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Encouraging Empathy

Here is a policy brief I wrote on how medical training tends to erode empathy and what can be done about it.

WHAT’S THE ISSUE?

Sir William Osler described medicine’s aims as “to cure sometimes, to relieve often, to comfort always.” To fulfill this profound calling, physicians must embody empathy. They must seek to understand what their patients are experiencing and imagine what it’s like to “walk in their shoes.”

 

Why is empathy such an important component of care? First, to diagnose a patient’s ailment, the physician must understand what the patient is experiencing and the context in which the problem is occurring.  Secondly, the very act of the physician listening to a patient’s story with genuine concern can itself be tremendously healing.  Third, only by seeking to understand a patient’s perspective is a physician able to provide care that fits the patient’s goals, values, and overall situation.

 

While an empathic impulse often leads people to enter medical school, studies show that students’ empathy tends to decrease as they progress through their education. [1]

As physician and essayist Danielle Ofri writes, “something in our medical training system serves to stamp out whatever empathy students bring with them on day one.”[2]

 

WHAT’S THE BACKGROUND?

 

Multiple theories have been proposed to explain the consistently observed decrease of empathy in medical students as they progress through their training.   One overarching cause is that students and their supervising physicians are often too overwhelmed with demands on their time, energy, and attention to focus on patients. A second cause is the lack of role models who instill the value of empathy in their students.  During their clinical rotations, medical students spend most of their time with interns and residents whose empathy is strained by the large volume of work they are expected to perform.  In this way, an ethic of efficiency over empathy is modeled for medical students. A third factor undermining students’ empathy is the emphasis on technology present at tertiary care centers where medical students train.  In these settings, the results of high-tech testing often receive more of the physicians’ and students’ attention than the actual patients in hospital beds.[3]

 

 

WHAT’S BEING TRIED?

 

Several solutions have been proposed and tried to ameliorate the erosion of empathy during medical education.  An increasingly popular approach is changing how the clinical year of medical school is arranged. Traditionally, students rotate through 2-8 week rotations of different fields of medicine such as pediatrics, internal medicine, obstetrics, and general surgery.  During these rotations, students’ capacity to become quickly competent in requisite knowledge and skills is assessed by supervising physicians. Just as a student develops familiarity and confidence in one rotation, he or she is switched to another one. This system often leaves students feeling too harried, inadequate, and overwhelmed to focus on patients and their needs. Thus, a growing number of medical educators are eliminating block rotations and instead utilizing an approach based on longitudinal relationships between medical students and patients.  In this approach, each medical student is assigned a panel of patients who they accompany to clinical encounters throughout the clinical year. As students follow their patients they learn about different fields of medicine, while getting to know the patients as persons who are more than their health conditions. In a study at Harvard Medical School, students who participated in a longitudinal program were found to have had more rewarding and humanizing learning experiences than their peers on traditional block rotations. [4] Nonetheless, enthusiasm for the longitudinal approach has been tempered by the concern, expressed by some residency directors, that it does not prepare students as well for residency as the traditional block method does.  In addition, it is much more difficult and complicated for schools to organize a longitudinal clinical curriculum than one using block rotations.

 

WHAT I PROPOSE

 

Strategies for helping medical students retain their empathy can be categorized into two types.  The first approach is changing the features of the medical training system that erode students’ empathy.  The second is to equip students to maintain their empathy even when myriad factors work to undermine it.  You might call this latter approach fostering empathic resilience.

 

Changing the System

As previously stated, an increasingly popular approach for reforming the medical training system to make it less erosive of empathy is changing the clinical year from a block method to a longitudinal one. But since many medical schools do not feel comfortable making this complicated change, it is worth considering alternative or complementary strategies.  One idea is to eliminate or at least deemphasize grading and evaluations in medical education.  Right now many medical students are so focused on achieving high marks in their courses that they neglect to give full attention to their patients. If grades and evaluations must remain, a greater emphasis should be placed on the empathy medical students demonstrate in their interactions with patients and staff.  In addition, the evaluation process should focus on helping students develop into outstanding physicians, rather than being a means of punishing or shaming students who are not living up to expected standards.

