Archive for the 'A Country Doctor Reads' Category

A Country Doctor Reads: Why Sweden isn’t Restricting Personal Freedom During the Covid-19 Pandemic – Svenska Dagbladet

I read in the news media that my native Sweden is not restricting personal freedoms the way other countries are. I just recently happened to subscribe to Svenska Dagbladet, one of the big Stockholm newspapers. Here is what they quote historian Lars Trägårdh saying about why:

“First, there is a deeper trust in public institutions in Sweden than in other countries. It is not blind injunctions that make us obedient citizens but faith in expert authorities who in turn trust their citizens. It is a matter of mutual trust.

Therefore, Swedish authorities believe that it is enough to make recommendations such as staying inside if you feel ill and avoid large crowds. “Use your brains“…. Classic Swedish freedom and responsibility in other words. May also be called common knowledge, common sense or sense of duty.

Secondly, the Swedish exception can be explained by the ban on ministerial rule. This is a deeply rooted rule that goes back to the 17th century when the foundation was laid for the Swedish state apparatus. This means that Sweden is governed by expert authorities and not the government. Politicians who want to show muscles in tough times should keep their paws away from apolitical institutions whose decisions are based on skill and expertise.

This is very deeply rooted in Sweden. Elsewhere in the world where they don’t have this strict rule, many politicians now take the opportunity to prove themselves as strong leaders and impose harsh prohibitions especially if it is an election year. “

A Country Doctor Reads: How South Korea Flattened the Curve – The New York Times

If Covid-19 were a vicious STD spread via toilet seats, you wouldn’t tell everyone to stay away from public places including their worksites for months while the economy contracts and evaporates until there were no more cases. You would just do CLEANING, WIDESPREAD TESTING and TRACE CONTACTS. That’s what South Korea did, AND IT WORKED —— @ACDocWrites on Twitter

As I watch the Covid-19 doomsday scenarios play out in the media, it becomes very clear that our strategy of shutting down life as we know it to stop this communicable disease makes relatively little sense if it is not done alongside aggressive standard epidemiologic practices.

To put it more bluntly: Mere isolation is just plain Medieval.

We know how to do this: We test asymptomatic people for HIV, hepatitis, gonorrhea, syphilis, tuberculosis and many other communicable diseases and in most cases we also deploy public health staff to trace contacts that need testing and followup.

So, why were we in this country so paralyzed, why did we resort to economy-halting measures that will likely wipe out retirement savings, cause widespread layoffs and permanent unemployment, bankruptcies and evictions and general despair like that of the Great Depression?

Now, I’m just a Country Doctor, and I’m not particularly interested in the science of epidemiology, but reading in The New York Times about what South Korea did I am baffled: Why did we not try harder to get more people tested early on?

A Country Doctor Reads: Job Crafting for Character – Harvard Business Review

Every once in a while something in the business literature catches my attention. Last week I found an article in the Harvard Business Review daily newsletter about Job Crafting. I had never heard the term, and I had not paid any attention to the possibility that how we view and approach our career can affect our personality and our morality instead of the other way around.

Business professors Smith and Kouchaki write:

“As originally presented by scholars Amy Wrzesniewski (Yale University) and Jane Dutton (University of Michigan), people can craft their jobs by first altering the way they think about their work (cognitive crafting), second, changing the scope and type of tasks they engage in (task crafting) and, third, changing the nature of their relationships and interactions with others at work (relational crafting). To date, most scholars and practitioners have explored job crafting as a means to make work more meaningful and satisfying, and potentially increase individual performance. But we suggest that you can also engage in job crafting to become your best moral self.”

I don’t often see articles about morality and business, and not often about health care and morality either, for that matter. But last week’s reading gave me reason to think about how our work can elevate us to a higher plane if we view it the right way. We often think that we bring some of our own selves into our work, but we don’t talk nearly enough about how our work shapes us and how we make daily choices in exactly how and in what direction we allow that to happen.

