SURGEON GENERAL’S RX FOR STRESS IN AMERICA

The National Institutes of Health (NIH) has put itself firmly on record as being deeply concerned about our national epidemic of stress at the individual, organizational and societal levels. NIH’s National Center for Complementary and Integrative Health (NCCIH) broadcast on September 7th its annual Stephen E. Straus Distinguished Lecture in the Science of Complementary Therapies. The lecture was titled A Nation Under Pressure: The Public Health Consequences of Stress in America.

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PROMOTING RESILIENCE WITH OPTIMISM AND MINDFULNESS

The American Psychological Association (APA) recently documented a worrisome increase in stress in the U.S. population (Stress in America https://www.apa.org/news/press/releases/stress). Uncontrolled stress can cause or worsen anxiety, depression, PTSD and a wide range of clinical conditions affecting every organ system. Medical students, residents and practicing physicians experience higher levels of stress than their age-matched counterparts at all levels of medical training....

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ALLOWING AWE IN MEDICINE

Of all the sciences, medicine uniquely combines all domains of the human condition-biological, cognitive, emotional, environmental, interpersonal and transpersonal. The more we learn about the benefits of the interpersonal and transpersonal dimensions of health, disease and medical practice, the more we seek to populate medical schools with well-rounded students and humanize medical training and the healthcare workplace.

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solitary, independent, rugged individualist collapses under the weight of evidence that loneliness can kill. Physicians are also affected. My lab partner in medical school committed suicide as an intern. One of my favorite physicians, to whom I referred for 25 years, committed suicide. My physician next door neighbor committed suicide.


Physician Burnout– A Public  Health Crisis

Multiple internal and external stressors can lead to physicians’ compassion fatigue, substance misuse, family discord, burnout, leaving medicine and suicide (6). Harvard Medical School and the Massachusetts Medical Society recently declared physician burnout a public health crisis (7). Our continuing education as physicians has historically focused on cognitive and technical CME as the cornerstone for professional development. But personal development of the whole person of the physician is receiving increasing emphasis.


AMA STEPS Forward Program (8) aims to improve practice efficiency and help you achieve the Quadruple Aim of improving patient experience, improving population health and lowering overall costs while also increasing your professional satisfaction. AAFP Physician Health First (9) prioritizes physician health and well-being as the foundation for a satisfying career, keeping you connected to your purpose and helping you provide the best possible patient care. The Mindful Practice Program (U Rochester School of Medicine) (10) helps develop the qualities of the exemplary physician- including the ability to be present and attentive, adopting a fresh and curious “beginner’s mind,” improving our relationships with patients and colleagues and cultivating greater self-awareness, resilience and insight into our personal lives and professional work.


Doctor as Drug

Balint popularized the phrase “doctor as drug” in his 1957 medical classic The Doctor, His Patient and the Illness, emphasizing the impact of physician communication and behavior on the patient’s clinical course. Cardiologist Bernard Lown, formerly at Harvard School of Public Health and original developer of the defibrillator, spoke eloquently about “the healing power of words” and “the lethal power of words” in his introduction to Norman Cousins’ 1983 The Healing Heart- Antidotes to Panic and Helplessness. Lown gives examples from his clinical practice and Cousins describes his own journey as patient, illustrating the healing power of the physician-patient relationship.


A recent RCT (11) showed that a one- sentence assurance from a physician in response to an induced dermal allergic reaction significantly reduced participants’ ratings of itchiness/irritation compared to a control. Their use of the sentence “From this point forward your allergic reaction will start to diminish, and your rash and irritation will go away” reminds me of the words I use at the end of patient visits in which some treatment or lifestyle behavior is recommended– I always say “I think this will help”– and I believe it.


Patients Can Be Good Medicine

Much has been written about the emotional cost of patient care–the vicarious trauma and compassion fatigue suffered by physicians. Less widely discussed is the vicarious healing and inspiration we receive by walking alongside those exceptional beings we call patients. As I interview physicians for a companion Profile in Compassion column in this magazine, I am struck by a recurring theme. In addition to describing their personal story of stress and burnout, physicians consistently report the personal benefits they receive from their relationships with patients. It is uplifting and healing to us as physicians to be in relationship with our patients’ strength, resilience, hope, courage, faith, determination, acceptance, humor, wisdom, forgiveness, compassion, generosity, optimism and gratitude.         


May you be blessed with healing relationships in your practice of medicine- healing for your patients and healing for yourself.