 

Another approach is decreasing the volume of work residents and medical students are expected to perform on clinical rotations.  If this change were made, the expectation would be that residents and students would spend the leftover time getting to know their patients in greater depth.  Less harried and overwhelmed residents would serve as better empathic models for the students they are supervising.

 

Since empathy is a characteristic often best learned by modeling, clinical faculty who will serve as inspiring examples of empathy should be valued.  As part of their faculty development, attending physicians should receive training in how to increase their own empathy and to model it for trainees.  When selecting and promoting clinical faculty, greater weight should be placed on the empathy that attending physicians demonstrate in their interactions with patients, students, and staff. Does the physician show genuine concern for and interest in the patients in his or her care? Or is the focus merely on test results, treatments, and getting the patient discharged?

 

Bolstering Empathic Resilience

In the culture of many hospitals and clinics, the supreme, overarching value is getting the day’s work done. The implicit idea is that once doctors plough through the workday’s demands, they can then start really living their lives.  Little effort is made to pay attention to and be mindful of the meaning of the work at hand. To combat this culture of efficiency students should be offered training in mindfulness.[5] Just as mindful eating means savoring the food you eat, so students could be trained to be attentive to the meaning of the work they are doing.

 

Mindfulness should also be encouraged through students writing about their clinical experiences in ordinary language. In this way, a coherent narrative can be formed out of the blur of the day’s clinical activity. In the Humanism and Professionalism Program at the Robert Wood Johnson Center Medical School, students meet regularly in small groups with mentors to discuss journal entries they write about their clinical experiences. In this way, they explore topics such as tribulations of patient care, positive and negative role models they are exposed to, and the specific challenges of maintaining humanism and professionalism in situations that often seem expressly designed to chip away at these values.  Students are also assigned readings that promoted reflection on the meaning and purpose of the practice of medicine.  To determine if this program was effective in helping students retain their empathy, two consecutive classes of medical students took a validated test of empathy before they started this program in their clinical year and then again at the end of the year. On average, researchers found no decline in empathy scores for both classes. The students in other studies using the same measure of empathy showed a decline after they finished their clinical rotations.[6]

 

Another means of enhancing students’ empathy is improving their communications skills.  One model for doing so emphasized the development of three basic communication skills namely, “recognition” of patient’s negative emotions, concerns, and inner experiences; “exploration” of these emotions, concerns, and experiences; and “acknowledging” them to generate a feeling in the patient of being understood.[7] Along these lines, students should be taught how to respond when patients try their ability to empathize. To accomplish this, facilitators and students could watch and discuss videos of physicians responding in a professional, healing manner to patients who are angry, worried, loquacious, not adherent to recommendations, and challenging historians. Students could also be videotaped responding to standardized patients presenting with similar scenarios. They could then receive feedback from the patients and faculty-members about how they might communicate more empathically.

 

WHAT’S NEXT?

 

Medical schools should consider taking the following steps to make their training system less erosive of students’ empathy.

 

1)   Change the methods of student assessment.  Place less emphasis on students’ grades and evaluations. The purpose of assessing students’ performance should be enabling them to be the best physicians possible. Student evaluations should not be a means of sorting out who will qualify for the most sought-after residency programs. This creates a competitive, cut-throat culture that is not conducive to empathy.

2)   Decrease the volume of work residents and medical students are expected to perform on clinical rotations.  Expect and ensure that trainees use the leftover time to get to know patients in greater depth.

3)   Promote empathy is clinical faculty.  Provide faculty development that teaches supervising physicians how to increase their own empathy and model it for trainees.  Select and promote clinical faculty who exemplify empathy in their interactions with patients, students, and staff.

4)   Provide training in mindfulness for students and their supervising physicians.

5)   Encourage students to write about their clinical experiences, creating narratives that reveal the meaning of their work.

