Upcoming Program
Healing the Healer, Rhinebeck, NY, September 7 – 12th, 2008.
22.5 Category One CME/CE

For many years I have been offering a week-long program in Hawaii for
health care practitioners. I am delighted to be offering the same
program in upstate New York at summer's end. Bring a friend, bring
your staff!

This workshop is designed for health-care workers of all backgrounds
and trainings to help cultivate a greater sense of life balance;
spouses and significant others are also encouraged to attend. Click
here for more information and to register.

My mother in-law was right; Dress like a doctor
(This article is dedicated to my mother in-law, who passed away last
month. We will miss you.)

My wife is an internist who has been in practice for many years (I
can't say how many because I don't want to sleep outside tonight). Her
mother, a traditional medical spouse, would often criticize her for
not dressing "professionally". This would always agitate my wife and
make her defensive. Does it really matter how we dress or is it our
'way of being' that matters. The answer is, both our dress and our
attitudes matter and it doesn't hurt if you're good looking too!

In a recent study, four hundred outpatients were shown photos of
physicians with different styles of dress. They were then asked which
doctors they would trust more and be willing to share difficult issues
with. This patient group had a mean age of 52.4 years; 54% were men,
58% were white, 38% were African-American, and 43% had greater than a
high school diploma. The patients clearly favored the professional
attire with white coat (76.3%, P <.0001), followed by surgical scrubs
(10.2%), business dress (8.8%), and casual dress (4.7%). This was true
for men and women, physicians and patients and also correlated with
trust, confidence and the willingness to share their social, sexual,
and psychological problems with the physician who is professionally
dressed (1). These correlates also exist in other areas of health care
such as podiatric medicine (2).

A study of OBGYN physicians showed that these correlates may not hold
true in all circumstance (3). These physicians were randomized to wear
business attire, casual clothing, or scrubs on a weekly basis for
three months. The business attire included a tie (for men) and a
buttoned white coat; the casual outfit excluded jeans but otherwise
was typical relaxed clothing and an optional unbuttoned white coat;
and the scrubs were hospital issue with no white coat. Patient
satisfaction scores were then analyzed.

The physician's style of dress had no impact on the patient's
perception of competency, satisfaction or their impression of the
physician's professionalism. This may be due to a skewed population;
younger women versus the more heterogeneous nature of other studies. A
larger effecter may be that, in this study, physician-patient
relationships developed over time and out weighed the initial
impression of style of dress.

In younger physicians and trainees, choice of clothing may actually
matter more than for mature physicians in all practice environments
(4). Dr. Pamela A. Rowland, a behavioral scientist and director of the
office of professional development at Dartmouth Medical School, who
has studied the impact of physician clothing on patient confidence
says: "Patients don't have your C.V. in front of them, and appearance
is all they have to go by," Dr. Rowland said. "If you don't meet their
expectations, their anxiety level increases."

This is particularly true for the younger generations of physicians.
Culturally, their style of dress is more casual than older generations
of physicians and patients. This can lead to the patient feeling
disrespected. In multiple studies, casual clothing decreased the
patients' confidence in the doctor.

Other preferences which enhance respect include:

Name tags
White coat
Visible stethoscopes
Dress pants, dress shoes, and a shirt and tie were ranked high for men
Makeup, lipstick, and stockings were ranked high for women.
Sandals and clogs, earrings or long hair on male physicians, and blue
jeans received the lowest rankings by respondents with  regard to
desirability.
Older patients regarded casual attire more negatively than younger patients did.
Private clinic patients considered casual attire much less desirable
than did patients who had Medicaid insurance.

And, by the way, it doesn't hurt if you look like one of those TV
docs! It turns out that if the patient thinks you are attractive, they
trust you more (6). The McDreamy effect.

And then there is the neck tie, that bacteria laden piece of silk…

So all in all my mother in-law was right—sorry I doubted you.

What to wear today? Effect of doctor's attire on the trust and
confidence of patients. S. Rehman, P. Nietert, D. Cope, A. Kilpatrick,
The American Journal of Medicine, 2005 Nov; Volume 118, Issue 11, pp.
1279-1286.
The Physician's Attire and Its Influence  on Patient Confidence; Adam
M. Budny, DPM *, Lee C. Rogers, DPM, Vincent J. Mandracchia, DPM, MS
and Steven Lascher, DVM, MPH, Journal of the American Podiatric
Medical Association, 2006, Volume 96, Number 2,  pp.132-138.
Does physician attire influence patient satisfaction in an outpatient
obstetrics and gynecology setting? Richard L. Fischer, MD, Clare E.
Hansen, RN, Robert L. Hunter, MD, J. Jon Veloski, MS, Am J Obstet
Gynecol, 2007, 196:186.
Resident physician attire: Does it make a difference to our patients?
Cha Ann; Hecht Bryan R.; Nelson Karl; Hopkins Michael P; American
Journal of Obstetrics and Gynecology, Volume 190, Issue 5, pp.
1484–1488.
Patients' attitudes regarding physical characteristics of family
practice physicians; Keenum AJ, et al., South Med J, December 2003,
96:1190-4.
The white coat effect: Physician attire and perceived authority,
friendliness, and attractiveness. Brase, G.L. & Richmond, J.,  Journal
of Applied Social Psychology, 2004, 34(12), 2469-2481.




Lee Lipsenthal, MD, ABIHM

Upcoming Program
Healing the Healer, The Omega Institute, Rhinebeck, NY, September 7 – 12, 2008.
22.5 Category One CME/CE for physicians, nurses and therapists of all backgrounds

Healthcare providers dedicate their lives to serving others, yet often stumble in taking care of themselves. Healing the Healer can help solve this dilemma.

