Happy, Healthy Docs

Congress Gets Serious About Stress and Mindfulness

Listen to this inspiring YOUTUBE video I found regarding mindfulness. In a Congressional hearing, Rep. Tim Ryan (D-OH) asks Secretary of Health and Human Services Kathleen Sebelius about stress reduction via mindfulness, and how it can help our nation.  What's this about?

Stress management requires being mindful, or self aware in a given moment.  For example, if I'm feeling strong anger, rather than reacting and yelling, I might ask, "What am I feeling right now?  What's going on in my body?"  I might answer, "I'm really feeling hurt under the anger, and my heart is pounding."  So to slow the pounding and feel the hurt rather than yell, I breathe deeply for 10 minutes.  Being mindful helped me create a workable stress management strategy.  Now I'm calmer, I feel better physically, and I prevented an argument.   

Mindfulness meditation is an excellent tool to learn self-awareness - and to manage stress.  It helps with anger management, reducing violence, ameliorating pain, curbing compulsive/addictive behaviors, and more - areas now getting national attention.  So next time I'm upset and want to soothe myself with a donut, I might instead become aware that I'm really feeling disappointed and take a walk instead.

To do it:  Sit quietly.  Close your eyes.  Take deep breaths.  Become aware of your breath, your emotions, your body, by asking, "How am I experiencing myself?" For example, ask, "What emotion am I feeling right now?"  Or, "Where is there tension in my body?"  Then sit with that awareness.  Ask again:  "What emotion am I feeling now?"  A new one may rise up into your awareness.  Do this for 5-10 minutes. 

With practice you'll really get to know yourself well.  Becoming aware of your emotions is important, especially if this is difficult for you.  Why is it important?  Until you know how you truly feel about something, you won't change it.  Emotion is a much better motivator than denial. 

Disruptive Behavior - Owning Your Anger

 

"Disruptive Behavior" is the 2009 buzz word by The Joint Commission with their new Leadership Standard LD.03.01.01 mandating hospitals to address this issue head on.  A major hallmark of a disruptive individual is an angry outburst, often at the most inopportune times - in front of colleagues, patients, and their family members.  The "classic" profile of disruptive physicians are male surgeons who yell in the operating room, but they are by no means the only doctors who may engage in this behavior.  In fact nurses and other health professionals also project their anger outwardly.  Often such individuals have difficulty taking responsibility for their behavior.  Instead they blame their anger on others, such as laboratory personnel who produce late test results.  While it's true that poorly functioning departments or hospital systems can be very frustrating, screaming at those who work in them is not the answer. 

If you are quick to respond with anger in frustrating situations, especially if it happens more than you - or others - would like, the problem may also lie within you.  When I first saw the above cartoon, I  thought Lucy's response to "Why are you always yelling at me?" might be, "Because you're an idiot!"  To my surprise, she took responsibility for her yelling.  That is the start of the healing process for those who can't control their anger.  Chronically angry people may blame others for everything and see themselves as right.  They can't see how their outbursts exacerbate their problems.  They don't do this on purpose.  They really believe they're not at fault. 

This topic can take up many blog posts.  As a first step, ask yourself:  "How well do I handle my anger?  Does it handle me?  Do I feel powerless to control it?  Does it get in my way at work?  Is it affecting my relationships?"  If you answer yes, consider that you could possibly use some help.  The first step is owning the fact that this area of your life isn't working and is causing you pain.  Give it some thought, and stay tuned for more on this.  

Learn to Reverse Negative Behaviors in a NO-COST STRESS MANAGEMENT Phone Seminar 2/17/09

 Are you stressed out because you have not very useful behaviors you'd like to change but can't?  Do you get easily angered and yell?  Are you disorganized?  Do you procrastinate, overeat, smoke, etc.?  Everyone has something.  So why don't we change?  One reason is we believe we can't.  You might find yourself thinking, "It's too hard, too much work, takes too much time, I'm not capable of changing that, I don't know how, I've tried and it didn't work, etc."  Most of us unconsciously think these thoughts all the time.  What we don't realize is that they drive our behaviors and keep us stuck in the negative ones.

