept the Reality of the Loss–The common initial reaction after the news of loss is delivered is protest and denial. This reaction can last for months, particularly if the death was sudden. As providers, we must help the families move beyond protest and denial so that they can begin to heal. Allowing families and children to be with the patient after death (before the patient is moved from the hospital room or bed) is a critical part to fostering acceptance of death.

2. To Work Through the Pain and Grief: Once the loss is accepted by the psyche, feelings of profound sadness and loss often occur. Sometimes these feelings can constitute clinical depression (situational). As I have stated in my previous blog on depression after sudden cardiac death it is critical that healthcare providers take time to meet with and assess the emotional health of loved ones after the death of a patient. Moving through grief may require counselling and discussions such as the one that Dr Sekere describes in the New York Times today are critical to this process. For many experiencing a significant loss, the first year following the loss is all about “learning to survive”.

3. To Adjust to An Environment Where the Deceased is Missing: Families have a difficult time adjusting to a world without a spouse or parent. Reminders are everywhere, and this can be good for the adjustment. Family members may have to take on new tasks (such as paying the bills or mowing the lawn) that were previously performed by the deceased family member. These practical transitions can be difficult. Talking about this adjustment with others–friends, support groups and physicians can be an important part of the process.

4. To Emotionally Relocate and Move On With Life: The process of emotionally relocating a loved one is a lifelong process. For families experiencing the loss of a spouse or parent (in the case of young children) time does not necessarily “heal all wounds”. This process may continue throughout life and things such as ritual and meaningful rememberances will certainly facilitate the process. For example, if dad always enjoyed putting particular decorations on the Christmas tree, it may be helpful to have a special night before Christmas where the children celebrate their dad’s life by hanging up those decorations and commemorating his life.

Closure is a difficult concept. The “Tasks of Mourning” involve learning to live with and adjust to the loss of a beloved family member. Although families may never completely adjust or emotionally relocate, it is important that they are able to learn to once again find hope and enjoyment in everyday life. As physicians, it is important to remember that we can help families dealing with loss by supporting, educating and coaching spouses and children through this process and prepare them to rekindle their desire to live life to its fullest.

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Unplugged and Liberated: The Joy of Falling off the Grid (if only for a little while)

How many times a during the day do you unconsciously reach down and grab your smartphone from your belt? If I make an honest assessment of my own smartphone use throughout the day, I  find myself grasping my phone quite frequently–sometimes in response to “false” vibration alerts and sometimes just out of habit quite similar to the learned behaviors of Pavlov’s dogs.   I guess that my obsessive-complusive (OCD) side probably promotes and really enjoys the repetitive checking behavior.   I reach for my iPhone while standing in line, while waiting to order a cappuccino, while walking down the street or at any other time when I am not actively engaged in some activity that precludes smartphone access.   Recently the New York Times published an article about unplugging from our smartphones.  In the piece, Jenna Wortham relates her experience with being forced to leave her smartphone behind while enjoying an afternoon at the pool.  For Ms Wortham, the experience was quite liberating.  After reading, I began to think about my own mobile-connectivity behaviors as well of those of my family and colleagues.  

According to Neilson, smartphones are used by 50.4% of Americans and for an average user with an average data plan may cost $1200 dollars annually.  In less than one year smartphone use has increased by 11%.  The number of Americans with no cell phone of any kind has plummeted to an amazing 12% as of February 2012.  This data is staggering.  More than ever our society is plugged in and connected–day to day, hour to hour, minute to minute.  Events (both newsworthy and not so newsworthy) are chronicled on social media sites such as Facebook and Twitter.  Access to real time information has many positive and practical uses such as communication during natural disasters, managing  travel, and alerting family of important events.  However, as Ms Wortham points out, there is a downside to always being connected.  A study from the British Psychological Society demonstrated that many smartphone users are so obsessed with staying connected that they actually experience phantom vibration alerts.  In this study, the investigators found that patients who experienced phantom vibrations were more likely to be highly stressed and most of these had their smartphones supplied by their employers.

