Tag Archives: outcomes

“Thinking” About How We Lead: How We Make Better Decisions and Produce Better Outcomes

As physicians we are trained to assimilate data, analyze and interpret findings, and make the correct decision–every single time.  Often these tasks must be performed very quickly and in emergency settings.  For those who perform invasive procedures, decisions are often made “on the fly” and can have significant consequences.  In addition to our clinical duties, physicians are now thrust into executive roles as well.  Managing practices, budgets, government mandates and regulations have now become part of everyday clinical life for many practitioners.  The concept of the physician executive is now commonplace—and for many doctors and practices– a key to survival in an unstable and volatile healthcare market.  Improving skills in both decision making and communication can be critical to success in the new world of healthcare.  Learning to LEAD is critical to providing outstanding care for our patients every single day.

This week in the Wall Street Journal, author Andrew Blackman explores the inner workings of a business executive’s brain–exactly how the brain functions when making effective decisions in the world of business.  Researchers evaluated how executives make decisions under a variety of circumstances–they localized the biologic processes that occur in the brain via advanced neurologic imaging techniques.  From a biological standpoint, this research provides great insight into how successful decision makers formulate plans and solve problems.  In addition, the research provides insight into how leaders can make more effective decisions when under duress.  Using complex imaging to map the electrical connections in the brain when decisions are made, researchers are able to better quantify–biologically–what makes some leaders better than others.

By shedding light on how our brain functions when making good decisions, we may be able to one day “train” our brains to utilize particular regions during specific tasks.  For now, much of what Mr Blackman reports concerning optimal conditions for making decisions is applicable to physicians and other leaders in medicine in one way or another.

According to the Wall Street Journal, there are several things to consider when making important decisions:

(1)  Deadlines and Time Pressures may Limit Creativity and Innovation

In medicine, every day is a deadline.  Schedules of patients packed into the office or procedure list remain a reality.  Making decisions under pressure is a big part of what physicians do on a daily basis.  However, the recent neuroimaging research indicates that often the deadline pressure may stifle creativity and lead to poor decisions.  Stress induces more activity from the area of the brain associated with “task completion” and less activity in the areas responsible for new and creative idea generation.  According to Harvard researchers, one way to potentially combat this change in thought centers during times of stress may be to train workers and leaders to become more self aware and use “mini meditation” to help the mind wonder.  Although in medicine, we are trained to REACT to acute situations, it may be that while we REACT, we can also work to explore other creative centers of our brains in the process.  By combining both quick REACTION and creative thought, we may not only be able to stabilize a critically ill patient but also provide a unique treatment plan going forward.

(2)  Worry and Uncertainty can lead to bad Predictions and poor decisions

I have been accused of being “Chicken Little” on more than one occasion.   Uncertainty is something that is commonplace in medicine yet it makes most of us uncomfortable.  As physicians we rely on data to make good decisions.  However, uncertainty remains a significant part of what we do in medicine on a daily basis.  We often deal with limited data and must make a decision based on the best available evidence.  Clinical trials bring us some level of certainty  but our patients are biologic organisms, each with potential differing responses to treatments and disease.  According to researchers, the areas in the brain that are activated when you are working on problems that are cause you worry are often associated with anxiety and disgust.  Many poor decisions are made due to the “worst case scenario” line of thought.  While worry and uncertainty can never be completely avoided, psychologists argue that the way to avoid poor decisions during these times, is to learn to accept uncertainty and control the things that you can control.  No decision is ever final–even in medicine there are opportunities to act, refocus and change directions if necessary.

(3)  Good Decision Makers may look past the Facts and Incorporate “Gut Instinct”

Many decisions in medicine are made by considering the best available data and incorporating clinical judgement and instinct in order to make a determination as to the best course of action.  Interestingly, when MRI scans were performed on the brains of very successful business executives who were involved in making difficult decisions, the areas of the brain responsible for emotion and social thinking began to light up more than the purely analytical areas.  Researchers concluded that those leaders who relied not just on facts but on gut instinct and emotion tended to be more successful.  Social thinking–in simple terms–is the ability to look at a problem from numerous angles.  Seeing the potential impact of a potential decision from multiple points of view can provide invaluable insight and may lead to better decisions in the long run.  In medicine, involving other team members–nurses, technicians, and support personnel–in the care and formulation of the patient’s treatment plan may actually help a physician leader to make better decisions.