Through discussion, movement, artwork, breathwork, journaling, and meditative techniques, we gain an understanding of the unique stresses faced by healthcare workers and their families, and discover how to diminish their harmful effects.

You will learn to:

Understand the relationship of stress and health
Learn new tools to modify our stress responses
Gain a deeper understanding of transpersonal healing states
Enhance your ability to communicate and love more deeply
Evaluate personality traits that help or hinder your progress, personal growth, and patient care
Adopt action planning tools to create positive changes in your life
This workshop is designed for healthcare workers of all backgrounds and training to help cultivate a greater sense of life balance. Spouses and significant others are also encouraged to attend. For more information and registration, click here.



Meditation
What if there was a product out there that allowed you, in 20 minutes, to prevent emotional outbursts, improve your sleep and blood pressure, and enhance the fun aspects of your life?  How much would you pay for it? Meditation is that product. And meditation is free. You don’t need equipment, accessories or fancy chairs. You just need a quiet place to sit and 20 minutes a day for meditation to work its magic. Aren’t you worth it? Well, all it takes is a little practice.

To some of you, meditation may feel like a foreign concept. It shouldn’t. Have you ever sat quietly on a beach, hypnotized by the waves? Walked in the woods, hearing the sound of the trees, and momentarily forgetting about your thoughts? Do you remember playing music or gardening, and just for a moment forgetting who or where you are? Have you ever prayed and felt a sense of connection with something bigger than yourself? These are meditative moments. Moments where it was enough for you to be just you, alone and in peace. In the language of psychology, these are transpersonal moments. In the language of religion, you are connecting with God or spirit. In the language of Hip-Hop, you are chillin.’

Meditation on those you love (5 – 20 minute practice)
There are many forms of meditation available to you. Most people find focusing on emotions of love and caring to be the most pleasing form. It intentionally focuses on the feeling of love, or being in love. It uses this emotion as a focal point to distract your mind from ‘busyness.’ This is my personal favorite as I am a diehard romantic. We often focus on things that cause anger and frustration; this is the way to inoculate against that habit.

You’ll need to generate a list of people, places or things that help you feel loving. It’s useful to write down the names of people in your life you appreciate. Include family, friends, mentors and even patients you are grateful for knowing. After doing this, follow the steps below.

First, find a comfortable position, then close your eyes. Take some slow, deep breaths until you feel relaxed and calm. Make the inhale much deeper than usual and the exhale long and slow. This lowers your sympathetic tone.

Picture yourself in a comfortable, peaceful place. What do you see there? Are you sitting or standing? Can you feel the ground beneath your feet or the place where you’re sitting? Try feeling the air. What does it feel like? Are there any smells you can identify?

As you relax, begin to see the faces, one by one, of those you had written about. As you see each one before you, remember fondly the times you spent together. Then thank them for the role they have played in your life. Focus on your appreciation and love for that person. In your mind, tell them how you love and appreciate them. Hear what they say back to you, if anything. Then let them go.

If your mind wanders, bring your focus back to this person or someone else you love.

Continue this practice as long as you like while keeping the deep breaths going. You can practice this over and over throughout the day or in one sitting. Vary the time as you see fit. However, you should start with at least 5 minutes each day.

Personally, I end this practice by focusing on my wife. (You will have to find someone else; she’s spoken for!) For me, it’s a great way to start the day.

By giving yourself this experience, you have altered your physiology as if you had really been in this place with these people. Your catecholamines drop, dopamine goes up, blood pressure decreases and heart rate slows. You also improve cortical function and performance. Not bad for a few minutes of appreciation!

“I shut my eyes in order to see” – Paul Gauguin

Favorite Meditation CDs
Mine, of course – Finding Balance Meditations and Imageries – a guided series of meditations to enhance your learning. Click here.

Jon Kabat-Zinn’s series. Visit: http://www.mindfulnesstapes.com/

Marty Rossman, MD’s CDs click here.

Just for fun
My favorite CD release of the past month is Jesse Malin’s Glitter in the Gutter. If you were to categorize it, think ‘alternative’, but the range here transcends that label. From the hard rocking “Prisoners of Paradise” (The Replacements are a clear influence here and elsewhere) to the lyrical rock song, “Don’t Let Them Take You Down,” you will find yourself singing along easily. An awesome summer driving CD! A must hear is the sweet duet with Bruce Springsteen called “Broken Radio” - sweet reminiscence of times past and worth the price of admission. Have a rockin’ summer!
Lee Lipsenthal, MD, ABIHM

Upcoming Teacher's Training
Those of you who are in health care education (residency, fellowship or medical school) may also be interested in our second annual
Finding Balance Teacher Training Program
Petaluma, California
July 19 - 23
 
Over 15 residencies and medical schools are using the Finding Balance curriculum. This is your opportunity to bring healthy curricular material to your institution and broaden your capacity as a teacher.

This 5 day teaching program will cover core areas of research on physician health, personality structure and interpersonal function. It is designed to train each participant to be a facilitating teacher in the area of physician and medical trainee health. Participants will be trained to teach both small and large group classes in the area of physician health as well as to lead seminars in this area.

For curriculum details, information and to register, click here.

The New Generation of Docs; Slackers or Realists?
The resident that walks into your practice as a new employee this year is very likely to have a different attitude towards work than you have. They are likely to want time off for family, evenings free and plenty of vacation time. Your response may simply be;
"I never had it that good, why should you?" You may see them as a problem and part of the 'slacker' generation.