There is certainly value to connectivity, but there is also great value in falling “off the grid” from time to time.  As Ms Wortham described, her day at the pool was initially met with separation anxiety from her phone.  However, she began to feel liberated by the separation and started to work “unplugged” time into her daily routine.  I believe that we can all learn from her experience.  Although technology is essential, we are still human beings and must continue to interact in human and personal ways.  We must re-learn how to weave in old-fashioned conversation to both family and personal time.  Stress and work related pressures definately promote smartphone obsession.  We must strive to take control of our technology habits and “unplug” at some point in every day.  Unplugging may allow one to participate in more physical activity or exercise, may improve family relationships and may provide a much needed mental break.  Although anxiety provoking, I also believe that it is critical to unplug when on vacation.  Although I have not yet succeeded at this yet, I am improving–during a 7 day vacation this month, I checked my email only 3 times. I found that by turning my phone off and locking it in the in-room safe, I was able to control a lot of my pathologic phone-checking behaviors.  I felt more relaxed.  I didn’t worry about what was going on at work simply because I didn’t really know–sometimes ignorance is truly bliss.
Our children learn from our adult behaviors and clearly mimic what they see. I briefly chuckled last friday night when my daughter had a school pal over for a sleepover.  Instead of talking at dinner they began to text one another (mind you, while sitting at the same table eating pizza!)  After thinking about it, I began to wonder what might happen to the next generation if we do not teach them how to manage technology use.  Will there be no more conversation?  Will social visits filled with laughter and stories from the past only be chronicled in YouTube videos and online blogs?  We must set a better example of technology management for our colleagues and for our families.  Embracing technology is critical to success in business, in medicine and in our daily lives.  However, we must manage technology responsibly and not allow connectivity to obviate the need for human interaction.  Unplug today.  Take a deep breath.  Lock your smartphone in the safe for an hour and fall off the grid (if only for a little while).

Psychosocial Effects of Acute Cardiovascular Events: Spousal Depression, Anxiety and Suicide After Myocardial Infarction

Cardiovascular events can have far reaching impacts.  Certainly the patients having the events are clearly affected in a life-changing way.  Patients are prescribed new medicines, are asked to make lifestyle changes and alter work and exercise habits.  However, families and loved ones are also greatly affected when cardiovascular disease strikes a spouse.  Most often, the focus is on the patient suffering the event and the spouse is left to worry and deal with fear and other emotions on their own.
Much has been written in the past about the effects of the death of a spouse on the emotional well being of the surviving family members.  As recently as this year, a study in Circulation examined the risk of death and MI in individuals following the death of a spouse or loved one.  These investigators found a significant increased risk (21 fold) of myocardial infarction (MI or heart attack) in the surviving spouse in the first 24 hours following the death during periods of intense grief.  To date, no one has directly examined the impact of specific cardiovascular events such as MI on the emotional well being of loved ones.  This week the European Heart Journal  published an interesting study on the effects that heart attacks (myocardial infarction or MI)  have on the emotional well being of spouses of patients.  The investigation evaluated over 16,000 spouses of patients suffering both fatal and non-fatal MI over an 11 year period.  Spouses of patients who suffered either fatal or non-fatal cardiac events were more likely to have anti-anxiety (benzodiazepines) or antidepressants prescribed.  In the group of patients that suffered from fatal heart attacks, these spouses had increased rates of depression and suicide as compared to control.  This study highlights another aspect of post MI care that providers must consider–the care of the family and spouse.  Attention must be paid to the individuals suffering alongside the affected heart attack patient.
Grief and anxiety are common reactions to illness and death in a close family member.  As providers we must be aware of the potentially serious negative impacts these intense emotions may have on those closest to the patient.  Athough we are certainly charged with caring for the patient, we must remain aware of family needs as well.
Here are my thoughts:
1. Communicate: Communication with family throughout the illness or event is of paramount importance.  Make every effort to provide information and insight to the spouse and other family members.  If a negative outcome is possible do your best to talk about these possibilities
2. Provide support:  When speaking with the family, make sure that you are able to offer emotional support.  Let them know that although you are clinically objective and working for the patient’s best interest, that you CARE.  Empathy is critical. Make sure that you alert appropriate support staff such as clergy, social workers, and case managers to visit with families of critically ill patients.
3. Follow up and Process:  Often when a spouse is lost to either a chronic or an acute illness or event, closure helps with emotional healing.  I believe it is important to provide support to the family in the days or weeks following a death or major cardiovascular event.  Schedule an appointment in the office to meet with the surviving spouse.  If you suspect depression, anxiety or other emotional disturbances, contact that patient’s primary care provider and facilitate treatment.
Grief can be a powerful negative influence in our overall health.  Clearly, the trauma surrounding a heart attack or cardiovascular death can cause significant emotional upset.  In some cases, as demonstrated by the European Heart Journal  study, this upset can progress to significant anxiety, depression and even suicide.  As caregivers, we cannot underestimate the impact that significant medical events have on spouses and families.  We must strive to not only care for the patient experiencing the event but also attend to those who share the life journey with the patient as well.
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Stress Management for Everyone: The Use of Yoga and Breathing Techniques—Just What the Doctor Ordered

