Month: May 2016

Categories
Emotion Lifestyle

Could mindfulness meditation help us to care for patients?

“We can only give away to others what we have inside ourselves”-Wayne Dyer

Empathy is the ability to understand and experience life from another person’s perspective, which allows an individual to care for others in a genuine way. In medicine, it is arguably one of the most crucial qualities required to be a good doctor. Research shows that empathetic doctors are perceived as better caregivers, and are less likely to face malpractice suits. (1-4) In another study, which looked at how physicians’ empathy affected clinical outcomes for diabetic patients, it was found that the physicians perceived as more empathetic were more likely to have patients with blood sugars and cholesterol levels under control. (5)

Demonstration of caring and altruism during the medical school application process is almost essential for entry. However, several studies have shown that student empathy is negatively affected by medical education, particularly on entering the clinical years of training. (4, 6, 7) Various factors have been explored to explain this. The higher workload of the clinical years, exam pressures, as well as facing the realities of medicine on the wards (as opposed to previously idealised media images), could all be contributing to the phenomenon.

Moreover, medical students come from a background of overachievement, and stress and anxiety can result from not performing to the standards they expect of themselves. (4) Perhaps as medical students we have also learnt to put on a mask of compassion, kindness and emotional distance to protect ourselves from the realities of life; or maybe it is emotional blunting from just meeting too many ‘people with problems’. (7) Whether the reason for our rise in cynicism is attributed to one or all of these explanations, it seems apparent that the care and compassion we are able to show to patients is primarily associated with our own mental state. With a continuous backdrop of studying and time pressures, the stresses of all life events are heightened.

There has been a large amount of research into the stress, burnout rates and psychological consequences of medical school training. In one multicentre study at American medical schools, burnout was found to be common amongst medical students, and it increased by year of study. (8) The general consensus is that the medical school experience is challenging and demanding, requiring resilience and a balanced lifestyle.

Could medical schools provide more support to ensure students are well equipped to face a career filled with emotionally demanding situations, whilst maintaining the levels of empathy and emotional understanding crucial for strong doctor-patient relationships? All schools offer some level of student support, such as counselling sessions for those students that are experiencing mental difficulties or life challenges. Unfortunately, it has been shown that a clear stigma continues to exist against mental health and guidance in simple life matters. This has been described as “the hidden curriculum”, a culture that exists where doctors and students are led to believe that we are invincible and cannot become ill, either mentally or physically. (9) Often the first signs of vulnerability to mental health issues manifest at medical school, which actually leads to breakdown much later on. (10) Rather than allowing our future doctors to reach their breaking point before seeking help, we could build strong foundations and encourage introspection alongside academic learning. This would help our medical students and doctors truly reach their potential.

One avenue that has been explored to prevent ‘compassion fatigue’ and burnout is through the practice of mindfulness meditation. One study found that post-intervention levels of anxiety and depression were significantly reduced. (11) Mindfulness is currently taught at 14 medical schools and is continually gaining popularity. The University of Rochester School of Medicine and Dentistry (USA) and Monash Medical School (Australia) are unique in that they have fully integrated mindfulness into their core curricula. (12) One study found statistically significant reductions in tension-anxiety in students on a mediation-based stress reduction (MBSR) program (from 14.5+/-7.2 pre-intervention to 12.4+/-7.0 post-intervention) in comparison to controls (11.3+/-6.3 pre-intervention to 13.4+/-6.9 post-intervention). (13)

What is Mindfulness?