“Whether you view your job as merely a paycheck, as a step up the career ladder, or even as a calling, we encourage you to also approach your job as an avenue for becoming a better person — as a laboratory for refining your character. Doing so will not only help you become virtuous, but it can help others as well. Psychology research on elevation (the moral emotion experienced upon witnessing the virtuous acts of others that leads to a desire to become a better person yourself) suggests that morality can be contagious. Crafting your job in a way that leads to exemplary behaviors might just result in a moral contagion that benefits others in your organization as well. Like a tiny pebble tossed into a vast pond, your simple job crafting efforts might ripple throughout your entire workplace. Try job crafting to make the world a better place — one life at a time, starting with your own.”

I guess we and the journals that cater to us need to claim some of our attention and reading time to consider not just drugs and diseases, patients and third parties but us, the healers, the physicians and other clinicians who are at constant risk of burning out if we don’t see the moral value in and resonate with the moral implications of how we do our work, of our behavior and of our attitudes.

The Science of Placebo and Nocebo Effects Puts the Doctor-Patient Relationship on Par With the Effectiveness of the Pharmaceuticals We Prescribe

Using a treatment without having any understanding of how it works is often thought of as unscientific and suggesting that a placebo can help a sick patient has until now been viewed as unethical.

The New England Journal of Medicine just published an article about placebo (making you feel better) and nocebo (making you feel worse) effects, two of the most intriguing aspects of the supposedly scientific practice of medicine. These phenomena have long been seen as complicating pharmaceutical research. But today we have a deeper understanding of how placebo and nocebo effects come about, down to the neural pathways. The fact that we understand the mechanisms better has made their use start to gain more legitimacy.

According to the article, placebo effects have been shown to be associated with the release of substances such as endogenous opioids, endocannabinoids, dopamine, oxytocin and vasopressin. We even have some understanding of which substances mediate which type of response. For example, placebo treatment of Parkinson’s disease raise dopamine levels and “increased pain perception through verbal suggestion, a nocebo effect, has been shown to be mediated by the neuropeptide cholecystokinin”.

In my own clinical experience (40 years last summer) and writing, the understanding of the impact of exactly how a treatment option is presented is a recurring observation and theme. See for example “Negative Expectations”, “Patients are the Real Healers”, “Patient Centered and Evidenced Based Medicine – Can We Really Have Both?” and “Getting it Right”.

As the NEJM article points out, many double blind clinical trials of medications for pain and psychiatric disorders show similar effectiveness of placebo and active substance. Another interesting statistic is that up to 19% of adults and 26% of elderly patients report side effects from placebos. The article, in linking placebo and nocebo effects to patients’ relationship with and trust in their physician suggests that a patient who stops a medication may not or not only be doing this because of perceived side effects but perhaps deep down due to mistrust in their physician.

Similarly, “patients with common colds who perceive their clinicians as empathetic report symptoms that are less severe and of shorter duration than those of patients who do not perceive their clinicians as empathetic; patients who perceive their clinicians as empathetic also have reduced levels of objective measures of inflammation such as interleukin-8 and neutrophil counts”.

As we present patients with treatment options, we need to give more thought to the risk-benefit of the traditionally all-important notion of informed consent.

I, for instance, have tended to present statistics in a counterproductive way. Instead of saying 5% of people get a particular side effect, the article hints that maybe we should say that 95% don’t get it while at the same time explaining the potential benefit of the treatment.

The article also suggests describing the severe or significant side effects a medication can cause and then mentioning that other, milder side effects can occur, but because of the nocebo effect, the mere mention of these has been shown to increase the statistical probability that patients may have them. Giving the option of hearing all the non-critical reported side effects has been called “contextualized informed consent” and “authorized concealment”.

I can’t help reflecting on how focused we are in medicine on the subject matter and how little we speak about the delivery of subject information. The business world seems to talk more about how to sell something than how to produce it. I think as physicians or scientists we look down on that, thinking that a cup of coffee is a cup of coffee, so why are all these people devoting their lives to how to sell that cup of coffee?

So we need to get off our high horses and take a look at how we present information about what we “sell”, because what we try and hope to sell may have greater impact on our “customers” future health than which brand of coffee they choose to drink.

The Polyvagal Theory: The Science Behind Therapeutic Relationships, Stress Related Illness and Long Term Effects of Trauma

The vagus nerve runs from our brain to our gut and along the way it connects with our heart. We used to think of it as a one-way signaling, but 80% of the activity in the vagus nerve travels the other way – from our gut to our brain.