Who is right, a doc that wants down time with family or one who dedicates themselves to medicine regardless of the costs? Statistics have shown that for the latter:

There is a 67% burnout rate (1)
A 38% rate of dissatisfaction with their work (2)
Higher than average cardiovascular death rates and suicide rates (3)
High rates of depression (4)
Other publications have shown that physicians who make time for family, spiritual growth, and volunteer work are happier and healthier (2, 5).

"Physicians who manage their own stress and feel happy
with their own daily circumstances are probably better physicians,"
American Medical Association President Ronald Davis.

My belief is that, as medicine changes, we must change as well. The style of practice that worked for physicians 20 years ago no longer works for most physicians. This style includes being the sole decision maker who fails to delegate, and who insists on being available 24 – 7. With increasing demands on physician's time, the growth and aging of the population, and the relative decrease in the number of physicians per capita, (especially in primary care,) it becomes impossible to maintain the 'old' style of practice (6).

The new style of practice includes:

An integrated team approach using other physicians and clinical team members
Flexible schedules
Accepting less continuity and using hospitalists
Electronic medical records for ease of access to information
Equal pay for equal hours worked
Between 1996 and 2003, the proportion of women graduating from U.S. medical schools who chose more "controllable" lifestyles — specialties allowing them to dictate hours spent on the job — doubled. Those opting for more flexible fields rose to 36% from 18%, according to a 2005 study published in the journal Academic Medicine. For men, it rose to 45% from 28%, the study showed (6).

In the business literature the number one contributor to work satisfaction is enjoying the work you do day to day. My concern with choosing your specialty based on lifestyle is that it will quickly lead to work dissatisfaction, as you are less likely to enjoy day to day working.  I believe this too is a mistake that many young physicians are making.

The short term solutions are to create more flexibility in practice options, greater pay for primary care docs for the patient management work that they do, such as the medical home concept, and to accept that the world of medicine has changed. The long term solution, besides the ones stated in the bullets above, is to educate more doctors and clinicians who will share their work as integrated teams.

From my stand point, there is no right or wrong. The young generation of physicians has as much to teach us as we do them.

The American College of Physician Executives, The Physician Executive, December 2006
E. Frank, McMurray J. E., Linzer M., Elon L., "Career Satisfaction of U.S. Women Physicians: Results from the Women Physicians' Health Study", Archives of Internal Medicine 159 (July 12, 1999): 13
Erica Frank, Holly Biola and Carol A. Burnett, "Mortality Rates and Causes Among U.S. Physicians", American Journal of Preventive Medicine, Volume 19, Issue 3, October 2000, Pages 155-15
C. Center, et al., "Confronting Depression and Suicide in Physicians: A Consensus Statement", Journal of the American Medical Association, 289 (2003): 3161–166
Rein Lepnurm, DrPH, Roy Dobson, PhD, Allen Backman, PhD, David Keegan, MD, "Factors Explaining Career Satisfaction Among Psychiatrists and Surgeons in Canada", Canadian Journal of Psychiatry, March 2006
J. Goldstein, "As Doctors Get a Life, Strains Show Quest for Free Time Reshapes Medicine; A Team Approach", The Wall Street Journal, April 29, 2008
Just for fun
Eat, Pray Love by Elizabeth Gilbert
OK, it's tough as a guy to recommend a 'chick' book, but I read it en-route from Asia and loved every minute. If you have a fondness for India, Bali or Italy, it's a must read. If you don't, this book is a personal travelogue through these countries that will make you want to buy a ticket! Enjoy the journey.


Lee Lipsenthal, MD, ABIHM

There are a few spaces left for our upcoming program:
Finding Balance as a Healer
Molokai, Hawaii
May 25 – 31
For more information (link to registration page)

Here's your last chance to sign up for a learning trip in paradise. A beautiful, simple setting on the quiet island of Molokai with amazing food…and waking up to the sound of tropical birds!
 

Those of you who are in health care education (residency, fellowship or medical school) may also be interested in our second annual:
Finding Balance Teacher Training Program
Petaluma, California
July 19 - 23
To register or for more information call Larry Cooper, 1-800-769-0639 or healthcl@silcom.com
 
Our mission is in this course is to train Health Care Educators in the Finding Balance in a Medical Life curriculum. This five day teaching program will cover core areas of research on physician health, personality structure and inter-personal function. It is designed to train each participant to be a facilitator teacher in the area of physician and medical trainee health. Participants will be trained to teach both small and large group classes in the area of physician health as well as to lead seminars in this area.

For curriculum details, information and to register click here.


How healthy are you?
The American Board of Integrative and Holistic Medicine (HolisticBoard.org) has been using a fantastic personal health assessment for many years now. It brings together emotional, physical, mental and spiritual health in an easy to use questionnaire.

I have made it available to you, in a printable PDF format, for your personal use and for use with your patients. Good luck on the test! Let's see how you do.


For your listening pleasure
As always, it is my desire to expose you to new and great music. I just purchased the CD called In the Name of Love: Africa Celebrates U2. This is a CD of brand-new covers of classic U2 songs by Grammy Award-winning and up-and-coming African artists including Angelique Kidjo, Les Nubians, Sierra Leone's Refugee All Stars, Vieux Farka Touré, Vusi Mahlasela and the Soweto Gospel Choir. The album was inspired by Bono's direct philanthropic impact via the launch of the ONE campaign and (RED), and his poignant outspoken public commentary on the immediate financial needs facing Africa.

It is fantastic!


We welcome your feedback on the information we provide, as well as any
questions you may have about our programs, and how they may be of help
to you and your staff. My email is: lipsenthal@aol.com

Best in health for you and your patients,



Lee Lipsenthal, MD, ABIHM

Visit us at  www.findingbalanceproductions.com; Email to us at healthcl@silcom.com

  Welcome to Finding Balance eNews. Please note that we have an upcoming program in San Diego, April 12 & 13th as well as a week long program in Molokai Hawaii, May 25th – 31st.