Meditate by Caleb Roenigk
Meditate by Caleb Roenigk

Mindfulness is a process to become more conscious of the present moment in order to manage thoughts, feelings and strong emotions. (14) Although it was historically known as a Buddhist practice, with the aim to alleviate suffering and cultivate compassion, it can be practised without spiritual or religious affiliation. In the late 1970s, Jon Kabat-Zinn, a physician at the University of Massachusetts Medical Centre, developed Mindfulness-Based Stress Reduction (MBSR), which takes away the esoteric aspects of the practice while retaining the core elements.  This has gained considerable popularity, particularly in the field of pain relief. (15)

 

A study into the effects of meditation practice on the brain, conducted at Harvard School of Medicine, found that with meditation there was increased gray matter in the frontal cortex, an area associated with working memory and executive decision-making. There was also thickening of three key regions displayed in the table below. (16)

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Furthermore, the amygdala, the area of the brain associated with the fight-or-flight response, and thus a key contributor to feelings of anxiety or stress, became smaller. (16) A second study by the same group found that practice for only 8 weeks appears to enhance regions of the brain associated with memory, sense of self, empathy and stress. (17)

Medical school and life as a doctor is a demanding career path. Thus, it can be argued that it is the responsibility of medical educators to both equip students with the academic knowledge required and the emotional intelligence to handle the day-to-day challenges. Mindfulness offers a method to teach medical students how to practically handle stressful emotions and situations, which helps them to become more centred, caring and empathetic. We can only give as much as we have, so it seems intuitive that students who are happier and mentally strong will provide better patient care. The evidence for mindfulness practice is very encouraging and it is interesting to see that two medical schools have already incorporated these practices into their curriculum.

Will mindfulness become as core to the medical school curriculum as the study of anatomy? If we value the mind as much as we do our bodies, then maybe it should.

Meditate and Prosper by Juhan Sonin
Meditate and Prosper by Juhan Sonin
  1. 1. Halpern J. What is clinical empathy? Journal of general internal medicine. 2003;18(8):670-4.
  2. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. Jama. 1997;277(7):553-9.
  3. Brownell AKW, Côté L. Senior residents’ views on the meaning of professionalism and how they learn about it. Academic Medicine. 2001;76(7):734-7.
  4. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Academic Medicine. 2008;83(3):244-9.
  5. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011;86(3):359-64.
  6. Ren GSG, Min JTY, Ping YS, Shing LS, Win MTM, Chuan HS, et al. Complex and novel determinants of empathy change in medical students. Korean journal of medical education. 2016;28(1):67-78.
  7. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine. 2009;84(9):1182-91.
  8. Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. Personal life events and medical student burnout: a multicenter study. Academic Medicine. 2006;81(4):374-84.
  9. Sayburn A. Student BMJ: Why medical students’ mental health is a taboo subject. London: Student BMJ; 2016 [accessed 4 Apr]. Available from: http://student.bmj.com/student/view-article.html?id=sbmj.h722.
  10. Marshall EJ. Doctors’ health and fitness to practise: treating addicted doctors. Occupational medicine. 2008;58(5):334-40.
  11. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of behavioral medicine. 1998;21(6):581-99.
  12. Dobkin PL, Hutchinson TA. Teaching mindfulness in medical school: where are we now and where are we going? Medical education. 2013;47(8):768-79.
  13. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003 15(2): 88-92.
  14. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. Jama. 2008;300(11):1350-2.
  15. Kabat‐Zinn J. Mindfulness‐based interventions in context: past, present, and future. Clinical psychology: Science and practice. 2003;10(2):144-56.
  16. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893.
  17. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging. 2011;191(1):36-43.

Featured image:
Meditation by Sebastien Wiertz

Categories
General Innovation Lifestyle Public Health

A New Type of Pharmacy – On Food Pharmacies and Their Importance for Type II Diabetics

In a world where drug companies and pharmacies remain pervasive, an innovative take on the word “pharmacy” is being developed in Redwood City, CA. A new food pharmacy has just opened up, stocked with fresh fruits and vegetables. Just what the doctor ordered – literally! Instead of paying supermarket prices for these foods, all you need is a prescription from the doctor.