A trick to changing behaviors is to bring to conscious awareness the UNDERLYING BELIEFS we have about not being able to change them, and to replace them with beliefs that work.  To help you see this in action, I'm offering a FREE TELEPHONE SEMINAR tonight from 8-8:45 pm EST.  I'll do a GUIDED RELAXATION EXERCISE to help you work on your particular problem.  You call in from the comfort of your home or office.  CLICK HERE TO REGISTER.  This session will also provide a sample of what we'll do in the Meditation and Relaxation Training Phone Seminars (DESCRIPTION) on 2/19, 2/26 and 3/5/09 from 7-8am or 8-9 pm.  Read more about that in the post below, which also tells you how to enroll in the 3 session series. 

New Tough NY Physician Discipline Laws

  On 11/3/08, new legislation became effective in New York making the disciplinary system more strict for physicians reported to the Office of Professional Medical Conduct (OPMC) for misconduct, and makes such information more accessible to consumers. 

These law changes make it even more imperative for clinicians with addictive and psychological problems to seek immediate treatment to regain their health and avoid discipline.  A report to OPMC can result in quick publicizing of charges, and possible losses of license, job, career, income, self-esteem, and thousands in legal fees.  Colleagues in leadership positions should ensure such individuals get help ASAP.  Such individuals can also self-refer or be referred to the Committee for Physician Health at 1-800-338-1833 or 518-436-4723. 

A synopsis of the law changes include:

1.  OPMC now makes charges against a physician public much sooner: after they are served vs. after an order is issued, and before appeals.  

2.  OPMC can more easily obtain a physician's personal medical records if they believe s/he may be impaired by addictive and psychiatric disorders.    

3.  Physicians must update their profiles every 6 months, a condition for license re-registration.  

Other law changes involve mandating clinical competency exams, reviewing malpractice histories to see if doctors should be investigated, and more.  Courts must also notify OPMC of physician misdemeanor and felony convictions, such as DWI's.

Go to www.abramslaw.com for an article fully describing the new law, "The Office of Professional Medical Conduct:  How Changes In Public Health Law Section 230 May Affect You" by Lawrence F. Kobak, DPM, JD and Michael S. Kelton, Esq.  

   

Perfectionism and Medical Errors: What's the Connection?

  After my last post on “Perfectionism:  An Unacknowledged Source of Stress” (below), I was asked to conduct Grand Rounds on this topic.  (Having only been a blog post, the stress of creating a perfect seminar on perfectionism was great.)  At its end, a participant told me it was a great talk, as it was a topic never discussed anywhere in medicine – an arena in which everyone is expected to be perfect.  This expectation attracts perfectionists into medicine, which in turn creates perfectionistic medical leaders who train new doctors to be perfect.  
    The low self-esteem (and fear of making errors) that underlies perfectionism can ironically be transformed into arrogance – the flip side of the same coin – when compounded by the rigors of medical training and sometimes accompanying demanding, highly critical clinical trainers.  Initially fearful residents who drive themselves very hard into becoming highly skilled practitioners, may eventually find themselves saying, “Me?  Make a mistake?  I DON’T MAKE MISTAKES!  I’M PERFECT!”  This creates a closing off to constructive criticism and feedback from others.
    My seminar discussion went onto that track.  An attending shared he had mistakenly mixed up medication orders for two patients.  A resident realized it, and kindly said:  “Dr. Smith (name changed), in looking at these two patient records I think there may be a mistake in your medication orders you might want to look at.”  Dr. Smith was very grateful to this resident.  She averted a possible disaster.  He was humbled by this and saw that despite his high skill level he was still capable of making medical errors.  He was aware of his humanism and imperfection.  
    He further shared stories of famous doctors, experts in their fields, who write the teaching manuals, create the training videos – and who still make mistakes and get sued for malpractice.  He said, “Wouldn’t it be great, if when a nurse says to such a doctor, ‘Doctor, please take a second look at the paperwork, as I believe you may be about to remove the wrong organ,’ that physician could respond with, ‘Thank God you noticed!’ vs. ‘Don’t question my authority!’?”   
    Dr. Smith's point was that BECAUSE no one is perfect, it’s vital for medical team members to stay humble and open to receiving constructive feedback from each other no matter what their status – AND to feel safe in giving it.  My point is the cure for perfectionism is to work on raising your self-esteem.   These two things work together.  True self-respect – vs. arrogance – creates a comfort level with one’s own imperfections and an openness to admit mistakes.  It also creates respect for others – a vital need for a functioning medical team that ultimately results in fewer errors and optimizes patient care.