I recently blogged about the stress that often accompanies the practice of medicine.  Although I mentioned several behaviors to avoid, I realized that I didn’t really provide any proper suggestions for managing the daily stressors that all of us feel (no matter what our occupation may be).  Patients, in particular, deal with high levels of stress.  These stressors are numerous and may include financial, health-related, job and family/relationship related.  Cardiovascular illness can certainly be exacerbated by emotional stress.  Stress raises levels of catecholamines and other stress hormones are also released.  This “high stress” biochemical state can precipitate acute cardiovascular events in susceptible patients.

As I was researching the previous blog I came across a lot studies that examined stress reduction techniques.  The strategies were quite varied; some simple while others were complicated and elaborate.  As I poured through tons of research papers (some good and some not so good), I asked myself,  “What is a strategy that almost anyone in the world can utilize to manage their own stressors?”    I became particularly interested in those that evaluated both breathing techniques and yoga for stress reduction.  I am a scientist at heart.  I typically recommend therapies to my patients that have been well studied and typically evaluated in randomized controlled clinical trials.  However, the management of anxiety, stress and the like is not as easily evaluated as a new drug for the treatment of congestive heart failure.  Individual emotions, personal differences in perception of anxiety and stress, and environmental factors make these subjects difficult to study.

A study in the International Journal of Yoga in 2012 examined the effect of yoga on stress in dental students performing their very first surgery.  100 dental students were randomized to either a set of 60-min stress reduction lectures or to 60 minute yoga sessions.  The yoga sessions focused on simple breathing and beginning moves.  The students’ level of anxiety in both groups was evaluated by two separate validated and reliable questionnaires both before and after their first surgery.  The group that was trained in yoga breathing related a significant reduction in anxiety and had superior academic performance as compared to the lecture only group. Another study published in Pain Medicine in February 2012 by Busch et al, examined the effects of deep and slow breathing techniques on pain perception in patients with chronic pain syndromes.  In this study subjects that were trained in deep breathing techniques had an altered pain perception and levels of pain and anxiety were reduced significantly

So, how can we all apply simple principles found in Yoga and breathing to reduce our daily stress?  Here are a few tips:

1. Practice Deep Breathing Meditation:  Find a quiet place and sit comfortably with your back straight.  Place one hand on your abdomen and one hand on your chest.  Practice breathing deeply and slowly from your abdomen.  Breathe in through your nose.  The hand on the abdomen should rise and the hand on the chest should remain still.

2. Visualize:  Practice deep breathing in a quiet place.  Visualize relaxation coming into your body with every breath and stress leaving with every exhalation.  Focus on the moment.  Try not to think about the day or what is to come in the future.

3. Practice “mini-meditation”:  Sit in a comfortable, quiet place without distraction.  Close your eyes and try to clear your mind (this is the hard part).  Stay unattached to thoughts of any kind.  As thoughts enter your consciousness, let them go.  As you learn to meditate, the periods between the intrusion of thoughts will become longer and longer.  Meditation is difficult and takes practice.  Start with shorter sessions (5 minutes) and work up to longer ones.