The first of its kind, this food pharmacy is an annex to the existing Redwood City free clinic known as Samaritan House. Patients with type II diabetes can get a prescription for fruits, vegetables, and even fish from a physician, and then pick up the free food at the pantry to help better manage their diabetes. The food is procured and delivered by the Second Harvest Food Bank, which is one of the largest food banks in the nation, feeding almost a quarter of a million people each month. Second Harvest also provides nutritious cooking demos given by local nutritionists1.

This one-year pilot program serves as a reminder that food is often overlooked as a primary method of treatment and prevention; a reminder we might need during our incessant drive to memorize pharmaceuticals and their mechanisms of action. Even when it is known that a patient’s congestive heart failure and diabetes may not be adequately controlled long term by medication alone, oftentimes physicians are strapped when it comes to options. Providing education on proper nutrition to a patient who simply cannot afford fruits and vegetables remains the passive and limited option, whereas food pharmacies such as Samaritan House are active steps in the right direction.

 

Source(s):

1http://www.sfexaminer.com/food-pharmacy-for-diabetics-launched-in-redwood-city/

Featured image credited to the US Department of Agriculture

Categories
General Reflection

Standing Outside the Match

My favorite online resource, Wikipedia, calls gambling, “wagering of money or something of value (referred to as “the stakes”) on an event with an uncertain outcome with the primary intent of winning additional money and/or material goods. Gambling thus requires three elements be present: consideration, chance and prize.”[1] It’s a funny quirk of medical student life that we all involve ourselves in gambling during our final year. The National Residency Matching Program (NRMP) can certainly fit the definition above. The med student wagers their future (“something of value”) on the Match (“an event with an uncertain outcome”) with the goal of finding the program that best suits them (“with the primary intent of winning”). The risk involved is certainly a calculated risk, as the give-and-take of applying, interviewing, and ranking allows us the opportunity to influence the outcome, but it is a risk nonetheless. In fact, it’s worth noting that much of the NRMP data was analyzed by Anna-Maria Barry Jester on the FiveThirtyEight blog last year. The major takeaway of her work was that while the system may very slightly favor the student, at the end of the day, it is the Match’s algorithm that decides.[2]

Fourth year med students are now receiving their “prizes” after going through the “consideration” and “chance” phases of the Match. As a 3rd year med student, I’m firmly rooted in the consideration phase. I’ve already decided my future specialty (family medicine), which is more than some can comfortably say, but now I have 500 programs to sort through, and how can anyone possibly decide where to apply? The consideration phase of my gamble on the Match is just as much of a lottery as anything. Sure, I get to make the final choices, but if there is a perfect program, how do I know it’s not the one I left off my list? It’s a familiar process at least, since it is similar to applying to medical school in the first place. I sent my applications out nationwide, to both osteopathic and allopathic schools. While the system didn’t rely upon an algorithm to decide, the stakes were nearly as high, with just as much uncertainty.

The process of sifting through residencies, though, is better left for another day. Currently, I just stand back and watch as my older brothers and sisters plan their futures. I’m both envious and wary. Certainly it would be nice to know, to have a clear objective. There is a lot of security in certainty. Then again, there is a reason the casinos are always so full in Las Vegas. People love the allure of any game of chance. When the dice are rolled, in that brief moment before the outcome is known, everyone has the potential to be a winner. No one puts a program as number one on their rank list hoping they aren’t selected to go there, just as no one places a bet on number 17 in roulette hoping the ball lands elsewhere.

I’m looking forward to the Match next year. I like to play the odds, always hoping that my number comes up. Luckily, while I may have no say in what cards are dealt in poker, I do have a say in how the Match ends. I get to meet with programs and all the people who populate them. I get to talk about my passions and plans and hope they get a feel for who I am on those interview days. And when I place my rank list, whatever choices I make, I hope I’ve done enough to pick a place that wants me just as much. When the Match algorithm runs, churning out the yes’s and no’s, I hope my number comes up.