The Minimization of Drunk Driving and DWI

With July 4th and the holiday increase in drunk driving, I've been thinking about a comment an instructor of mine made years ago when I was in training to become a Credentialed Alcoholism and Substance Abuse Counselor.  He said, "People convicted of 1 or 2 DWI's/DUI's in reality probably have hundreds of "DWI's" for which they were never pulled over."  The enormity of that statement struck me.  In other words many people routinely drink and drive but only rarely get caught.  Such people, and society in general, greatly minimize the significance of this.  They see this behavior as being a "problem," or see themselves as "having a drinking problem," only if they get caught and convicted, regardless of how often in reality they drink and drive.    

An editorial by Michelle Chen in the July 1, 2008 issue of Newsday, a Long Island, NY newspaper, further reminded me of whether people look at their own drinking and driving behavior.  In Nassau County, NY, the County Executive recently put on its website a "Wall of Shame," a frequently visited site of photos of people charged with driving while intoxicated.  While questioning whether shame and mass humiliation work, Ms. Chen makes an interesting point:  "When shame devolves into spectacle, we enter a moral theater where the audience's reaction, not the nature of the offense, is the key player.  The Wall's awkward faces probably elicit more snarky chuckles than grave reflections on the dangers of reckless driving.  It's validating to know you're not "them."  And there's the titillation of knowing that your own transgressions remain secret because of your smarts or good fortune." 

Unfortunately cars can be huge weapons of destruction on the road.  And coming out of denial about personal behavior requires a willingness to be self-honest.  Do you drink and drive?  How often?  Are there passengers and kids in the back seat?  As health professionals there's an even greater social responsibility to get honest.  I used to smoke.  I'm a Health Educator.  I couldn't bring myself to teach smoking cessation classes until I quit.  It's hard to be a role model, and it's even harder to look inward at ourselves.  But driving under the influence and thinking it's no big deal is even worse.  As Ms. Chen says  in conclusion, "It's unclear whether the Wall [of Shame] will make roads any safer, but it could at least force us to turn the lens on ourselves..."      

Physician Discipline: The Case of Impairment

Several articles (6/17+20/08) have appeared in Newsday, a major newspaper of Long Island, New York, about publicizing physicians being investigated for misconduct. New York is not one of 40 states that publicizes charges brought against physicians - such charges are secret. NY only publicizes disciplinary actions taken against physicians. Governor David Paterson has proposed a bill to change this, where once a doctor is formally charged, all proceedings would become public. The bill was prompted by the case of Dr. Harvey Finkelstein, a Long Island doctor whose infectious disease practices led to giving at least one patient Hepatitis C. It took the health department 3 years to inform his patients.

Whether this bill becomes law or not, it raises the issue of early intervention to save the lives and careers, and to prevent the discipline of physicians suffering from substance abuse and other addictive and psychiatric disorders. Doctors who have colleagues who show up at work with alcohol on their breath, who act out with inappropriate expressions of anger, who steal narcotics from the worksite, etc., are still hesitant to intervene with such colleagues. Not wanting to get their friend in trouble, thinking it's none of their business, and being fearful of retribution are some of the many reasons colleagues don't interfere. This avoidance of the issue enables their ill peers to continue on in their sickness with no consequences, and with no medical help. This enabling can literally be deadly for the affected physician. And if their negative behavior is left unchecked, it can lead to a loss of job, license and career - and more public humiliation if this bill gets passed. My point here is not to condone or not condone the publicizing of charges brought against physicians.