As many times before, I read an article in The New York Times that made me dig deeper into a medical subject, this time the vagus nerve, and the term “Polyvagal Theory” got me going.

We now understand that there are three levels of activity in this system, and that each one of them can influence our bodily functions, our emotions and even our perception of reality.

This deeper understanding of the vagus nerve has been named the Polyvagal Theory.

The three functions of the vagus nerve represent three different stages in evolution and the newest one, involving our conscious mind, can’t necessarily override the older two.

The oldest part of the system regulates our intestinal functions and has the ability to decrease our heart rate to the point of unconsciousness and our brain function to the point of shutdown or, in psychological terms, dissociation – playing dead, if you will.

The middle aged system can raise pulse and blood pressure and is the carrier of our famous flight or fight responses.

The newest vagus function is involved with social connections and whatever conscious regulation of the influences of the other two systems we are capable of.

Dr. Stephen Porges explains this in his books, articles and videos:

The fight or flight response is well studied and well accepted and I think most of us understand fairly well how it works. What I find the most fascinating aspects of the vagal system are the other two.

The shutdown ability of the oldest part of the system appears to explain a lot of the late effects of trauma, including dissociation and some cases of irritable bowel syndrome, for example. These conditions are associated with heart rate variability differences resulting from altered vagus nerve signaling by this system.

The younger system of social regulation was one I hadn’t really heard of and it suddenly made me understand therapeutic relationships not only in a social context like mother and child, friends or loved ones but also clinical ones, in a way that I had only intuited up until this point. This part of the vagal system is involved with control of our facial expressions, intonation of voice, gestures and all kinds of emotions involved in human contact.

Our ability to interpret things like facial expressions and intonation is dependent on whether we feel threatened in any way, and the polyvagal theory includes something called neuroception. Dr. Porges writes:

“Neuroception is proposed as a ‘reflexive’ mechanism capable of instantaneously shifting physiological state. Neuroception is a plausible mechanism mediating both the expression and the disruption of positive social behavior, emotion regulation, and visceral homeostasis.”

Neuroception can make us misread facial expressions and impair our ability for social engagement, both aspects of the newer vagal system. It can trigger panic attacks with heart palpitations and impulses to flee when the middle aged system is activated. It can also make us faint or mess our pants if we are paralyzed with fear due to activation of the oldest vagal pathways.

Our social regulation happens on many levels, and has its foundation in mother-child bonding. The so-called social neuropeptides, oxytocin and vasopressin are present in the same anatomical areas that are involved in vagal stimulation. The vagus nerve also regulates cytokine activity, involved in immune reactions.

Dr. Porges points out that humans have an inherent but limited ability for self regulation of emotions and their bodily correlates, although we can learn more of that even as adults through yoga or meditation and by exposing ourselves to soothing music for example. The foundation of human emotional regulation however is interpersonal relationships.

He writes:

“In order to co-regulate with another person, we need certain social engagement behaviors to feel safe with that person. Engagement turns off defenses. There are 3 behaviors: Facial expressions, gestures and prosodic vocalizations (intonation of voice the higher more soothing the voice the more safer perceived). Eye gaze can be seen as a threat at times for some trauma clients but prosody of voice is more of a stronger behavior for eliciting safety. Therapists can be mindful of all three behaviors in their therapy sessions with clients. Humans need others because regulators of physiology are embedded in relationships.”

This brings me back to what I wrote earlier this month in a post titled “Ten Building Blocks of Therapeutic Relationships”:

“It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.”

Sounds positively vagal, now that I know a little more…

If Nothing Else Works, Try a Horse

Equine assisted therapy keeps coming up for me. I hear about people who provide it and I know people who are curious about it. Last weekend I read a piece in The Wall Street Journal about it that had some quotable things in it.

After reading it, I did some more research, and found a few interesting connections. For example, Hippocrates, the father of medicine, whose name (I never reflected on it) literally means Horse Power(!) described the health benefits of horseback riding two millennia ago in a work called “Natural Exercise”.