(4) Effective Leaders must stay positive and Inspire Teams

When leaders begin to inspire teams of people and lead with passion, certain other areas are activated in the brain–particularly those areas associated with positive emotions and social thinking.  Along with involving other team members in the care of the patient, it is essential for an effective leader and decision maker to incorporate “praise, encouragement and rewards” when motivating teams to perform at a high level.  Creating an emotional bond among members of a medical team can be as simple as asking for input from all involved parties and recognizing outstanding contributions to patient care.

The Bottom Line…

Business executives are adept at making determinations that affect millions (if not billions) of dollars and these decisions can move markets.  In medicine, we must make decisions every single day. While some decisions may be trivial, others may permanently impact the lives of our patients and their families.  Moreover, from a business standpoint, the management of a medical practice in today’s market requires impassioned leadership and great skill in order to remain viable. The work that is done with neurologic mapping in decision making may have provide us with guidance in the future as we develop new leaders.  It may be that through practice and coaching, we will one day be able to activate specific areas of the brain when we are working to make tough decisions.  The strategies and skills that we are able to glean from these types of research activity will allow us to be more effective physicians, leaders and executives in the years to come.

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Charisma In Medicine: Inspiring Others To Improve Patient Care

By its very nature, Medicine involves close personal contact with others.  Communication with patients, families, staff and colleagues is essential to success.  All physicians have different ways in which they communicate–some more effective than others.  The best communicators are able to inspire, engage, and cultivate trust.  Everyone is born with different skill sets and communication styles may vary widely.

Recently, I came across an article in Inc.com that discussed the importance of charisma and how it can improve the success of leaders in the business world.  Author Jeff Hayden goes on to describe 10 habits of very charismatic leaders.  As I read the piece, I began to reflect on ways in which these tips could make me and my physician colleagues better communicators and better leaders in the world of medicine…

As we always do when tackling an issue in medicine, lets start with the available data….

Websters defines charisma as :

1. A personal magic of leadership arousing special popular loyalty or enthusiasm for a public figure

2. A special magnetic charm or appeal 

So, how can this help us take better care of our patients?  If we are able to inspire and produce excitement amongst our team–from nurses, to physician extenders, to support staff–both our patients and our employees will have a better experience when working with us.  If we are able to appeal to our patients and their families we are able to provide much needed trust and are more likely to be able to partner with our patients in an effective way. 

As we examine Mr Hayden’s Tips for Charismatic Leaderships more carefully, we can find insight into ways in which we can improve our own communication with patients, colleagues and staff:  (In each case below, I have listed Mr Hayden’s Tips from his Inc.com article and then applied them to our space as physician leaders)

1. Listen more than you talk–This one is tough for many physicians.  In training we are taught to speak up when you know the answer.  We are often motivated to provide quick results and to communicate them readily.  We strive to quickly assimilate facts and produce a plan.  However, much can be learned by listening–to patients, to families and to other healthcare team members.  When team members see that their ideas are considered by the leader, the tend to be more engaged and more productive.  It matters not who gets credit for the individual pieces of the puzzle–it is more important that the puzzle is completed successfully and the credit becomes a group effort.

2. Do not practice selective hearing–It is essential that physician leaders treat all team members with respect.  Everyone has a role to play and it matters not what title or status a particular individual may hold in the team heirarchy.  By including everyone (and making each person feel like a contributor) we inspire hard work and more participation. Ultimately the patient receives much better care. 

3. Put your stuff away–In the age of mobile phones, ipads and computers on the hospital wards distractions abound.  However, when leading a team and listening to others express opinions and ideas, it is essential to leave the digital media in its holster–nothing makes others feel more unimportant than a disinterested leader.  Take time to engage each person on the team and avoid the distractions of a text, a phone call or a tweet.

4. Give before you receive–In medicine it goes without saying but be sure to put your patients and their families first.  Within the care team, allow others to take credit and receive praise for a job well done before any is directed your way as the leader.

5. Don’t act self important–Medicine breeds ENORMOUS egos–particularly in world-renown academic centers.  To be more effective, we must put ego aside– forget the fact that you may have published half of the manuscripts in the medline search that the medical student just performed.  Focus instead on others and what they bring to the team.  Remember, we are all human–we are all connected.