Featured image:
Gambling by Alan Cleaver

Categories
Lifestyle

Blue bird day, fresh pow, and a baby on the way

Meet Laura Matsen Ko, orthopedic surgeon, avid runner/skier/hiker/cyclist, and new mother to a  beautiful baby boy, Logan.  Laura and her husband, both orthopedic surgeons at Orthopedic Physician Associates (opaortho.com), practice and adventure in the Pacific Northwest. Together, they developed the website, seattlejointsurgeons.com, which allows patients to access comprehensive and accurate information on orthopedic care.

I met Laura recently on Instagram via a post shared by Oiselle (oiselle.com), a Seattle-based women’s running apparel store named after the French word for bird. In the post, photographed by Kevin, Laura is captured as a pregnant backcountry skier posed on the summit of snowy Mt. Baker.  A flurry of follow requests, instant messages, and emails between us quickly snowballed into a cross-country friendship.  Our easy rapport is not unexpected considering our shared passions. We are both passionate about helping injured athletes (and specifically pregnant athletes) get back to their sports as soon as possible.  After learning of my research interests in antenatal exercise, Laura agreed to a semi-formal interview about her background and experiences related to exercise during pregnancy.

 

First, tell me a little about yourself. I did some Instagram sleuthing and noted scrubs, ortho, a lot of snow, and Thomas Jefferson.

I was born and raised in Seattle, Washington. I went to Whitman College in Walla Walla, WA where I enjoyed being an outdoor leader on backcountry ski trips and mountaineering trips. My senior year I decided to go out for Cross-Country, and surprised myself by placing 9th at Nationals (D3).  Then I bike raced that spring and got 2nd at Nationals (D2). That was a huge surprise and a thrill.

I went to medical school in Portland, Oregon at Oregon Health and Sciences University (OHSU) and continued on at OHSU in an Orthopedic Surgery residency. I did two Ironmans while I was there, including qualifying for, and finishing, the world championship in Kona, HI.

About that time I got to meet my husband who was a year behind me in the Orthopedic Residency, and I finally convinced him to go for a real date with me after one of our rainy runs together.  Throughout residency we trained for various marathons together and enjoyed active vacations; anything from cycling to backcountry skiing. 

After we finished residency, we headed to Philadelphia. I did a fellowship in Adult Reconstruction. I chose the field of hip and knee joint replacement surgery because it gives me the opportunity to help people return to the activities they enjoy using surgery and personalized rehabilitation.

 

How many years have you been a backcountry skier and mountaineer?

My father and older brother taught me in my teenage years.  We had been backpacking our whole lives, they had been climbing, and I always aspired to go out with them.  When I was 13 I took a year-long course with my Dad to learn how to safely rock climb, mountaineer, snow camp, and manage avalanche risk and rescue.  That winter my brother took me out in the backcountry and I got stronger and smarter. That summer we climbed five Washington volcanic peaks including Mt Rainier.

 

What kind of role does skiing have in your life?

Backcountry skiing is a wonderful treat—unlike running it does take a bit of equipment and a bit of driving but it’s totally worth it! I love getting out into the wilderness without anyone around. I equally love the hiking up (“skinning” up) the mountain as much as the fresh, sweet turns on the way down!

 

Tell me about your pregnancy.

Logan was my first pregnancy.  I have always been active, and continuing my activity seemed right to me.  I bike-commuted to my work at the hospital, rain or shine, which was about a 15-mile commute. I did this through my second trimester, and then we decided it was too high of a risk to continue cycling due to the short and often rainy dark days in Seattle.  My OB, husband, and father all pushed me to stop bike-commuting.  I ran up to two weeks prior to him being born.  I skied two days before he was born—in bounds alpine one day and three days of very rigorous backcountry skiing.  These were about 6 hour days of hiking hard uphill and then skiing down in fresh powder.  It was so fun to feel like I was sharing this experience with Logan.

Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Multi-night mountaineering trip in the Washington Cascades with husband Kevin at 18 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Hike with my Dad at 19.5 weeks gestation.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.
Seattle Half Marathon at 32 weeks gestation. Time: 2:00.