Horse therapy today encompasses both riding and being in the presence of horses, including grooming them, without necessarily riding them. Riders with physical disabilities can sometimes do as well or better than most other riders, for example the Danish dressage rider Lis Hartel, who won a silver medal in the 1952 Helsinki Olympic Games in spite of partial leg paralysis from polio, which prevented her from mounting her horse unassisted. Since then there have been many studies on the benefits of horseback riding on balance, coordination and muscle control for patients with neuromuscular diseases.

There is also more and more research published on what being with or riding horses can do for psychiatric conditions, from veterans with PTSD to depression to substance abuse.

Meggan Hill-McQueeney, featured in the WSJ article, runs an Equine Assisted Therapy program. She had a profound first experience with therapeutic riding:

M, a life­long eques­trian, first wit­nessed the heal­ing power of horses while work­ing af­ter col­lege on a ranch in Col­orado, where she was teach­ing peo­ple to ride. A fam­ily had brought their 4-year-old son, a boy with Down syn­drome who was un­com­mu­nica­tive. Some­thing about the horse cap­ti­vated him. Sit­ting in the sad­dle, he signed “horse”—the first word he had ever com­mu­ni­cated. His mother started cry­ing, which prompted his first spo­ken word too: “Mama.”

Horses, being prey animals, are exquisitely sensitive to their environment and their survival depends on fleeing from predators. They can sense the intentions of animals and humans around them. They are said to be able to smell adrenaline and they can “read” the intentions of predator animals and save their energy if such animals are only passing through without intentions of attack. They can synchronize their heart rates with the humans who care for them.

I know from my own experience with rescued Arabians, who as a breed have a reputation of being easily excited, that they help me be calm and unhurried around them. It is almost as if they provide me with biofeedback and reflect back to me what my own degree of tension might be. And not just because an edgy 1000 lb animal could inadvertently hurt me, but because I so much enjoy their unfrightened peacefulness and kindness, I automatically correct my own frame of mind in their presence.

As Meggan Hill-McQueeney puts it:

“When you’re near a horse, you have to prac­tice the art of keep­ing your en­ergy in a good spot. To trust them, they have to trust you. Help­ing the horse rec­i­p­ro­cates to help­ing the per­son. It’s just so nat­ural, but it ends up chang­ing you.”

Her focus is helping veterans and her mission is to prevent suicides. The article concludes:

This year, BraveHearts will see more than 1,000 veterans, and Ms. Hill-McQueeney longs to reach even more. “Is it unconventional? Innovative? Does it help?” she asks. Her answer to all those questions is “yes.” “We’ve got an epidemic of veteran suicide in this country,” she says. “If nothing else works, try a horse.”

Revisiting the Concept of Burnout Skills

I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.

Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.

Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.

In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.

Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.

The Harvard Business Review piece listed four pitfalls and described two types of leaders, which in our case would be clinical leaders: Leader A and Leader B.

Dr. B is a walking recipe for burnout and Dr. A may be the one whose job feeds his soul, at least to some degree (you still have to like people and medicine):

These four pitfalls run through the minds and daily realities of primary care doctors constantly, I dare say:

Just do more: The future reimbursement model is said to be based on value, loosely speaking. But clinics’ quarterly cash flow is largely determined by patient volume. Doctors have patient quotas, and any quality related incentives or requirements are typically tacked on top of the productivity targets without much infrastructure or time set aside for figuring out how to reach those targets in any kind of systematic way.

Just do it now: We certainly are operating in a constant state of emergency to at least some degree. Particularly the addition of quality targets is done in a not very proactive fashion, but much more reactive, with short term “fixes” that tend to be disjointed, as if we are all trying to make improvements to a moving vehicle while also trying to keep an eye on the road.

Just do it myself: Oh, yes, we have all heard about every staff member practicing to the top of their license, but everyone seems so busy, so how many times a day do we think “It’ll take me longer to get this done if I delegate it to someone else, I’ll have to tell them I need this done, how to do it and then – will I trust that it actually got done?”

Just do it later: Sometimes now is the right time, and sometimes later is the right time. But who decides? Physicians tend to put what the HBR calls “value add” work on the back burner, because changing how we work requires detaching from the short sighted thinking of getting through the piecework of the day. We don’t take enough time to think about what we’re doing and why.

Burnout happens when you work hard without seeing real alignment between your efforts and your goals and values, if you get right down to it. I have read and written much lengthier definitions, but the graph in this article made me shorten mine.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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