For other information on On-Line CME, Books, CDs and programs, please visit FindingBalanceProductions.com


Catch Some Zs


Some of you may be familiar with the expression to catch a couple of Zs. This is derived from the use of the letter Z in comic strips to indicate sleeping. Apparently we docs are not catching enough Zs!


In a randomized, internet-based questionnaire, the American College of Chest Physicians Sleep Institute (ACCP-SI) surveyed 5,000 US physician members about current sleep habits and how sleep affected work and day-to-day performance (1). Of the 581 respondents, 70 percent reported needing at least 7 hours of sleep to function at their best during the day, yet physicians reported sleeping an average of 6.5 hours on a workday.


Physicians reported "making up" for lost sleep on the weekends or days off by sleeping an average of 7.5 hours a night. Furthermore, 43.1 percent of physicians indicated their current work schedule did not allow for adequate sleep. Physicians rarely reported insomnia or difficulty initiating or maintaining sleep. However, 21.8 percent reported not feeling refreshed upon waking at least a few nights a week.


Most physicians indicated that sleep issues did not significantly impact work performance or other daily activities. However, 18 percent of physicians reported missing at least one family or leisure activity due to sleep issues.


In an earlier article, reported in Internal Medicine News, it was stated that 52 percent of 500 primary care physicians randomly surveyed by telephone reported have sleep difficulties, averaging 15.8 nights of sleep difficulty/month. When you further analyze the difficulties: 20 percent took an average of 26 minutes to fall asleep, 19 percent dozed off while driving and 20 percent used sleep agents at least twice per month.


This is concerning for our long and short term health. The short term concern is falling asleep while driving. While you may consider this a rare event, I suspect that you can remember at least one time arriving home or to the hospital and not remembering how you got there. It is also likely that you caught yourself dozing off while driving, awaking quickly to catch yourself.


The long term ramifications are also concerning. Too little sleep may raise the risk of developing heart disease. In the nurse's health study, women who averaged five hours or less of sleep a night were 39 percent more likely to develop heart disease than women who got eight hours. Those sleeping six hours a night had an 18 percent higher risk of developing CAD than the eight-hour sleepers (3).


Lack of sleep is associated with hypertension, elevated cortisol and catecholamines, lower glucose intolerance and lower heart rate variability, all of which are associated with increased CAD risk.


In summary, we tend to under-value and under-estimate the importance of sleep – please catch some Zs!


American College of Chest Physicians (2008, March 5). Most Physicians Sleep Fewer Hours Than Needed For Peak Performance, Report Says. ScienceDaily. Retrieved March 6, 2008, from http://www.sciencedaily.com/releases/2008/03/080304075723.htm
 
Dr. Thomas Roth, Ph.D., Chief of the Division of Sleep Disorders Medicine at the Henry Ford Hospital in Detroit (Internal Medicine News, 12-1-96, pg. 1).
 
A Prospective Study of Sleep Duration and Coronary Heart Disease in Women Najib T. Ayas, MD; David P. White, MD; JoAnn E. Manson, MD, DrPH; Meir J. Stampfer, MD, DrPH; Frank E. Speizer, MD; Atul Malhotra, MD; Frank B. Hu, MD, PhD, Arch Intern Med. 2003;163:205-209.

Just for fun


I've been listening to a lot of Joshua Radin recently. I first heard him on the sound track of the movie, The Last Kiss as well as on the Scrubs soundtrack. His voice is very reminiscent of Art Garfunkel's (of Simon and Garfunkel), sweet, whispery and soft. For a great sample check out the song Star Mile on the album We Were Here. Highly recommended!



Thanks for reading,

Lee Lipsenthal, MD, ABHM

Finding Balance Newsletter, Volume 7, February 2008 Visit us at  www.findingbalanceproductions.com; Email to us at healthcl@silcom.com

  My apologies, our web manager accidentally sent the January Newsletter in error. Here is the February Newsletter.

Welcome to the February Finding Balance news letter. For this month, I would like to give you some pointers on clinical interactions. Thanks to those of you who have purchased my book, Finding Balance in a Medical Life and to those of you who have taken the Finding Balance CME On-Line course. For more information, go to FindingBalanceProductions.com.

By the way, there are two upcoming seminars as well; San Diego April 12-13 and Molokai, Hawaii May 25 – 31st. See you there!

The keys to effective patient interactions

What are the ingredients of an effective clinical interaction? Is it when we are enjoying teaching the patient what we know? Is it when the patient's need is the greatest and we feel most useful? Or is it just 'the right-time/right-place' for the two of you? All of these are likely effectors of our clinical outcomes and the patients' experience of us. With this in mind, how can we maximize our interactions and outcomes? The following keys should guide you in this direction:

Be Present – This may seem obvious, however it is not always easy to do. The state of presence takes practice. In essence, it is the ability to quiet the noise in your head long enough to focus on the person before you.

Your capacity for presence can be enhanced with short and long term practice. The best of the long term practices for this purpose would be mindfulness meditation. The best short term practice would be empathetic listening – ask yourself how you would feel if you were this patient. While this in 'projective' in nature, it enhances your presence emotionally.

Be Open Minded – Don't presume that you know what is going on for the patient at this visit, ask them. While this may sound simplistic, many of us, especially seeing a patient for the first time, project our beliefs on the patient. For example, seeing an obese elderly woman, our first tendency is to think about dietary issues, physical activity, diabetes and cardio-vascular risk. These presumption will lead to ask about these things when, in fact, this patient may be there for sexual dysfunction. Your focus on the "obvious" distracts the patient from their core reason for being there and diminishes the likelihood that they will ask you about this difficult issue.

