We are living incarnations of a love that preceded us.
Vibrant, with ailing petals that should fall.
A knot in the throat, a conjuring of another’s quintessence,
as music brightens the void.
As we love others perhaps we can feel the face
of eternity shining down upon us.
If we could but hold on to love,
to be mindful of its primacy,
we might never grow dim again.
Hosting Grand Rounds is a rewarding experience in that it compels you to read through a wonderfully diverse, informative, and insightful collection of thoughts from around the health care world.
Here are some highlights from the past week, and thanks to all who contributed. Enjoy, and read as many as you can:
Dr. Val shares a book review that she published on Scientific American’s website about “Tabloid Medicine: How The Internet Is Being Used to Hijack Medical Science for Fear and Profit.” In this important book Robert Goldberg, PhD, explains why the Internet is a double-edged sword when it comes to health information, empowering some to better decisions, while misleading others into dangerous ideologies such as the anti-vaccine movement. A must-read post and book!
Shrink Rap discloses a story about a psychiatrist who is distraught about an on-line review that he believes was posted by a patient still under his care, and explores the ethics and credibility of such a dilemma.
Future Docs presents a cogent argument for why you should want a medical student to be involved in your care. Apparently people are now suing medical students along with doctors. Has it really come to this?
Maria from In White Ink reflects on the sacred spaces that are opened by a hospital key card, and reminds us of the privilege that comes with being invited into the private world of a sick patient. She is a most eloquent and thoughtful physician-writer.
Dr. Pullen delves into the recent admission by Lady Gaga that she tested borderline positive for Lupus, and suspects the uncertainties surrounding the ANA test are to blame for a common predicament.
Enabling Healthy Decisions debates the relative merits of multi-tasking versus focused thinking, and advocates for the old-fashioned focused thinking which engages the hippocampus and allows us to apply knowledge.
Medical Lessons asserts the importance of the salutation “doctor” for some patients, including the star of The King’s Speech, and reminds us of the respect conveyed by using formal names.
Clinical Cases and Images marvels at a report of a heart that has endured 67 stents and 28 coronary angiograms. The cost, cumulative radiation, and logistics are unreal.
Suture for a Living highlights research into a new breast cancer oncogene, ZNF703. Hopefully practical applications will include targeted therapy similar to Herceptin.
Onc RN shares a lovely poem of sorts about hope, and the sobering work of a would-be healer.
ACP Internist asks whether everyone taking a statin drug really needs to in light of news that up to 25% of adults are now taking these medicines.
ACP Hospitalist highlights new research showing that bacterial contamination of physicians’ newly laundered uniforms occurs within three hours of putting them on, making them no more or less dirty than the traditional white coats.
Nuts for Healthcare considers the future of pharma and concludes that the drug development paradigm favors drugs with high prices that are supported by proven better outcomes.
Health Blawg outlines two large fines announced last week by HHS in cases against HIPAA violators.
Mind the Gap laments that more is not done to prevent the falls of the elderly, as recently experienced by his own mother. A commenter points towards a helpful CDC tip sheet for those looking to take responsibility.
Emmy asks some important questions about the nature of breast cancer and its causative factors.
BJC Health shows how a stressful time in his life created symptoms reminiscent of a condition he frequently diagnoses and treats – fibromyalgia.
Jill of All Trades rehashes a discussion that is all too common with a patient who does not see the irony between cause and effect.
Insureblog revels in the good news that a daily cocktail or glass of wine may help ward of dementia.
Health Business Blog interviews an expert at the University of Rochester about the NIH’s planned drug development center.
Hanging by a Stethoscope reveals a phenomenon in the Filippino health care system in which patients often seek medical certificates excusing work absences, instead of seeking treatment, per se.
Healthline explains a new head lice treatment for adults and children.
Pam Ressler offers an interview she gave about her research in narrative medicine, blogging, and social media in health care.
The Happy Hospitalist points out that white males seem to face longer odds for admission to medical school.
Allergy notes reviews some salient points about chronic spontaneous urticaria.
~
This concludes Grand Rounds for March 1st, 2011. I’d like to thank all the contributors who shared some excellent writings this week, and would like to encourage those who write about health and medical topics to keep Grand Rounds going. Your contributions, readership, and inspiration help forge a community.
Next week’s Grand Rounds will be at Dr. Pullen’s site, so head on over soon.
Thank you!