6. Realize that other people are important–As Mr Hayden states clearly–”you already know what you know..you can’t learn anything new from yourself”  Listen to what others have to say–focus on their opinions and learn from their biases.

7. Shine the spotlight on others–Everyone feels validated by praise.  There is never enough praise to go around.  As the team leader make sure that you are adept at deflecting praise from yourself to those around you.  Team members who feel that their work is recognized and appreciated as excellent tend to work harder and produce more.

8. Choose your words–How we go about asking others to perform tasks can greatly alter their perception of the task.  If a task is presented as an obligation, it is viewed very differently than if it is presented as an opportunity or a privilege.  By carefully choosing your words you inspire others and make them feel as thought their position on the team is a critical component for success.

9.  Do not discuss the failings of others–Let’s face it, the hospital is a fishbowl and people gossip.  However, nothing is more destructive to team dynamics that when a leader speaks negatively about a team member, a colleague or another physician.  This behavior undermines morale and does not inspire confidence.

 10.  Admit your own failings–It is essential for teams and leaders to feel connected.  Nothing promotes connection more than when a leader admits his or her own mistakes and failings to the group.  However, when admitting a mistake it is essential that the leader set an important example–when admitting a failing also admit what was learned through the event and what corrective actions you plan to take to avoid the mistake in the future. This sets a wonderful example for self improvement for the team and at the same time promotes connectedness within the care team.

What’s the Bottom Line?

Effective communication and inspiring leadership are essential to the success of any medical team.  When teams are engaged and focused on the ultimate goal–the care of the patient–outcomes improve.  It is the job of the physician and other team leaders to motivate people and form cohesive, effective teams.  As leaders, we can learn a great deal from the business and political world–charisma is a characteristic that can move markets and change the course of entire nations.  Charisma allows a leader with a vision to effect change.  Charisma can be the difference in connecting with patients, families and co-workers.  Charisma can ultimately improve care and improve the delivery of care–the key is to learn to focus on them….not on me…..

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Exploring The Leadership Potential of Three Little Words: Applying “I Don’t Know” To Medicine

Recently I read an interesting article on leadership published at Inc.com.  Although most of the journal is focused on those in business, many of the pieces on leadership are very applicable to those of us in Medicine.  In this article author Curt Hanke writes about the inspiration and leadership positives found in the three simple words:  “I Don’t Know.”   On first blush, we may think that a leader speaking these words may no longer inspire confidence and may lose the support of his or her troops.  However, as Mr Hanke goes on to detail, the words “I Don’t Know” may provide inspiration and motivate teams to perform even better.

As physicians, we are leaders–we lead teams, we lead students and other trainees, and most importantly we lead patients.  There are times when we lead and guide patients and families on very challenging journeys through brutal, sometimes devastating diseases.  Often, being a good leader is the most important part of our job.  With leadership comes many responsibilities– and those whom we lead look to us to show confidence as we provide guidance in uncertain times.

As physicians are leadership roles are two fold:

1. We lead teams of caregivers with a common goal–the best outcome for our patients.  Our teams look to us for confident judgements during crisis (such as during a code blue) and guidance when making day to day clinical decisions.  Our teams are bright and capable.  Our team members are diverse both in training, ability and in education–nurses, physical therapists, pharmacists and other physicians–all working in concert to achieve clinical success.

2. We lead patients and families.  We are the experts in a complex field that is foreign to many–we are relied on as guides, as advisors as well as generals on the field of battle.  We must inspire confidence and show kindness at all times.  Our patients are often frightened and uncertain.  We must help them learn, grow and adapt to changing medical and clinical scenarios.

To lead in this way can be very challenging but is not terribly dissimilar from leading in the business world.  We must be prepared–with knowledge of disease and the best available therapies.  We must be aware of the strengths and weaknesses of each individual on our medical team (including our own) and we must be able to motivate those in very different roles to band together for common good.  We must lead patients and families with compassion–we must understand things from their perspective and apply their needs into the equations we use to make clinical decisions.  We must lead both groups with honesty.  We must be willing to say “I Don’t Know” when appropriate.

Then we must harness the power of “I Don’t Know” in four distinct ways (according to Mr Henke):

1. Creates Possibilities--As a leader, saying “I Don’t Know” in medicine, may create an opportunity to bond with patients, families and team members.  Having the courage to articulate your shortcomings as the leader may actually garner more respect and tighten bonds through your honesty.