The day I went into labor I did elliptical and weights and performed a major total hip revision surgery.  Throughout the second half of my pregnancy I had some issues with SI joint and foot pain, but in general my body held up well.

I did a lot of research about heart rates, but the data seemed inconsistent. 

 

Laura’s difficulty navigating antenatal exercise guidelines is not surprising.  A study by Lieferman (2012) demonstrated that almost half of medical providers (48%, N=89) were unfamiliar with current national exercise guidelines for pregnant women and half of respondents advised a reduction in exercise in the third trimester, even for uncomplicated pregnancies.  Concurrently, a 2006 study demonstrated that about half of surveyed obstetricians recommended heart rate maximums and a reduction in exercise load during the third trimester—two policies not specified in current guidelines (Entin, 2006).

The American College of Obstetrics and Gynecology (ACOG) and the U.S. Department of Health and Human Services recommend that healthy pregnant and post-partum women engage in 30 minutes of moderate intensity exercise for most, if not all, days of the week (ACOG, 2015; DHHS, 2008).  Pregnant women who habitually perform vigorous-intensity aerobic activity may engage in higher intensities under the guidance of a medical provider.  Heart rate maximums are no longer indicated.  Instead, pregnant women use ratings of perceived exertion to monitor their exercise intensity.  For most women, moderate effort is comparable to a brisk walk, at an intensity one can maintain for hours. It should result in heavy breathing, but not so much that the exerciser is unable to hold a short conversation. Vigorous activity, on the other hand, should make the exerciser feel short of breath, but still able to speak a sentence.

Obstetrics (OB) providers are encouraged to educate women about the health benefits of exercise during pregnancy. These benefits include improved gestational diabetes control, lower rates of antenatal and post-partum depression, and relief for back pain.  There are several absolute contraindications to exercise during pregnancy, including incompetent cervix or cerclage, multiple gestation at risk of premature labor, persistent second- or third-trimester bleeding, and preeclampsia.  For a full list of absolute and relative contraindications, consult the ACOG Committee Opinion Number 650 (ACOG 2015).  Certain activities are also identified as safe or unsafe.  Unbeknownst by Laura, down-hill snow skiing is listed as an activity to avoid due to an inherently high risk of falling and subsequent abdominal trauma.

Laura continues:

I didn’t really follow [the guidelines] after talking with friends and reading.  I didn’t do sustained high intensity intervals, but if I was running stairs and my heart rate got up to 165-170 on the way up but dropped to 120 on the way down, I felt that my baby was getting sufficient perfusion.  Each mother has a different pregnancy experience and the biggest factor is to listen to your body.  Exercise made me feel happy and alive so I kept doing it.  Plus pregnancy can do such a warp on body image.  Exercise helped normalize my feelings about the changes in my body.

 

Why do you think it is most important to listen to your body?

We are all so different. As you’ve seen with your med student classmates, we need different amounts of sleep, caffeine, food, exercise, fresh air… so no single guideline will work.  We all must strive to learn our bodies. 

My physician friend had a 10-lb baby.  She was extremely active, and pre-pregnancy she ran and played soccer.  Obviously our pregnancy (and delivery and post-partum) experiences were totally different and not fair to compare.  She says she tried to play soccer 7 weeks post-partum and she “felt like her uterus was going to fall out.” Another physician friend had a 9 lb baby with a very large head.  She was walking over 5 miles a day until she delivered, but is challenged to get back to walking more than a couple blocks now (2 weeks post-partum) after her more traumatic vaginal delivery. A third physician friend who had always been extremely active in basketball and volleyball was placed on bed rest at 22 weeks for all three of her babies. 

I never want to be compared to other women or make other women feel that they just didn’t push hard enough because of my activity levels.  I’m one person and this was one pregnancy. The next pregnancy could be totally different!  These other women are a lot tougher than me—they had a more challenging pregnancy, delivery, and recovery.  And they had to be very patient with their bodies.

 

Did you have any conversations with your OB provider(s) about your exercise practices during the pregnancy?  