                          

Know Your Limitations– We all are limited in our abilities to help and heal the patient. Ask yourself honestly, if you are able to help this person before you. If the true answer is yes, go for it, if it is no, is there another resource for this patient? Anything short of this is deceptive and wastes your time; their time and they will not have their desired outcome.

Go at the Patient's Pace– In helping patients to make lifestyle change there are two, almost opposite approaches, rapid all-encompassing change or slow, small gradual change. The key to knowing which way to go is knowing the patient.

For example, Mr. (or Ms.) Speedy, the high powered, entrepreneurial patient with heart disease, will want to see changes with their next lipid test or exercise test. With this patient, a rapid series of life style change will work well. They will see quick results, feel better faster and see rapid changes in objective parameters. This difference will motivate them towards continued progress. However, maintenance can be a challenge to Speedy. This person will need to develop a support system around them for long term success; flying solo only works in the short run. Help them to identify ways of finding support. For Speedy, this may be an exercise group, with the same people each week (or multiple times per week). The Speedys of the world like to be surrounded with people who are working hard to be healthy and like to help others when they stumble. This gives them a sense of meaning and motivates their further change. Over many years, this need for external gratification by helping others diminishes and Mr. Speedy realizes that he is really doing this work for himself and the people he loves.

The opposite end of the spectrum is Mr. (or Ms.) Couch Potato. Couch Potato has had many years of vegetative existence. If you gave Couch Potato the regimen you gave Speedy, they would purchase the supplement, buy the exercise equipment and sit on the couch looking at it, getting depressed. This, in the long run, is more harmful than beneficial to them.

What is the healthy approach to Couch Potato? Developing the will to change should be the first step with this person, before the implementation of change. Roberto Assogioli, the renowned Italian psychiatrist, suggests that allowing the person to master small, meaningless tasks develops the positive attitude and motivates a person towards healthy change. As an example, he describes asking the patient to stand on a chair, once a day for five minutes at a time. The first time they do this, they will feel silly and restless. The next day they will feel bored but confident and by the end of the week, they will have mastered chair standing. Assogioli used this with patients who where profoundly depressed, giving them new tasks each week until their confidence grew.

How can we apply this to Couch Potato? You may want to ask them to eat one healthy food each day. This allows them to try something new without eliminating their comfort foods. You may want them to walk for 5 minutes each day. Tell them, even if they want to do more, only do 5 minutes. Let them master each small step before they move on to the next. While these gradual approaches may try your patience, they will greatly enhance the lives of your patients.

Be Positive – Our patients need our encouragement and congratulations with each success. Don't forget to remind them of what they are doing well.

Be "Lovingly In Their Face" – Sometimes a strong hand is needed when a patient is using defense mechanisms which work against them. With each visit, there may be new reason why they didn't follow your recommendations. Be careful about 'buying in' to these defenses. For most of us this is clear with addicts, but you may wish to think of each patient as an 'unhealthy life style addict'. With this in mind, people pleasing co-dependent behavior on our part is detrimental to their health. You may even reach a point where you have to say "If you're not willing to do the work, I can't help you any longer." Honesty is healthy!

Manage Anxiety – Anxiety increases catecholamines and cortisol. This state leads to a diminished cortical function in detailed discrimination. For example, if a car is coming at you at 60 MPH your thought process is "Car-Jump" not "Gee, that red Ford pick up is running at 60 MPH. I therefore need to jump 10 feet to the left." The jump reflex I a meso-limbic brain process, not a cortical one, so under stress we use our 'mid-brain' and have less need for upper cortical discriminatory function. How does this affect the physician patient relationship?

The average patient in your office experiences stress in being there. They may be there to talk about issues which provoke anxiety or fear. In reality the majority of patients have some amount of stress in your office. With this, they have higher catecholamines and cortisol. This then diminishes their cortical capacity (and yours too if you are not relaxed). With diminished cortical capacity, they are less likely to understand what you are trying to teach them. It is therefore important to help you patient relax. Here are some tips:

Use soothing music and lighting.
If you use dressing gowns, make them comfortable and non-exposing.
Use comfortable furnishings. Generally furnishing which are found in the home serve this purpose.
Use humor. This helps you and the patient to relax.
Be human. Pretension isolates you from the patient.
Use touch. Touch is relaxing for most patients, but not all. Start with touching the patient below the elbow and see their reaction. Hugs heal, but may be too much for some, especially the first time around. Ask permission!
Be Real – Maintaining a real adult to adult relationship with a patient (or parent) helps to ease patient anxiety. It also lets the patient know that you are a compassionate human is who looking out for their best interest. This then motivates the patient to please you with positive changes. When this relationship is maintained, patients are more likely to adhere to recommendations you make, come back to see you regularly and sue you less frequently. They are more likely to be respectful of your time and office visits become more efficient and effective. Not bad for just being a human! (Ruth Freeman,  A psychodynamic understanding of the dentist-patient interaction, BDJ May 22, 1999 v. 186(10)).