2. Inspires Engagement–As a leader, saying “I Don’t Know” in medicine may provide opportunities for others to take center stage and bring forward ideas that they may have otherwise kept to themselves.  It allows others to think more creatively and inspires team members to find “ownership” in working to solve a particular clinical mystery or treatment problem.

3. Avoids Complacency–As a leader, saying “I Don’t Know” in medicine provides me with the motivation to learn more and to be better.  Not knowing the answer right away drives me to reflect on my particular skill set and take stock in what I can do better both as a leader and as a team member.  When the leader works to improve, it often inspires growth among team members as well.

4.  Inspires “Fun” During Difficult Times–As a leader, saying “I Don’t Know” rather than a positive effect on morale–A culture of “I Don’t Know” produces engaged team members and these engaged team members are more productive.  Ultimately a more productive medical team results in more positive patient outcomes.

Effective leadership is vital to success in both business and in medicine.  The most effective leaders know their own limitations and are not afraid to share that with the team that is inspired to follow them.  Courage to say “I Don’t Know” may be the difference in discovering the most accurate diagnosis and prescribing the most effective treatment plan for a patient and their family.  Be willing to admit when you fall short–as Socrates stated “The only true wisdom is in knowing [what] you don’t know”

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Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

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Providing The Best Care For Our Patients: Sometimes An Old Dog Must Learn A Few New Tricks

When I was in training at Duke University Medical Center, we prided ourselves on practicing evidence-based medicine.  During my tenure there, Dr Robert Califf had constructed the clinical research mecca known as the DCRI (Duke Clinical Research Institute).  As cardiology fellows in training, we were all actively engaged in clinical trials and quickly understood the importance of choosing therapies that had been proven to be safe and effective through rigorous evaluations in randomized controlled clinical trials.  (RCT).  In fact, when making rounds in the coronary care unit (CCU) with my attending physician, I can remember being chastised because I had prescribed an ACE inhibitor without mortality data rather than one that had been proven to save lives.  In the eyes of my attending,  I had wrongly assumed “class effect” and had used an unproven therapy.

This week in the New York Times, author Nicholas Bakalar explores the same issue in today’s medical practice.  In a recent publication in the Mayo Clinic Proceedingsinvestigators evaluated 10 years of published studies in a single high impact journal.   Of the studies evaluated, 367 represented an examination of a well established medical practice or therapy.  Surprisingly, 147 of these studies of established practices found that the accepted therapy was no better or even worse than the alternative treatment practice.  Of these well established treatment practices that were examined, nearly 40% were found to be ineffective or actually harmful to the patient.  However, physicians continued to utilize these particular therapies.  Why?  What can we do to effect changes in practice?

Old habits die hard.  Often, in medicine, the momentum it requires to make a change in practice can be overwhelming.  We often do things because mechanistically, they just make good sense.  Many physicians that are procedure-oriented like myself fall into the trap of believing that if we are able to impact the cause of a problem or change the course of the disease, that the outcomes will be improved.  This is not always the case.  For example, in the case of coronary artery disease, it makes sense that if we “un-block” an occluded coronary artery, we should be able to make the patient live longer.  In fact, the data clearly shows that angioplasty and stenting are valuable in relief of symptoms but have no impact on mortality.  This does not necessarily mean that we should not revascularize patients percutaneously BUT it does mean we must understand the true impact our revascularization procedure will have on the patient and their quality of life.

In medical school, most physicians were trained to think as scientists.  The scientific method suggests that scientists should evaluate a problem in the following manner:  1. ask a question, 2. make a hypothesis, 3. develop a “test” for the hypothesis and then 4. Collect and interpret the results.  As practicing physicians, we must continue to think like  scientists and look for evidence to guide our clinical decision making.  We must ensure that even if we believe that a particular treatment makes good biologic and mechanistic sense, it must still be proven effective by rigorous clinical trial evaluation–if it is not or if it is shown ineffective, we must find alternative therapies without delay.