6)   Equip students with communication skills that will enable them to better empathize with patients.

 

 

[1] B.W. Newton et al.  “Is There a Hardening of the Heart During Medical School?” Academic Medicine 83 (2008): 244-49; M. Hojat et al., “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Academic Medicine 84 (2009): 1182-91; M. Neumann et al., “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents,” Academic Medicine 86 (2011): 996-1009

[2] Ofri, Danielle. What Doctors Feel: How Emotions Affect the Practice of Medicine. p. 30 Beacon Press, 2013.

[3] Verghese, Abraham. Culture Shock—Patient as Icon, Icon as Patient. New England Journal of Medicine. December 25, 2008. 359;26

[4] Chen, Paulene.  Reinventing the Third-Year Medical Student, New York Times, April 19, 2012.  http://mobile.nytimes.com/blogs/well/2012/04/19/reinventing-the-third-year-medical-student/

[5] Dobkin, Patricia & Tom A Hutchinson.Teaching mindfulness in medical school: where are we now and where are we going? Medical Education, 2013; 47: 768–779

[6] Rosenthal, S. Humanism at heart: preserving empathy in third-year medical students. Acad Med. 2011 Mar;86(3):350-8.

[7] Suchman, A.L. Markakis, K., Beckman, H.C. & Frankel, R. (1997). A model of empathic communication in the medical interview. JAMA, 277, 678-682.

 

 
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Posted by on March 28, 2014 in Uncategorized

 

The Power of Stories

I cannot shake the conviction that fiction, whether in literature, movies, or theater is of lesser value than learning “real” information about the world.  Thus, my reading tends to consist mostly of non-fiction books such memoirs or works of history, biography, philosophy, and theology.  And unless I find a movie to be truly extraordinary, I often leave the theater with the sense that my time could have been better spent doing something else. 

 

At that same time, I see great errors in this way of thinking.  Fictional stories also provide information about the world.  The works of writers such as Shakespeare, Homer, and Tolkien render greater insight into reality than today’s news, much of which will be forgotten tomorrow. 

 

All of this comes to mind as I just finished reading journalist Ron Suskind’s piece Reaching My Autistic Son Through Disney in the New York Times.  Suskind begins by sharing his son Owen’s story.  He writes

“In our first year in Washington, our son disappeared.  Just shy of his 3rd birthday, an engaged, chatty child, full of typical speech — “I love you,” “Where are my Ninja Turtles?” “Let’s get ice cream!” — fell silent. He cried, inconsolably. Didn’t sleep. Wouldn’t make eye contact. His only word was “juice.”

 

My wife, Cornelia, a former journalist, was home with him — a new story every day, a new horror. He could barely use a sippy cup, though he’d long ago graduated to a big-boy cup. He wove about like someone walking with his eyes shut. “It doesn’t make sense,” I’d say at night. “You don’t grow backward.” Had he been injured somehow when he was out of our sight, banged his head, swallowed something poisonous? It was like searching for clues to a kidnapping.

 

After visits to several doctors, we first heard the word “autism.” Later, it would be fine-tuned to “regressive autism,” now affecting roughly a third of children with the disorder. Unlike the kids born with it, this group seems typical until somewhere between 18 and 36 months — then they vanish. Some never get their speech back. Families stop watching those early videos, their child waving to the camera. Too painful. That child’s gone.”

Owen became obsessed with Disney movies.  When he regained his ability to speak, it was in the form of repeating lines from these films.  Then at age 6 1/2, a breakthrough came.  Owen’s older brother Walt was celebrating his 9th birthday.  Suskind writes that

After roughhousing with buddies in the backyard at the end of his party, Walt gets a little weepy. He’s already a tough, independent kid, often the case with siblings of disabled kids. But he can get a little sad on his birthdays.

 

As Cornelia and I return to the kitchen, Owen walks in right behind us.