After the computer known as Watson easily dispatched of the best two human Jeopardy contestants in history, IBM announced that one of the first applications of their artificial intelligence technology would be in the medical field. We should soon expect virtual physician assistants in the exam room. At least one of my friends even speculated that the days of human doctors are numbered.
Is it possible that machines will replace humans in the doctor-patient relationship? I doubt it. According to a study done by the Mayo Clinic in 2006, the most important characteristics patients feel a good doctor must possess are entirely human. According to the study, the ideal physician is confident, empathetic, humane, personal, forthright, respectful, and thorough. Watson may have proved his cognitive superiority, but can a computer ever be taught these human attributes needed to negotiate through patient fear, anxiety, and confusion? Could such a computer ever come across as sincere?
Here’s an artist’s conception (read: farce) of how such an application in the examining room might play out. I’m afraid some major calibrations might be needed to substitute artificial intelligence for an “ideal” physician. What do you think?
To watch this Oscar-nominated cartoon on a full screen, follow this link:
http://www.xtranormal.com/watch/11199353
Grand Rounds will be held here next Tuesday! Please send me a link and brief description of any good medical blogging from this week you would like highlighted- either written by you or another medical blogger you read. Please send by Sunday night, February 27th.
Selfishly I’d like to read some posts that discuss current events going on right now, and reflective, creative pieces… but all are welcome!
Email:
drcharles.examining
(at gmail.com)
“This job is killing me” is not a statement of jest. It is a desperate plea of outright sincerity.
Stress, anxiety, depression – all have been associated with an increased risk of cardiovascular disease and mortality. But can interventions to help people cope with stress positively affect longevity and decrease risk of dying? The results of a new study in the Archives of Internal Medicine would imply the answer is an encouraging “yes.”
Constructively dealing with stress is easier said than done, but it would seem logical that if we can reduce our psychological and social stressors we might live longer and delay the inevitable wear and tear on our vessels. This study proved that one such intervention, cognitive behavioral therapy (CBT) for patients who suffered a first heart attack, lowered the risk of fatal and nonfatal recurrent cardiovascular disease events by 41% over eight years. Nonfatal heart attacks were almost cut in half. Excitement may be dampened by the fact that all-cause mortality did not statistically differ between the intervention and control groups, but did trend towards an improvement in the eight years of follow up.
Definitely less suffering. Maybe less deaths.
The authors state that psychosocial stressors have been shown to account for an astounding 30% of the attributable risk of having a heart attack. Chronic stressors include low socioeconomic status, low social support, marital problems, and work distress. Emotional factors also correlated with cardiovascular disease include major depression, hostility, anger, and anxiety.
An experienced and specifically trained psychologist usually directs cognitive behavioral therapy for patients. It has been proven to help conditions ranging from social anxiety to borderline personality disorder. While such therapy is by definition supervised and directed by a professional, perhaps we can benefit from a crude understanding of its methods.
In this study, the CBT focused on 5 key components – education, self-monitoring, skills training, cognitive restructuring, and spiritual development. It emphasized stress management, coping with stress, and reducing the experience of daily stress, time urgency, and hostility. The program was highly structured, performed over 20 two-hour sessions during the course of a year.
Education – the goal was for participants to learn more about cardiovascular disease, specifically about anatomy, physiology, symptoms, consequences, the relationship between stress and heart disease, and the symptoms and signs of stress.
Self-monitoring – this goal encompassed becoming more alert to body signals of stress such as heart rate, muscular tension, and pain, with greater attention to behavioral and cognitive clues. This was accomplished in part by the use of diaries to observe, monitor, and reflect upon reactions and behaviors, as well as the use of group processes to enhance observational skills and understanding.
Skills training – this goal was to reduce negative thinking, and to learn to act constructively rather than simply reacting to everyday problems. I’ve heard this method described elsewhere as the imperative to “respond, not react.” A drill book was used for daily behavioral exercises, practicing alternatives to anger, frustration, and depressive reactions. Problem solving and communication skills were rehearsed in the group setting as well.
Cognitive restructuring – this goal involved recognizing negative, hostile, and stress-triggered thoughts and attitudes. Efforts were made to change the participants “internal dialogue” through constructive self-talk, focusing on hostility, worries, and self-defeating attitudes. This component seems to have relied the most on the specialized training of the psychologists to deliver a restructuring of maladaptive thinking styles, again through individual and group efforts
Spiritual development – the goal was to encourage a spiritual reflection upon life, and what is desired for the future. Individual goals, quality of life, and the importance of significant others were discussed. The social and emotional support of the group helped foster self-esteem, optimism, trust and emotional intimacy.