My point is to strongly encourage physicians to intervene with impaired colleagues well before the problem ever reaches the disciplinary level - when their illness is still in a very early stage. Enabling addicted or psychologically ill physicians does not help them, their patients, or anyone else in their lives. Viewing these problems as the medical illnesses they are can drastically change the willingness of colleagues to intervene. While negative behaviors cannot be used as excuses to avoid discipline, they must be seen as reasons to quickly help peers in trouble to save their lives. Avoiding discipline becomes an added advantage in such circumstances.

An important resource in the US for impaired physicians are Physician Health Committees run by State Medical Societies. To find the program in your state contact the Federation of State Physician Health Programs. In New York, from whence I write, that program is the Committee for Physician Health.

Components of Meditation and Relaxation Techniques - #2) A Comfortable Position

   Download AbdominalBreathingPodcast.mp3

This is post #2 on 4 Necessary Components of Meditation and deep-breathing Relaxation Techniques (RT’s). (Without all four just do your best.) They are:

1) A quiet environment
2) A COMFORTABLE POSITION
3) An object on which to focus
4) A passive attitude

A Comfortable Position??
This may seem ridiculously obvious – of course you want to be comfortable if you’re trying to relax. But the position you’re in and your degree of comfort make a difference. Remember: the goal is to be comfortable, but not so much that you fall asleep. Here are the basics:

Get Physically Comfortable
If you can, wear comfortable, loose clothes. Remove eye glasses, shoes, dangling jewelry, and loosen tight belts. If you’re at work, just do your best with this.

Stay Awake During Practice
As a rule, meditation and RT’s are done during the day – morning and early evening are ideal, but do whatever works for you. The intention is to stay awake and alert, though deeply relaxed. With that said: if you have trouble falling asleep, doing deep abdominal breathing, or progressive muscle relaxation in bed can help. But generally pick a time of day and physical position which are conducive to staying awake. Lying down to do RT’s when you’re chronically fatigued will probably put you to sleep. It’s much better to sit up.

When Sitting
Meditation is best done sitting. If in a chair, use a straight-backed chair and put the small of your back against the back of the chair. Sit straight without slouching, but not rigid. Keep your head up. Imagine a string attached to the top of your head pulling you up to the ceiling. Uncross your legs, put your feet flat on the floor, and let your uncrossed hands rest in your lap or at your sides. Allow your body to be open. I personally avoid recliners (too comfortable), and chairs with high backs. If you can lean your head against it, you’ll more likely nod off.

If sitting on the floor sit cross-legged with your hands at your sides or in your lap, on a pillow if needed. Meditation centers sell very firm meditation pillows on which to either sit or sort of squat on, where the pillow is under you sideways and you’re sitting on your knees a bit higher up. These work really well and help keep your back straight. (I have one of these. In the days when you could actually take luggage onto a plane for free, I took it with me when I traveled. It made for a great conversation piece with the flight attendants.)

When Lying Down
Again, use caution here – avoid falling asleep. It’s best to use a not-too-comfortable surface. Use a floor with a rug and a small pillow under your head if needed. Or use a yoga mat. Beds and cushy couches cause sleepiness.

When Standing Up
Standing up, you say? How would that be comfortable? Well, in stressful situations when you’re standing, RT’s can come in handy. Just stand straight on both feet equally, and breathe deeply. Keep your eyes open or closed depending on the circumstance. Try this when you want to strangle the slow clerk at the check-out counter. Or at the podium right before you have to give a speech. No one will even know you’re doing it.

Components of Meditation and Relaxation Techniques – #1) A Quiet Environment

If you’ve been following my blog, you’ve tried the posted Abdominal Breathing podcast:

Download AbdominalBreathingPodcast.mp3

To help you do it better, I’ll describe 4 components necessary for successful practice of meditation and deep breathing based relaxation techniques, beginning in this article with #1. If you can’t have all four, do your best and practice anyway. They are:

1) A quiet environment
2) A comfortable position
3) An object on which to focus
4) A passive attitude

A Quiet Environment
Ideally:
It’s best to practice in a quiet environment without distractions. Disconnect or turn off pagers and phones. Let calls go into voice mail. Dim the lights. Put up a “Do Not Disturb” sign or let people know you’re taking a 10-20 minute break. This requires cultivating the attitude that “I’m entitled to quiet, down time for myself.” Do you actually believe this? If so, it’s easier to set aside the time. If not, suffer through the guilt. It will eventually disappear.
Not Ideally:
If you meditate at work and can’t turn off your gadgets, find an alone spot and do it anyway. Chances are the phone won’t ring. If it does try again later.