He looks intently at us, one, then the other. “Walter doesn’t want to grow up,” he says evenly, “like Mowgli or Peter Pan.”  We nod, dumbly, looking down at him. He nods back and then vanishes into some private reverie.

 

It’s as if a thunderbolt just passed through the kitchen. A full sentence, and not just an “I want this” or “Give me that.” No, a complex sentence, the likes of which he’d not uttered in four years. Actually, ever.

We don’t say anything at first and then don’t stop talking for the next four hours, peeling apart, layer by layer, what just happened. Beyond the language, it’s interpretive thinking that he’s not supposed to be able to do: that someone crying on his birthday may not want to grow up. Not only would such an insight be improbable for a typical 6-year-old; it was an elegant connection that Cornelia and I overlooked.

 

It’s as if Owen had let us in, just for an instant, to glimpse a mysterious grid growing inside him, a matrix on which he affixed items he saw each day that we might not even notice. And then he carefully aligned it to another one, standing parallel: The world of Disney.

 

After dinner is over and the boys retreat upstairs to their attic lair, Cornelia starts to think about what to do now. It’s like he peeked out from some vast underground and then vanished. He’s done this before, but never quite like this. “How on earth,” she says almost to herself, “do you get back in there?”

 

I feel she’s asking me. She has been the one lifting the burden each day, driving him to therapists and schools, rocking him to sleep as he thrashes at 3 a.m. I’m the one who tells stories, does voices, wears a propeller hat. Her look says, “Find a way.”

 

Soon I’m tiptoeing up the carpeted stairs. Owen’s sitting on his bed, flipping through a Disney book; he can’t read, of course, but he likes to look at the pictures. The mission is to reach around the banister into his closet and grab his puppet of Iago, the parrot from “Aladdin” and one of his favorite characters. He has been doing lots of Iago echolalia, easy to identify because the character is voiced by Gilbert Gottfried, who talks like a busted Cuisinart. Once Iago’s in hand, I gently pull the bedspread from the foot of Owen’s bed onto the floor. He doesn’t look up. It takes four minutes for Iago and me to make it safely under the bedspread.

 

Now crawl, snail-slow, along the side of the bed to its midpoint. Fine.

I freeze here for a minute, trying to figure out my opening line; four or five sentences dance about, auditioning.  Then, a thought: Be Iago. What would Iago say? I push the puppet up from the covers. “So, Owen, how ya doin’?” I say, doing my best Gilbert Gottfried. “I mean, how does it feel to be you?!” I can see him turn toward Iago. It’s as if he is bumping into an old friend. “I’m not happy. I don’t have friends. I can’t understand what people say.” I have not heard this voice, natural and easy, with the traditional rhythm of common speech, since he was 2. I’m talking to my son for the first time in five years. Or Iago is. Stay in character. “So, Owen, when did yoooou and I become such good friends?”

 

“When I started watching ‘Aladdin’ all the time. You made me laugh so much. You’re so funny.”

 

My mind is racing — find a snatch of dialogue, anything. One scene I’ve seen him watch and rewind is when Iago tells the villainous vizier Jafar how he should become sultan.

 

Back as Iago: “Funny? O.K., Owen, like when I say . . . um. . . . So, so, you marry the princess and you become the chump husband.” Owen makes a gravelly sound, like someone trying to clear his throat or find a lower tone: “I loooove the way your fowl little mind works.” It’s a Jafar line, in Jafar’s voice — a bit higher-pitched, of course, but all there, the faintly British accent, the sinister tone.

 

I’m an evil parrot talking to a Disney villain, and he’s talking back. Then, I hear a laugh, a joyful little laugh that I have not heard in many years.”

Through the medium of Disney movies, Suskind was finally able to communicate with his son.   The boy he lost came back to life.  How had these children’s stories penetrated Owen’s small, closed world? 

More generally, why do stories teach and change us in ways that didactic teaching cannot?  Why did Jesus teach and form his disciples through parables?