Just for fun

I good friend of mine sent me a link to a lecture by Randy Pausch. Randy is a professor at Carnegie Mellon. This Last Lecture Series was designed to allow faculty to give the lecture that 'they always wanted to give'. Randy is dying of cancer and this is truly a 'last lecture'. It is a bit long, but worth it.

http://video.google.com/videoplay?docid=-5700431505846055184

His Bio:

Randy Pausch is a Professor of Computer Science, Human-Computer Interaction, and Design at Carnegie Mellon, where he was the co-founder of Carnegie Mellon's Entertainment Technology Center (ETC). He was a National Science Foundation Presidential Young Investigator and a Lilly Foundation Teaching Fellow. He has done Sabbaticals at Walt Disney Imagineering and Electronic Arts (EA), and consulted with Google on user interface design. Dr. Pausch received his bachelors in Computer Science from Brown University and his Ph.D. in Computer Science from Carnegie Mellon University . He is the author or co-author of five books and over 70 articles, is the director of the Alice (www.alice.org) software project, and has been in zero-gravity.






Thanks for reading,

Lee Lipsenthal, MD, ABHM

Visit us at  www.findingbalanceproductions.com; Email to us at healthcl@silcom.com

Welcome to the first Finding Balance Newsletter of 2008. Many of you have already accessed Finding Balance's CME On-Line. Thanks for using this fun way to get CME at home. For more information on Finding Balance in a Medical Life programs, training and products go to FindingBalanceProductions.com .

This months' topic:

Keeping up with the literature; a broken paradigm

Do you have a pile of journals at your bedside or desk side? Do you feel guilty that you haven't read them?

A close friend of mine told me about a scenario that occurred after the death of his father, a prominent psychiatrist. When my friend and his family were cleaning out his father's house, they found journals scattered all over. They could not believe the number of journals that his father had kept (read or unread). On the second day of cleaning, they found a walk-in closet that contained thousands of journals, some of them never opened.

We all hold the belief, to some degree, that in one of these journals lies some wondrous pearl of wisdom that will make us a better doctor or help solve a patient's problem in the future. My question to you is; how will you find that pearl of wisdom in the mess next to your desk in anything less than twelve hours?

In the 1940s there were three major medical journals in the United States . All three were monthly subscriptions, two of which were newsletters. Keeping up with the literature meant pouring yourself a coffee on a Sunday, sitting in your comfy chair, and reading for an hour or two. Many of your professors grew up with this paradigm; keeping up was critical and possible.

Since that time, the volume of medical literature has grown exponentially. More research is being done worldwide, and it is more accessible than in the past. In addition, the average physician receives multiple journals, including throwaway journals, weekly. It is impossible to keep up with the literature anymore, yet when we see the overwhelming pile next to the bed, we feel incompetent as physicians and scientists. After all, we were told, "If you don't keep up with the literature, you are not enough". One colleague of mine was told, "If you don't keep up with the literature, people will die." This creates anxiety and frustration for us all.

Today we all have an incredible, inexpensive resource: it's called the Internet. It is now possible to find the answer to a problem, if one exists, in minutes. It is also possible to reassure yourself if no answer exists.

Let go of the old paradigm of keeping up with the literature, and be thankful that you have a world of information at your fingertips. Take an hour a week to be pro-active. Read a journal that you truly enjoy and know that it serves your patient, quells your anxieties, and feeds you inner science nerd, an important part of who we are as physicians. For the rest of the information, be thankful that the Internet is at your finger tips. It is now feasible to search the literature for answers within seconds. And most importantly, stop piling up old journals, especially 'throw-aways'. You will appreciate the lack of clutter.

Resources for understanding the literature:

Daniel Friedland, MD, ABHM author of Evidence-Based Medicine: A Framework for Clinical Practice has created an excellent web site to help you understand and research the realm of evidence based medicine ( http://www.supersmarthealth.com/index.php ).

Some of the recommended resources are:

ACP Journal Club (http://www.acpjc.org/?wni )
Journal Watch (http://www.jwatch.org/ )
InfoPOEMs ( http://infopoems.com/product/features_dailyip.cfm)
And he suggests that providers can also keep up using healthnews services like:

Medscape ( http://www.medscape.com/welcome/news)
MD Consult (http://www.mdconsult.com)
Yahoo Health News ( http://health.yahoo.com/news/)
 

Just for fun:

I really love the new CD by Anoushka Shankar and Karsh Kale "Breathing Under Water,". Anoushka is the daughter of Ravi Shankar, the renown classical Indian musician. This new album is a mixture of Sitar music, pop and trance-like sound. Truly beautiful to hear. It features a number of collaborators, including Ravi Shankar, Sting, Norah Jones, Shankar Mahadevan, Sunidhi Chauhan, Vishwa Mohan Bhatt, the Midival Punditz and many more...



Thanks for reading,

Lee Lipsenthal, MD, ABHM

I am delighted to announce the availability of our new
Finding Balance CME On-Line Programs. These on-line
educational models have been created to enhance your
lifestyle and your ability to teach your patients about
healthy life choices. Finding Balance CME On-line is a
series of 12 sessions, on-line, through the Finding
Balance website. Each session is worth one hour of CME
category one credit, with text reading and questions to be
answered. Upon completion of each session, you will be
able to download a one-hour CME certificate of completion.



CME On-line has been developed to provide you with easily
accessible on line content to help you and your patient in
the area of life balance. The sessions can be done in
sequence or separately at your discretion. I hope you
enjoy them!