Medicine remains an art.  The way in which we are trained has a significant impact on how we practice later in our careers.  In residency and fellowship, we are taught the current, state of the art therapies for that particular time.  Thankfully, medicine is not static–innovations and improvements in care occur almost every day.  We must learn to adapt to changes in the “state of the art” as medicine continues to advance.  A good scientist (and a good physician) continually evaluates the “state of the art” in order to see if there are better ways to treat and serve our patients.  It is essential that we continue to practice evidence based medicine and provide the best PROVEN therapies  (and reject those that are found to no longer be effective)–even if it means and “old dog” must learn a “new trick”

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Considering A Divorce From Your Doctor? Here’s What You Need to Know

Just As in marriage, the ability to communicate is essential to any successful doctor-patient relationship.  In fact, the most successful doctor-patient relationships are a lot like a marriage.  Both parties must be willing to listen, to negotiate and to support each other’s decisions.  As I have stated in many previous blogs, outcomes improve significantly when patients are engaged in their own healthcare.  Engagement only occurs when doctors and patients are able to effectively work together to solve health problems.  The days of the paternalistic physician dictating lifestyle changes and treatment plans are long over.  Today, patients are better informed and armed with information as they enter the office for consultation.

Unfortunately, just as in marriage, not all doctor-patient relationships work out.  Sometimes changes have to be made in the spirit of moving forward with effective healthcare. This week in the Wall Street Journal, author Kristen Gerencher addressed the issue of “When to fire your Doctor”.  In this piece Ms Gerencher provides sound advice on how to determine when it is time for a change.  She mentions 5 warning signs that may indicate that a divorce and remarriage to another provider is important.  In particular, if you feel worse when you leave your physician’s office than when you arrived, it may be time to consider a change.

Here’s my take on the warning signs that the WSJ mentions:  (the warning signs listed are directly from the WSJ article, the commentary below each one is mine)

1. You leave with more questions than answers.  

It is critical that physicians take the time to communicate clearly to patients.  Essential to this communication is allowing time for questions AND clarifying any misunderstandings or addressing concerns about a treatment plan.  This can be challenging for doctors in the current healthcare environment where federally mandated documentation requirements and pressures to see more patients in less time are limiting the time once dedicated to patient discussion.  However, it is essential to the health of the doctor patient relationship that physicians do not allow these conversations to be pushed aside.  Remember, patient engagement is key.  An informed patient is much more likely to be engaged.

2. Your doctor dismisses your input.

In the age of the internet, patients often come armed with lots of information (lots of which is unreliable and shady at best) that is obtained from online searches.  Rather than simply dismiss the information as junk, it is important to guide our patients to more reliable and more accurate sources of internet information such as MedPage Today and other good patient friendly information sites.

3. Your doctor has misdiagnosed you.

Medicine is not a perfect science.  It is important that you work with your doctor every step of the way along your path to diagnosis.  Mistakes in diagnosis happen–however, these mistakes are not always negligence.  Consider if your physician has carefully considered your problem and has provided a well thought out differential diagnosis before leaving due to a misdiagnosis.  It is important that communication continues during the process of misdiagnosis.  If there is no good communication at this stage, it may be time to choose another provider.

4. Your doctor balks at a second opinion

A good physician is never afraid of a second opinion.  In fact, I often welcome a second opinion in cases where there are multiple choices of a plan of action.  It is essential that patients feel comfortable with their treatment plan–a feeling of comfort breeds engagement and engagement is key for success.  As physicians, we must be willing to put our egos aside in order to provide the best possible care for our patients.

5. Your doctor isn’t board certified.

When choosing a physician, it is vital that you examine his or her background and training.  Typically, doctors must complete a course of training in residency and fellowship in order to be boarded in a particular specialty.  Board exams (some written and some oral) must be passed and competency must be proven.  Once certified, physicians must maintain competency through continuing medical education and re-certification every 10 years.  If your doctor is not board certified, it is not necessarily the end–ask why.  There are several reasons that they may not be including overseas training that is not recognized in the US by the US societies responsible for board certification.

Choosing a doctor is a lot like choosing a spouse.  Decisions should be made in cooperation with one another and both sides must contribute to planning and execution of the chosen course of action.  Patients must weigh options, consider pros and cons and discuss issues with their provider and the provider’s staff when unhappy with a particular physician or physician group.  IF communication is not productive and there is no engagement, patients must make a change.  Good healthcare is a two way street.  Doctor and patient must work in concert in order to achieve optimal outcomes.

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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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