The structure of each session was similar to most CBT programs. This included a weekly specific theme, starting each session with progressive muscular relaxation, followed by reflection and discussion of homework assignments. The current theme was discussed and tied in with previous and new themes, ending with a new homework assignment, often individually tailored. A variety of educational media and materials were used.
Specific skills and themes were tailored to the participants, and the authors noted a predictable (if not clichéd) pattern. Women more often needed focus on self-confidence and self-assertion skills, while men were more often in need of ways to cope with aggressive and hostile behavior.
Another gender difference centered around social networks. Women were often over-involved with social ties, subduing their own self-interests, while men’s social networks tended to provide more unconditional support. (I would also insert another cliché here that men I see in my own practice often suffer from poor tending to social ties, and consequent isolation).
Limitations of this study include the population of patients studied – over 90% were white and of Swedish ancestry, and over 75% were male. There was an overall all-cause decrease in mortality for those attending the CBT program, but this tendency did not meet statistical significance. Prior similar studies have shown conflicting results of stress reduction programs, some concluding that stress management does not affect cardiovascular mortality. However, the authors also reference 2 meta-analyses of health education and stress management programs for patients with coronary artery disease that found a pooled 34% reduction in cardiac mortality and a 29% reduction in recurrent heart attacks. Meta-analyses are generally considered to be of higher authority than individual trials since the evidence they collect is from multiple independent trials.
So what does this study mean?
Perhaps in a broad sense we can confirm our intuitive sense that stress is harmful to us. A stressful job, aggressive people, a bad relationship, depression, and anxiety all place undue wear and tear not only upon the health of our psyche, but also upon the health of our very substance. More importantly, our hearts and minds can benefit from everyday measures to reduce stress, and to deal constructively and optimistically with the internal and external battles we face.
Participation in a supervised cognitive behavioral therapy group, especially after one suffers a first heart attack, seems like a good idea, and might just prevent or delay a significant burden of recurrent cardiovascular disease.
At the very least, studies like this reaffirm our collective need to step back, to reflect upon the pace and tenor of our strident lives, and to methodically work on a less reactive response to our daily conflicts. It is almost as if an empathic approach to ourselves is needed, one that genuinely considers our woes with some healthy distance, perspective, and practiced coping skills.
Respond, don’t react.
Study Citation:
Randomized Controlled Trial of Cognitive Behavioral Therapy vs. Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients with Coronary Heart Disease: Secondary Prevention in Uppsala Primary Health Care Project (SUPRIM)
Arch Intern Med. 2011; 171(2): 134-140.
A patient reading a copy of Prevention in the waiting room brought to my attention an interesting article entitled “7 Foods That Should Never Cross Your Plate.” I would have to agree that these seven commonly eaten foods should be avoided, so I’ll rehash them here, along with 3 more of my own choosing to flesh out a New Year’s 7 + 3 = Top 10 list.
The lead into the article implores the reader to recognize that “Clean eating means choosing fruits, vegetables, and meats that are raised, grown, and sold with minimal processing.” Michael Pollan, the regarded author of The Omnivores Dilemma and In Defense of Food, puts it even more simply: “Eat food. Not too much. Mostly plants.”
So here are the food items to avoid, in no particular order:
I just learned (via The New York Times) of a new Google tool that allows the curious person to type in a word or phrase and see how often that term is mentioned in over 5.2 million books over the past 500 years. The Google Ngram tool draws from 500 billion words contained in books published between 1500 and 2008 in English, French, Spanish, German, Chinese and Russian.
If every picture tells a story, then perhaps we can intuit some knowledge from this incredible graphing tool, the analytical powers of which would have been unthinkable only a few years ago. Of course lines on a graph are just data, and exercises in interpretation can be creative, manipulative, dull or brilliant. That’s why it could be fun.
Here are a few I came up with:
This week the Congressional passage of a bill to extend Bush-era tax cuts was big news. Obama’s health care legislation passed earlier this year remains in limbo as judicial challenges and a Republican Senate gear up to attack. How do the terms “tax cuts, medicare, and medicaid” stack up in terms of their prevalence in our written discourse over the last 100 years?
Does the hive conscience since the 1960’s have a greater appetite for money in one’s own pocket than concerns about health welfare?
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