Session content:

Life Balance and Balance Self Assessment – In this session
the participant will gain greater insight into the concept
of life balance and how it affects performance and
well-being
Physician work satisfaction – This session will review the
contributors to physician work satisfaction.
What Makes a Happy Doc? – This session will outline the
key contributors to physician work satisfaction and
provide tools to enhance satisfaction.
The Physician personality – this session will focus on
areas not covered in depth in the workshop sessions.
Work Addiction – This session will focus on addictive
behaviors and how they affect the family, performance and
our work lives. The core model will be of work addiction
and the 12 step concepts.
Physician health – this session will cover the current
state of physician health and physical well-being.
Diet choices and health – This session will review the
various 'diets' available and contrast them with each
other.
Exercise and health – this session will review the
literature on the benefits of exercise, types of exercise
and scheduling of exercise habits.
Managing stress; meditation - this session will review the
medical literature in the areas of stress management using
meditation.
Managing stress; yoga - this session will review the
medical literature in the areas of stress management using
yoga.
Managing error – This session will review the key areas
regarding medical error and malpractice concerns.
Spirituality, religion and spiritual counseling - This
session will include a review of the literature in the
area of spirituality the role of the physician in
spiritual counseling and on the health.


To get to Finding Balance CME On-Line, go to
FindingBalanceProductions.com and click on CME On-Line

http://www.FindingBalanceProductions.com

Visit us at  www.findingbalanceproductions.com; Email to us at healthcl@silcom.com

Welcome to volume five of the Finding Balance Newsletter. In this venue, I will try to provide you with useful thoughts, tools and fun recommendations. For more information on Finding Balance in a Medical Life programs, training and products go to FindingBalanceProductions.com.
Finding Balance has just completed a successful launch of our Total Physician Wellness Program (year long intervention) with Kaiser in Atlanta. I just want to publicly acknowledge their team for an amazing job!

Chattiness

Here's the scenario; you are in the exam room, one on one, and they won't stop talking. They are telling you about themselves in ways which can't be useful to you at all. You are trying to be polite and respectful, but inside, you're frustrated and irritable. Why can't they just focus on the reason for this visit? Finally, after what feels like an eternity, they stop talking about themselves and you can get to the point of the visit. Some doctors can really talk. Yes, I said doctors!

We have all had patients who will talk our ears off. They consume our time when we are busy and they talk about issues and concerns unrelated to the visit. On average, I would guess that about 2-3% of our patients are just there to talk. We sit with them, forcing a smile and trying to nod appreciatively knowing that we need to get moving, but doctors may be as guilty of this as their patients.

A study, published in the The Archives of Internal Medicine, looked at physician 'chattiness'. One hundred primary-care doctors in the Rochester, NY area participated in this study in which they agreed to allow two people trained to act as patients come to their offices sometime over the course of a year. The test patients would surreptitiously make an audio recording of the encounter. The investigators analyzed recordings of 113 of those office visits, excluding situations when the doctors figured out that the patient was fake. The outcomes were disturbing.

In one third of the visits, the doctor talked about themselves and their own interests, health behaviors and even vacations, without tying it back to the patients concerns. A sample conversation was as follows (taken from Gina Kolata, NY times, June 2007):

A new patient comes into a doctor's office weighing 204 pounds. He's six feet tall. The following conversation ensues:
Doctor: Is that up a little bit for you, weight-wise?
Patient: It might be up a few pounds. I used to jog and I just haven't ...
Doctor: See, 'cause I'm weighing more like 172, 173 and I'm six foot. And I'm still running. I'm doing the 5 and 10 and 15 K's. The half marathons and ...
Patient: So, I'm 30 pounds heavier than you?
Doctor: Right now, yeah.

Why would we do this in one third of all office visits? Susan H. McDaniel, lead author of the study, stated; "We were quite shocked. We realized that maybe not 100 percent of the time, but most of the time self-disclosure had more to do with us than with the patients."

It is often important for us to comfort or relate to the patient with our own experience and we often use it as a way of connecting with the patient and possibly to teach the patient ways of managing their health issues. This can be healthy and humane, but in this study, it appeared that the physicians were 'just talking to be talking'.

What would be a more appropriate way to connect? If you have had a similar health issue and feel that disclosing a personal story would be of comfort to the patient, then do so. However, do so in a concise way without loads of unnecessary personal disclosure. It may even be useful to ask the patient permission to do so. In the end always tie your story back to their health concern.

A good rule is to ask yourself, when you are about to tell your story, 'is this for me or for the patient?' If it's for you, you probably shouldn't bother. After all, most of us dread the 2-3% of our patients who just want to talk. And, after all, they are the ones paying for the visit!

Physician Self-disclosure in Primary Care Visits: Enough About You, What About Me? Susan H. McDaniel; Howard B. Beckman; Diane S. Morse; Jordan Silberman; David B. Seaburn; Ronald M. Epstein, Arch Intern Med. 2007;167:1321-1326.

Just for fun
Levon Helm, famed drummer and often lead singer of The Band, has released his first solo album in 25 years. This album, Dirt Farmer, marks his return to performing after a bout with throat cancer. The album is gritty American music at it's best, from rock to bluegrass and country in between. If you are fan of The Band, you'll love this CD.



Thanks for reading,

Lee Lipsenthal, MD, ABHM

Visit us at  www.findingbalanceproductions.com ; Email to us at healthcl@silcom.com

Welcome to volume four of the Finding Balance Newsletter. In this venue, I will try to provide you with useful thoughts, tools and fun recommendations. For more information on Finding Balance in a Medical Life programs, training and products go to FindingBalanceProductions.com.

Workaholism in Medicine
What if there was a substance that made you stay away from home until very late and kept you awake at night? What if this substance created multiple family problems to the point of destroying your marriage? What if this substance decreased your efficiency and your ability to concentrate, and made you irritable and fatigued? What if this substance increased your risk of back problems, gastrointestinal disorders, heart disease, and stroke? What if you felt that discontinuing the use of this substance meant that your success and your self-definition would cease to be?

This is often how addicts feel about their drug of choice. They are so identified with the drug that they would lose themselves without it. On seeing a patient with these self-destructive tendencies, most of us would try to convince them to seek therapy or find other forms of help to eradicate the destructive substance from their lives. Unfortunately this is how many practicing physicians begin to approach the work of medicine. We become work addicted!