Where do I meditate?
Ideally:
Have a place at home and at work. At home create a comfortable space – a quiet room, a chair, a pillow on the floor. Use the same space consistently. Keep it clean and comfortable – conducive to relaxing. At work, find a room where you can be alone – your office, an on-call room. Many hospitals have a chapel or meditation room – GREAT places to disappear to.
Not ideally:
At home, use whatever space is available – including the basement or bathroom. Whatever works. At work do the same. Use a bathroom if it’s your only option. Pick a well-hidden single stall one, or a multiple stall one where people can come and go and not bother you.

Other Options:
Sit in your parked car if you feel safe. I’ve meditated in many well-lit parking lots. During lunch spend 15 minutes there, and go back in to eat. Trains and buses also work, but aren’t as quiet. With practice you’ll tune out the noise. But you might set an alarm in case you fall asleep so you won’t miss your stop!

Please comment – share suggestions, where you’ve meditated and how you made it work. Thanks!

Relaxation Techniques and Meditation - Why Bother? WITH PODCAST

 Link here and at end to RELAXATION TECHNIQUE PODCAST:

Download AbdominalBreathingPodcast.mp3

Relax, or Relaaax??
Have you ever done meditation or similar relaxation techniques (RT’s)? My audiences respond to this question with: “Yes, I exercise, watch TV and relax, read a book, etc.” These activities may be relaxing, but are not RT’s. RT’s include things like abdominal breathing, meditation, and visualization. They are deep breathing-based, and provide an object of focus. They’re an integral part of STRESS MANAGEMENT programs. Like physical exercise, they require practice, discipline, scheduling, and once you overcome your initial resistance you look forward to them, and eventually can’t imagine how you’ve lived without them.

Deep Relaxation vs. Sleep
RT’s put you into a unique physiological state. Purposeful slow, deep breathing while focusing on a word, phrase or image – while awake and alert – creates deep relaxation in the body. Alpha brain waves cause this sensation. This is unlike sleep where the brain is in theta and then delta brain waves, and during RT’s there’s a much greater decrease of oxygen consumption than in sleep. With RT’s the body slow down, and healing can occur. Why is this important?

It has to do with the "fight or flight" response. Human beings are designed to gear up physiologically to respond to danger, and relax once the threat is over. A caveman, in his day, who sees an approaching tiger either runs or tries to kill it. To react, his breathing, blood pressure, and heart rates rise, cortisol and glucose are released, his muscles contract and his vision becomes acute. With escape or a dead tiger his body slows – metabolism, blood pressure, heart and respiratory rates decrease. He calms down, recovers and bodily functions return to normal. Today’s “threats” are chronic – traffic jams, difficult colleagues, troubled marriages, endless work hours. The body, not knowing the difference, still prepares for the tiger, but doesn’t rebound into relaxation. The result is hypertension, heart disease, backaches, resentments, chronic frustration, etc.

Relaxation techniques to the rescue!
By taking a break during a stressful day or event and doing a RT or meditation, your body gets its chance to revert to normal. This does not occur anywhere nearly to this degree by simply watching TV or reading. It requires a concerted effort and special techniques to achieve this deep level of relaxation. Think of it this way: regarding physical exercise, cavemen did a lot of it just to survive a day, and didn’t need to go to the gym. Today our sedentary lifestyles create a need to set aside time to work out and actually exercise. The same is true with RT’s. Because we no longer have much down time, and we’re multi-tasking, stressed and physically ill, we now need to set aside time to physiologically, deeply relax. Makes sense, doesn’t it?

PODCAST
Once again, here is a PODCAST with an 11-minute relaxation technique called ABDOMINAL BREATHING. Try it, and visit this site often to do it, to get some R&R during your work day or at home. Please write a response and let me know what you think of it.

Download AbdominalBreathingPodcast.mp3