 
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Posted by on March 9, 2014 in Uncategorized

 

Bolstering Moral Resilience

People enter the profession of medicine for a variety of reasons.  Certainly self-interest often plays an important role in somebody choosing to be a doctor.  Prospective physicians are well aware that at the end of a long road of education and training, there is the virtual guarantee of a reliable, respectable, and sometimes lucrative job.  But it is also the case that many doctors-to-be are motivated by the desire to help their fellow human beings.  Entering medicine holds out the promise of becoming a healer, of engaging in work that really betters the lives of others.

It is a sad fact that medical students seem to lose a significant amount of this altruistic impulse as they progress through their medical training. Physician and essayist Danielle Ofri writes that

something in our medical training system serves to stamp out whatever empathy students bring with them on day one.  The research appears to conclude that it is the third year of traditional medical curriculum that does the most damage.  This is a dispiriting finding, as the third year of medical school is the one in which medical students take their first steps into actual patient care.  For most students, the third year of medical school is eagerly awaited.  After two long years sitting in classrooms, you get to actually do what it is that doctors do—be in hospitals, take care of patients.  One would think that these first steps into real patient care would bring forth all the idealism that drove students to medical school in the first place—idealism that is sorely tested in the first two years of memorizing reams of arcane facts.

But the reverse seems to occur.  After their seminal clinical experiences involving real contact with real patients, medical students emerge with their empathy battered.  Their ideals of medicine as a profession are pummeled by their initiation into the real world of clinical medicine.  And it is in this demoralized state that we send them into residency to accrue what are arguably the most influential and formative experiences of becoming practicing physicians.

Ofri goes on to consider why the clinical years of medical school tend to undermine students’ compassion and empathy.   The most frequently identified culprit is what is often termed the hidden curriculum.  Ofri writes that

the formal curriculum—what is taught in the lecture halls, what is embodied in the school’s mission statement, what is intoned by the deans and senior faculty who usher the students into the sacred world of medicine—can be trounced by the hidden or informal curriculum that the students are submerged in once they enter the clinical fray.

During the clinical years of medical school, students spend most of their time with interns and residents.  These are physicians who just finished medical school and are now receiving intensive training in whatever specialty they selected.  These interns and residents from whom students receive most of their training are usually expected to perform a large volume of clinical work in a brief period of time.  Thus, as Ofri writes,

these physicians-in-training typically develop a whatever-it-takes-to-get-it-done attitude” that “breeds an efficiency that often dispenses with niceties. . . The primacy of pragmatism laced with gallows humor and ever-present physical exhaustion submerge the idealistic medical students in a decidedly unromantic view of medicine.  The philosophical musings of Osler, Hippocrates, the deans, and the old-school attendings have little traction here.

The medical student observes that even the most thoughtful and humanistic intern operates under the brutal calculus that every minute spend on nonessentials simply prolongs the work.  Sure, it’s wonderful to have an in-depth conversation with a patient, to do a more thorough physical exam, to patiently explain the disease process to a family member, to read up on a rare disorder, to attend that lecture on communication skills, to visit a patient a third time in the day, to make those extra phone calls to unravel a patient’s medical history, to let a patient ramble on without interruption—but none of these will get the work done. . . Whatever the medical student has been taught, and even genuinely believes, about the ideals of medicine, the primacy of empathy, the value of the doctor-patient relationship—all of this is swamped once he or she steps into the wards.  Even the most idealistic student can start to view every new admission as an additional burden, every patient’s request as another obstacle to getting the work done, every moment of casual conversation as a moment less of sleep.  It’s no wonder that empathy gets trounced in the actual world of clinical medicine; everything that empathy requires seems to detract from daily survival.

As part of the task force designing the bioethics and humanities curriculum for the new Dell Medical School in Austin, one of my goals is to bolster medical students’ moral resilience.  I want to help physicians-in-training maintain a moral vision for their work even when a variety of forces threaten to undermine it.  In future blog posts, I will consider how medical educators can encourage students to operate with a moral vision in which caring for patients and their well-being is the ultimate, guiding value.