The practice of medicine becomes our drug of choice. We live in a culture that supports the practice of medicine above all else, which can often exclude our families and our health. If we stopped being a doctor, who would we be?

Unlike alcoholism, workaholism is rewarded with accolades and financial success, making it a very difficult process to stop. A workaholic has lost the ability to slow down and find value in anything other than work. Workaholism is a compulsive behavior and is probably related to other compulsive behaviors and addictions. I tend to think of it as a pre-disposition which can be modified by learning new behaviors, but for some, the compulsion is so invasive that medical treatment may be needed.

Workaholism is not measured by the number of hours you give to work. If that were the case, you would all be workaholics at this point in your career. It is more about the way you approach work and how it controls you and your ability or inability to focus on things unrelated to your career. Workaholism can also be measured by how work affects your life outside of medicine. If you have trouble shutting off your thoughts about your work and career, you may be a workaholic.

Intriguingly a wonderful psychiatrist friend of mine, upon filling out the work addiction test (below), realized the level of his work addiction. When we got into discussion about this, he insisted, "But I love my work." I then asked if his work has had an adverse effect on his life. His response was, "On my first marriage, yes." This is work addiction. If work is damaging your health and relationships, you may wish to consider this as a possibility.

We are often in denial about these behaviors because they feel productive. In a workshop, one colleague told me that she could cut down on her work anytime she wanted to. On saying these words, which many alcoholics in treatment have said to her, she knew that she was stuck!

Work Addiction Risk Test
The test below will help you evaluate your level or potential for work addiction. It is taken from Bryan E. Robinson's book, Chained to the Desk: A Guidebook for Workaholics, Their Partners, and Children, and the Clinicians Who Treat Them (New York University Press, 1998).

The following test was devised to help you evaluate yourself. Score yourself as follows:

1 = never true; 2 = sometimes true; 3 = often true; 4 = always true

Total your score, and then look at the scale below.

_____1. I prefer to do things myself rather than ask for help.
_____2. I get impatient when I have to wait for someone else or when something takes too long.
_____3. I seem to be in a hurry and racing against the clock.
_____4. I get irritated when I'm interrupted while I'm in the middle of something.
_____5. I stay busy and keep many irons in the fire.
_____6. I find myself doing two or three things at once, such as eating and writing a memo while talking on the telephone.
_____7. I over commit myself by biting off more than I can chew.
_____8. I feel guilty when I'm not working on something.
_____9. It's important that I see the concrete results of what I do.
_____10. I'm more interested in the final results of my work than in the process.
_____11. Things never seem to move fast enough or get done fast enough for me.
_____12. I lose my temper when things don't go my way or work out to suit me.
_____13. Others complain that, without realizing it, I ask the same question after I've already been given the answer.
_____14. I spend a lot of time planning and thinking about future events while tuning out the here and now.
_____15. I find myself continuing to work after my coworkers have finished.
_____16. I get angry when people don't meet my standards of perfection.
_____17. I get upset when I'm in situations where I cannot be in control.
_____18. I tend to put myself under pressure with self-imposed deadlines.
_____19. It's hard for me to relax when I'm not working.
_____20. I spend more time working than on socializing, hobbies, or leisure activities.
_____21. I dive into projects to get a head start before all the phases have been finalized.
_____22. I get upset with myself for making even the smallest mistake.
_____23. I put more thought, time, and energy into my work than I do into relationships with other people.
_____24. I forget, ignore, or minimize celebrations such as birthdays, reunions, anniversaries, or holidays.
_____25. I make important decisions before I have all the facts and have thought them through.

Scoring:
25–56 You are not work addicted.
57–66 You are mildly work addicted.
67–100 You are highly work addicted.

The Realities of Work Addiction This material is also adapted from Bryan E. Robinson's Chained to the Desk. Work addiction is a compulsive disorder that workaholics carry into the workplace. It is not created by the workplace. Work addiction is a mental-health problem, not a virtue, and it can create more problems than it can solve for the workplace. The superhero facade masks deeper emotional and adjustment problems that workaholics shield with their accomplishments. Workaholics do not sacrifice free time and family time for their work; they do it for ego gratification. Although most workaholics say that they enjoy their jobs, work satisfaction is not a prerequisite to work addiction. Workaholics become chemically addicted to their own adrenaline because of the stress they put themselves under, and they crave additional crises to maintain work highs. Work addiction can be a primary addiction or a secondary one that blends with other addictions. Workaholics do not have to be gainfully employed to become addicted; it can happen with any compulsive activity. Recovering balance after work addiction improves work quality and productivity, and helps workaholics become happier and more effective at what they do. Achieving balance from reduced work addiction requires more than cutting back on work hours; it involves deep personal introspection and insights, as well as attention to the parts of life that have been neglected.

I am not trying to pathologize us all, but I do believe that work addictive tendencies are highly prevalent in the medical community. Like other addictive behaviors, work addiction can't be 'treated' by the individual.

If you score high on the above test, I strongly suggest Chained to the Desk as a great place to start. I also cover this in great lengths in my own book, Finding Balance in a Medical Life, which will be available in October, 2007.

Fun Stuff
For those of you who love sweet jazz guitar, my pick of the month is Laurence Juber's "I've Got the World On Six Strings". This is a beautiful solo acoustic guitar album where Laurence interprets the work of Harold Arlen, composer of "Over the Rainbow", "Stormy Weather" and "That Old Black Magic".



Thanks for reading,

Lee Lipsenthal, MD, ABHM