Yes… some. They thought I was a little nuts but were supportive.  Except for the skiing.  My OB was a little shocked to hear that I’d been skiing.

In the first couple weeks post-partum I mostly tried to work on some baseline fitness with walking and stairs.  I tried to wait until 6 weeks to really increase my activity but I wasn’t able to wait.

 

Explain the 6 week mark. 

Well I was told by my OB and the nurse practitioners to not exercise hard until 6 weeks.  BUT I started running at day 16 and as of 4 weeks was up to about 30-40 miles a week with one day of hill repeats and one day of fartleks. I made it to 8 miles in sub 8 pace with a couple 7:30 until around 4 weeks.  I think my first race will be a half marathon at 2.5 months postpartum.  I’m not going to be the fastest.  Partly because of recent pregnancy but also because of sleep deprivation, returning to work, and not having enough time in the day!

16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.
16 days post-partum. 7.2 mile run with baby Logan and husband Kevin at 8:37 minute pace.

Do you have any friends who also skied during their pregnancy?  

 I knew people who were running and rock climbing in their pregnancy and a lot of friends who just stayed fit with walking.  I don’t know anyone else who skied during their pregnancy but I’m sure people out there do it!  I’d mainly suggest borrowing your father’s huge rain coat and possibly his ski pants because there is no way you’re fitting in your bibs from pre-pregnancy.  And don’t push the speed and steepness; mostly enjoy being out there!  You don’t want to fall.

There are definitely other pregnant skiers and a few inspired, future Mamas:

5

On the mountaineering trips, what, if any, issues did you have with harness fit?

Due to the season I didn’t mountaineer in the second half of pregnancy, so it wasn’t an issue.  One of my friends got a lower and upper body harness for her pregnant rock climbing trips.

 

What kinds of emotions did you encounter during your pregnancy when you were not able to do activities that you enjoy?

I found it super frustrating when others placed restrictions on me. My husband quickly found that he had to present my change in activities as a risk/ benefit. When he told me “no more cycling,” I just wanted to rebel. However he did recently have to fix a clavicle fracture on a woman who was 16 weeks pregnant. She got hit while bike commuting. Thankfully her fetus is okay.  That story will make me more conservative with my cycling in my next pregnancy.

At 4.5 weeks post-partum I restarted bike-commuting to work for some half days of clinic.  It felt amazing to be back out there and I was so much faster with less weight, higher lung capacity, and likely an increased hematocrit. 

 

Is there anything you want to tell future mothers? 

Listen to your body and don’t read too much.  Wear support stockings if you work on your feet.  Know that you will lose the weight.  Fast. 

 

Physicians?

Support your patients.

For future and current obstetrics providers, the Canadian Society for Exercise Physiology developed the PARmed-X for Pregnancy, a physical activity readiness medical questionnaire that guides discussions on exercise during pregnancy in an outpatient setting.  The form may be accessed online (http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf) and is useful for most pregnant women.  Athletes, however, have sport-specific safety concerns, training goals, and requirements that may be unfamiliar to the average obstetrics provider.  These topics may be explored on an as-needed basis during prenatal visits.

A big thank you to Laura Matsen Ko for sharing your inspiring story!  Thank you also to my friend Hannah, who initially tagged me in the Oiselle Instagram post.

 

References

  1. Leiferman, J., Gutilla, M., Paulson, J., Pivarnik, J. (2012). Antenatal physical activity counseling among healthcare providers. Open Journal of Obstetrics and Gynecology, 2, 346-355
  2. Entin, P. L., Munhall, K. M. (2006). Recommendations regarding exercise during pregnancy made by private/small group practice obstetricians in the USA. J Sports Sci Med, 5, 449-458.
  3. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol 2015;126:e135–42
  4. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans.  Department of Health and Human Services Washington, DC; 2008.

Featured image:
Laura Matsen Ko skiing. Photographed by Kevin Ko.