Resources


  1. Relationship-centered Care- A Constructive Reframing   J Gen Intern Med 2006; 21:S3–8
  2. A Nation Under Pressure: The Public Health Consequences of Stress in America  https://nccih.nih.gov/news/events/ lectures/SES17  
  3. Cigna survey on loneliness (2018) https://www.cigna.com/newsroom/news-releases
  4. Centers for Disease Control and Prevention (CDC) (2017)  https://www.cdc.gov/vitalsigns/suicide/index.html
  5. Centers for Disease Control and Prevention (CDC)(2018)  https://www.aafp.org/news/health-of-the-public/20181210lifeexpectdrop.html
  6. New England J of Medicine, Tait Shanafelt MD (Mayo Clinic) June 2016 video https://catalyst.nejm.org/videos/
  7. Harvard School of Public Health and Massachusetts Medical Society (2019)   https://www.hsph.harvard.edu/news/press-releases/
  8. AMA STEPS Forward https://edhub.ama-assn.org/steps-forward
  9. AAFP Physician Health First https://www.aafp.org/membership/benefits/physician-health-first.html
  10. Mindful Practice® Programs, U of Rochester School of Medicine https://www.urmc.rochester.edu/family-medicine/mindful-practice.aspx
  11. Physician Assurance Reduces Patient Symptoms in US Adults: an Experimental Study (2018), J Gen Intern Med 33(12):2051–2

Relationships are at the very heart of medicine


I recently saw one of my favorite patients whom I had not seen in 10 years. I have thought of her often since the hospital took over my Estill County practice in Irvine and I moved to Lexington. Wanda always lifted my spirits. She always asked me how I was doing because she cared about me. We joked and laughed while managing her chronic medical conditions. She was good medicine for me. Seeing her again got me thinking about relationships in medicine.


Consumer choice in the medical marketplace and mandated patient satisfaction surveys highlight the clinical and financial importance of positive relationships. As physicians, we work in relationships with our patients, colleagues, staff, organizations and community. Importantly, we also work in relationship with ourselves–physically, mentally, emotionally and, some would add, spiritually.


Relationships Can Heal

Relationship-centered care (RCC) acknowledges the pivotal role that relationships play in medical outcomes, the quality of care and the quality of caring (1). RCC includes the unique humanness and personhood of all relationship participants and a whole-person perspective, including physical, mental, emotional, interpersonal and transpersonal aspects of the human experience. RCC acknowledges the mutual bi-directional impact on all relationship participants and rests on a foundation of reciprocity, ethics, morality, service and justice.

BY JOHN A. PATTERSON MD, MSPH, FAAFP

RCC underscores the importance of promoting resilience, managing stress, preventing burnout and cultivating compassion–for physicians and all those with whom we are in relationship.


Epidemic of Stress

Former Surgeon General Vivek Murthy actively campaigns to address the epidemic of stress in America (2). He includes social support and relationships, including co-worker relationships, as part of his nationwide public health prescription, citing research showing the positive health impact of having an emotional confidant at work. As Surgeon General, all his staff were offered meditation instruction and often meditated together at work- improving office morale.


Widespread Despair

A survey by Cigna documents the erosion of supportive relationships and the epidemic of loneliness in our society (3). The CDC reports that nearly 45,000 lives were lost to suicide in 2016 and that life expectancy (a snapshot of national health) declined twice between 2014 and 2017, driven by suicide, drug overdoses and alcohol- the “deaths of despair” (4)(5). This epidemic is affecting all geographic, political, gender and age groups. The great American myth of the

JOHN A. PATTERSON MD, MSPH, FAAFP

Dr Patterson chairs the Lexington Medical

Senator Alvarado earned his bachelor's degree in biology from Loma Linda University (California) in 1990, and then went on to receive his Doctorate in Medicine in 1994. He completed his medical residency in Internal Medicine and Pediatrics at the University of Kentucky in 1998. Society's Physician Wellness Commission and is certified in Physician Coaching. He is on the family practice faculty UK College of Medicine and teaches nationally for Saybrook School of Integrative Medicine and Health Sciences (San Francisco) and the Center for Mind Body Medicine (Washington, DC). After 30 years in private family practice in Irvine KY, he now operates the Mind Body Studio in Lexington, where he offers integrative mind-body medicine consultations specializing in mindfulness-based approaches to stress-related chronic conditions and burnout prevention for helping professionals. He can be reached through his website at www.mindbodystudio.org