Stress affects all of us in a negative way.  We must learn to manage our stress in order to become more successful in our daily lives.  The benefits of breathing, meditation and basic yoga principles are that they are all readily available and require no specific equipment.  Most importantly, these activities are free and can be done almost anywhere.  Certainly, if you want to learn and focus on more yoga, classes in a yoga studio or gym may be beneficial.  However, for relief of daily stress, simple breathing exercises, visualization and meditation may be just what the doctor ordered.

Managing The Stress of a Life in the Chaos of Medicine

Let’s face it, the practice of medicine today is fraught with stress.  Physicians are not only expected to make critical decisions concerning the health and well being of their patients but are also needed to make real CEO-level business decisions every day.  Healthcare systems are purchasing practices and assimilating doctors like the Borg from the Star Trekseries.  More and more is being asked of providers with a concomitant reduction in reimbursement.  Physicians are also people, with families–spouses and children, homes and pets.  Often the stress of work brings unrest to the home as well.  In order to provide excellent care to our patients it is imperative that physicians are able to develop strategies to manage stress at work and at home.Many physicians are trained in residency and fellowship programs that include a military-like hierarchy; responsibility at every level and accountability at the top for all actions below.  This environment creates stressful situations and interactions and forms the foundation upon which many exceptional careers are built.  However, at no time during my training did I receive mentoring in stress management nor did I ever feel emotionally supported.  The long hours of residency are not the problem.  The lack of support is.  Medical education today needs to provide more of a focus on training the “whole physician”; not only training the hands and mind of young doctors but training their hearts.  Stress is a natural part of medicine and medical training.  What makes physicians more effective is how they deal with these daily pressures.  Many physicians in training are also beginning married life and starting to have families.  We have all heard the stories of divorce during residency.  In fact, some surgical programs  of actually unofficially boast about a 110% divorce rate (implying more than one failed marriage in their trainees).  All new marriages can be challenging but additional pressures are felt by those in training– financial burdens of student loans, lack of quality time together and sleep deprivation.  Families are an integral support group for physicians in training.  In my experience, one of the reasons I made it through my fellowship training was the relationship I had with my wife.

Physician burnout is real in today’s practice–the seeds may very well be planted in residency training and early practice.  Family relationships feel the strain and can be a very important support mechanism.  Although little is taught in medical school and residency, there are a few keys to managing this stress.  Here are my thoughts:

1.  Make time for family.  Incorporate family into routine activities such as grocery shopping, going to the drug store, laundry, etc.  Even though you may be accomplishing “household work” you can do it together.  There is always time for conversation while driving in the car (even with the kids)

2. Schedule “dates”.  Even though trainees are often on call as frequently as every 3rd night in some programs, it is very important to schedule a date with your significant other.  It may be as simple as a trip for coffee, ice cream or dinner and a movie.  Get a babysitter if you have kids and do this at least once a month.

3. Make daily “3 Minute Check Ins”.  Every day, no matter how busy you may be, take 3 mins to send a text, make a quick phone call, or send an email to your significant other.  It makes such a difference to the person on the other end to know that even though you may be incredibly busy, there is always time to check in.

4. Leave work at work.  Hang your work related problems on a hat rack. Although it is important to share frustrations and process challenges at work with your spouse or significant other, it is imperative that you do not project work related anger and frustration toward your family.

5. Ask for help.  Medicine breeds independence and self reliance.  Often asking for help is seen as a sign of weakness in training.  However, we must all learn to rely on others to help us process difficult emotions.  Many training programs and hospitals provide Physician Self Referral counselling and these should be taken advantage of during difficult times.

Medical education is vital to training the physicians of tomorrow.  In the US today, we are able to train some of the most successful and talented doctors in the world.  However, this training can be stressful and this stress may continue through years of practice.  We must learn to manage work related stress in more productive ways.  Habits die hard and many negative habits are learned in training.  It is my hope that residency training programs will continue to make advances in supporting the emotional needs of trainees.  Helping young physicians manage family life, demanding work schedules and stress will allow us to produce a new breed of doctors who are more equipped to avoid burnout.  By helping physicians manage stress and develop positive coping mechanisms, we will be better able to care for our patients in the years to come.