 
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Posted by on March 2, 2014 in Uncategorized

 

How We Endure

Arthur Kleinman has a beautiful essay in the most recent issue of The Lancet entitled How We Endure.  He writes,

for billions of poor people in our world, enduring pain, misery, and suffering is not only a description of their everyday reality but the moral message that they share with their children. And this is true as well of many people in rich societies who must endure seriously debilitating illnesses, disabling accidents, terminal organ failure, end-stage neurodegenerative conditions, and the final days of dying. While the media constantly conveys hopeful messages that cures are around the corner, and that even where treatment is futile people can still be “happy”, families and individuals struggle to come to terms with the genuine reality of enduring the unendurable. The acceptance of mortality, loss, and minds which are afflicted without the means of repair may be part of the wisdom of a career in medicine, but it doesn’t fit well with the upbeat media messages of the contemporary culture of consumer desire, personal social ambition, and technological ascendency over pain and suffering.

 

Poverty, joblessness, migration, and other social realities of our era, along with the experience of major natural disasters, nonetheless revivify for many the importance of striving to endure. For professionals who complain of burn-out and for family caregivers who exhaust their own inner resources, for those involved in humanitarian assistance, and for many other people faced with unrelenting hardship, and physical and emotional burdens, it might prove useful to reconsider the value of enduring in human experience. Instead of asking why patients, caregivers, physicians, aid workers, and other health professionals burn out, suppose we ask how they endure? And I mean by endure withstand, live through, put up with, and suffer. I do not mean the currently fashionable and superficially optimistic idea of “resilience” as denoting a return to robust health and happiness. Those who have struggled in the darkness of their own pain or loss, or that of patients and loved ones, know that these experiences, even when left behind, leave traces that may be only remembered viscerally but shape their lives beyond.

 

When I was a medical student at Stanford University during the early 1960s, I was given the responsibility of holding the hand and trying to calm a young girl who had been severely burned and had to go through the daily horror of debridement of her wounds in a whirlpool bath. She was in great agony, screaming with pain and fear. It was my assigned task to calm her and control her wild thrashing. Day after miserable day, I tried to do some good, to help her, but completely failed. Her suffering was an assault on my sense of agency and harrowing to watch. So I asked the little girl how she endured the fearsome procedure, because as I admitted I could barely endure accompanying her. She looked at me and to my complete surprise told me what she was experiencing while grasping my hand harder. She went on each day to tell me more about what her experience was like, and in the process became calmer and easier for the staff to work with. She endured because she had to endure in order to go on living. And she helped me endure what had become a devastating clinical role. Neither of us was resilient, in the contemporary meaning of the term; she withstood and kept me going as well. She taught me more in those moments than any book or clinical mentor could have done.

 

In caring for his wife during her experience of the ravages of Alzheimer’s disease, the late writer E S Goldman explained that he endured because the caregiving was there to do, it had to be done. The commitment to the other person was fundamental. That is how I felt about caring for my own wife who suffered from the same destructive disease; and I have heard many family caregivers of relatives with progressive and terminal conditions voice the same moral sentiment.

Kleinman’s piece reminds me of the many heroic caregivers I see in my practice almost everyday.  They know their loved ones’ physical and mental limitations from conditions like Alzheimer’s, Parkinson’s, or congestive heart failure will only become more severe.  Yet they nonetheless lovingly give their all to provide their husband, wife, father, or mother the best life possible.  Kleinman writes that 

the sinologist Michael Puett describes an ancient Chinese tradition that teaches that no matter how arduous we work at building human purpose and value in our lives, we are always ultimately defeated by all the negative things in the world. Nonetheless, our task is still to cultivate what is most human and domesticate what we can in the face of failure. . .

 

Our cultural images today seem blinded to life’s limits and dangers. While emphasising human flourishing and celebrating happy outcomes, they obscure the reality of human conditions. Physicians can work hard at achieving the best outcomes, while still acknowledging that their patients, like they themselves, must prepare for lives lived under some degree of constraint. This means that each of us at some point must learn how to endure: the act of going on and giving what we have. And we need, on occasion, to step outside ourselves and look in as if an observer on our endeavours and our relationships—personal and professional—to acknowledge the strength, compassion, courage, and humanity with which we ourselves endure or help to make bearable the hard journeys of others. These are the qualities that make acceptance and striving, if not noble, then certainly deeply human—worthy of respect of ourselves and those whose journeys we share.

 

Read Kleinman’s entire essay here.

 
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Posted by on February 11, 2014 in Uncategorized

 

Illness and Disease

In an article entitled Culture, Illness, and Care, medical anthropologist Arthur Kleinman writes about the important distinction between illness and disease.  He defines diseases as “abnormalities in the structure and function of body organs and systems.”  In other words, disease is what is actually physically wrong with the body.  In contrast, illness is what patients experience when they are sick.  This is profoundly influenced by multiple factors such as a person’s culture, social situation, and the meaning attributed to symptoms.

 

Kleinman writes that the focus of modern medicine tends to be disease. Doctors are trained to find a distinct abnormality in the structure and function of the body and provide an effective remedy.  This approach works for straightforward problems such as appendicitis and pneumonia that have a clear biological cause.  It is much less useful for conditions that do not have a clear physical etiology.  This is a significant limitation since about 50% of visits to the doctor are for complaints without an ascertainable biologic base.

 

In some cultures, physical symptoms are the most acceptable way of expressing psychological problems such as anxiety and depression.  When I volunteer at a local clinic that provides care for immigrants and refugees, I try to always ask about the stories of the people I see.  In learning about their life journeys and hardships, the causes of otherwise inexplicable physical symptoms, such as headaches, chest pain, and shortness of breath, often reveal themselves.

 

I have asked patients suffering from illnesses without a straightforward diagnosis and treatment how physicians can be most helpful.  They tell me that sometimes doctors become frustrated when they cannot find a diagnosis and cure for what is wrong.  I must admit that I have at times felt nervous seeing somebody whose symptoms I cannot understand and effectively treat.  But many of these patients tell me they understand that doctors cannot always figure out what is wrong.  They don’t expect us to be miracle-workers.  What these patients tell me they most appreciate is a physician who will not stop caring and trying to be helpful. 

 

 
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Posted by on February 9, 2014 in Uncategorized

 

The New Cholesterol Guidelines

Tim Russert’s sudden death from a heart attack in 2008 took America by surprise.  It seemed clear to everybody that a good man died too young.  But the condition that killed him—coronary artery disease–is actually the most common cause of death in the U.S. and around the world.

In coronary artery disease (CAD) is a waxy substance called plaque builds up inside arteries that supply blood to the heart. Fortunately, over the past few decades many less people are dying of this disease.  As this New England Journal of Medicine article demonstrates, the reduction of cholesterol is the single greatest factor explaining the decrease in deaths from coronary artery disease. 

So it was significant when on November 12, 2013, the American College of Cardiology released new guidelines for treating cholesterol.  Here are some of the key points from the guidelines.

First, the guidelines emphasized that only the cholesterol medicines called statins have been shown to reduce the risk of developing and dying from coronary artery disease.  Although other medicines such as Zetia, Niacin, and Tricor do lower cholesterol, they don’t have robust evidence for lowering your risk of getting and dying from a heart attack.

Secondly, the guidelines no longer recommend aiming for a target cholesterol level.   Formerly, physicians and patients would try to lower cholesterol below a certain number. But in the studies that show statins reduce the risk of heart disease, patients were placed on either a statin or placebo and then followed to look for a difference in the incidence of heart attacks.  Thus, faithfully translating these studies into practice means simply putting people with or at risk of coronary artery disease on a statin.

And who is at risk for coronary artery disease?  Who should doctors put on a statin?  The guidelines point to the following 4 groups of individuals who benefit from these drugs:

1)    People with a history of coronary artery disease (CAD) or cerebrovascular disease.  The latter refers to folks who have had a stroke or mini-stroke

2)    People with LDL cholesterol levels above 190.  LDL is considered the bad cholesterol since it deposits plaque in arteries.  People with very high levels of LDL have been found to experience a higher incidence of heart disease and at a younger age. 

3)    People with diabetes, age 40-75.  Statins are recommended for diabetics since they have a markedly higher risk of developing CAD.

4)    People aged 40-75 who have a 7.5% risk or higher of developing CAD in the next 10 years.  This is the most controversial of the new guidelines.  Since many people have over a 7.5% risk of developing CAD in the next ten years, if this recommendation is put into practice, a good deal more folks will be placed on statins. 

Overall, I see these guidelines as a welcome advance.  They better reflect what the studies on cholesterol and CAD actually tell us.  They also simplify treating cholesterol.  Rather than aiming for a certain cholesterol number, patients and doctors can now focus on deciding whether starting a statin will be beneficial in their individual situations. 

 
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Posted by on January 24, 2014 in Uncategorized

 

Conquering Cedar Fever

Unlike some of my classmates in medical school, diseases themselves are not something I often feel a passion to study.  I find philosophy, theology, politics, literature, history, psychology, and so many other subjects much more interesting.  But when I see a person suffering and looking for answers and relief, I am motivated to learn all that I can to help.

So while the topic of allergies is not something that really revs my jets, I think it’s worth writing about since it’s affecting so many Austinites right now.  Indeed, I don’t recall ever seeing so many congested, itchy-eyed, hoarse, coughing, rhinorrheic people all at once. 

So what exactly is occurring when people suffer from allergies?  In response to airborne particles such as cedar, inflammation occurs, causing sneezing, itching, and fluid buildup.  There are 4 major categories of allergens, or substances that causes allergies: Pollens, Insects, Animal Allergens, and Molds. 

The ideal response to allergies is identifying the offending allergen and avoiding it. So in the cedar fever season, affected individuals should close the windows of their car and home, stay indoors when possible, and shower every night before bed to removes cedar from their skin and hair.  But, of course, remaining inside all day is pretty impractical and lame. 

The next step, then, is to take steps to reduce the inflammation that the allergens cause.  Here are some steps for doing so.

Rinse Your Nose

This is particularly useful for treating drainage down the back of your throat, sneezing, nasal dryness, and congestion.  It helps by rinsing out allergens and irritants from the nose.  Do it once or twice daily.  Saline nasal sprays and irrigation kits can be purchased over-the-counter.

Steroid Nasal Sprays

These are the first-line treatment for allergies.  I most commonly prescribe Flonase (Fluticasone) since it’s generic and cheap.  These drugs have few side effects and significantly relieve symptoms in most people.  You may need to use a nasal decongestant like Sudafed for a few days before starting the nasal spray to reduce nasal swelling.  Be patient as it can take days to weeks for these sprays to have their full effect.

Antihistamines

Think Allegra, Zyrtec, Claritin.  These relieve itching, sneezing, and runny nose, but doesn’t help with nasal congestion.  Antihistamine nasal sprays such as Astelin, Astepro, and Patanase are also available and work quickly.

Singulair

I add this medication when people are not receiving sufficient relief from the other treatments. Some people find it to be quite effective.

Steroid Pills or Shots

If you’re really struggling, a short course of Prednisone or a corticosteroid shot can provide quick, dramatic relief.  However, your symptoms are likely to quickly return unless you get on a maintenance treatment.  Because of their side-effects, steroid pills are not a viable long-term strategy for managing allergies.

Allergy Shots or Drops

If all else fails, I send people to an allergist for allergy shots or drops. They contain solutions of the allergens to which a person is allergic.  By receiving them, your immune response to the allergen lessens over time.  The downside of this approach is that it can be time-consuming and somewhat expensive.

Good luck with your allergies!

 
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Posted by on January 17, 2014 in Uncategorized

 
 
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