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How to make the move away from opioids for chronic noncancer pain
Standard care of chronic noncancer pain should start moving away from chronic opioid treatment, which can put patients in greater danger of developing a substance use disorder, according to evidence presented at a meeting held by the American Pain Society and Global Academy for Medical Education.
As the effects of the U.S. opioid epidemic continue to gain public attention – recently spurring a declaration of a state of emergency –
Use of opioid therapy for pain conditions such as osteoarthritis, fibromyalgia, and migraine – once a common treatment approach – has been shown to be a dangerous breeding ground for opioid substance use disorders, and physicians would do well to re-evaluate their treatment methods, according to Edwin Salsitz, MD, assistant clinical professor at Mount Sinai Beth Israel Hospital, New York.
“Each prescriber is going to have to review this, digest it, reflect on it, and decide what they are going to do,” said Dr. Salsitz in an interview. “Base it on the Centers for Disease Control and Prevention’s guideline as a good starting point, and then individualize it for yourself and your patients.”
One of the major steps toward lowering the rate of opioid addiction through prescription is avoiding opioids as a treatment for acute pain.
“The first recommendation [of the CDC guideline] is nonpharmaceutical therapy, including physical therapy, massage therapy, acupuncture, and cognitive-behavioral therapy – and there’s a whole lot of evidence for these types of therapy,” said Dr. Salsitz. “The second option is that if you’re going to use medications, use those that aren’t opioids, like Tylenol, Motrin, and antidepressants.”
If opioids are necessary, said Dr. Salsitz, immediate-release opioids in limited prescriptions are a good way to lower the risk of addiction.
“The extended-release opioids have many more milligrams than the immediate-release opioids,” according to Dr. Salsitz. “For example, in New York state, we have a law now that says for acute pain, you cannot prescribe for more than a 7-day amount.”
That 7-day limit helps keep excess opioids out of households, he noted, making it harder for patients to share their medication with friends and family, which has proven to be the most common source for opioids during the onset of substance use disorders. In the first 12 months of use, friends and family members accounted for 55% of reported sources of opioids, according to the U.S. 2010 National Survey on Drug Use and Health.
Providers may also want to consider screening pain patients for psychological disorders, Dr. Salsitz said, as many psychological conditions are associated with a high risk of developing a substance use disorder. Patients with major depression, dysthymia, or panic disorder were 3.43, 6.51, and 5.37 times more likely, respectively, than those without to initiate a prescription for and regularly use opioids, according to a study cited by Dr. Salsitz (Arch Intern Med. 2006 Oct 23;166[19]:2087-93).
One of the largest barriers preventing providers from implementing these methods, however, is a lack of resources, particularly in rural areas with increasing rates of opioid substance use disorders and limited provider options.
While these limitations do pose a problem, physicians should not feel they can’t provide proper care, according to Dr. Salsitz. “I think that each individual provider, wherever they are located, can do a reasonable job.”
Global Academy and this news organization are owned by the same company.
[email protected]
On Twitter @eaztweets
Standard care of chronic noncancer pain should start moving away from chronic opioid treatment, which can put patients in greater danger of developing a substance use disorder, according to evidence presented at a meeting held by the American Pain Society and Global Academy for Medical Education.
As the effects of the U.S. opioid epidemic continue to gain public attention – recently spurring a declaration of a state of emergency –
Use of opioid therapy for pain conditions such as osteoarthritis, fibromyalgia, and migraine – once a common treatment approach – has been shown to be a dangerous breeding ground for opioid substance use disorders, and physicians would do well to re-evaluate their treatment methods, according to Edwin Salsitz, MD, assistant clinical professor at Mount Sinai Beth Israel Hospital, New York.
“Each prescriber is going to have to review this, digest it, reflect on it, and decide what they are going to do,” said Dr. Salsitz in an interview. “Base it on the Centers for Disease Control and Prevention’s guideline as a good starting point, and then individualize it for yourself and your patients.”
One of the major steps toward lowering the rate of opioid addiction through prescription is avoiding opioids as a treatment for acute pain.
“The first recommendation [of the CDC guideline] is nonpharmaceutical therapy, including physical therapy, massage therapy, acupuncture, and cognitive-behavioral therapy – and there’s a whole lot of evidence for these types of therapy,” said Dr. Salsitz. “The second option is that if you’re going to use medications, use those that aren’t opioids, like Tylenol, Motrin, and antidepressants.”
If opioids are necessary, said Dr. Salsitz, immediate-release opioids in limited prescriptions are a good way to lower the risk of addiction.
“The extended-release opioids have many more milligrams than the immediate-release opioids,” according to Dr. Salsitz. “For example, in New York state, we have a law now that says for acute pain, you cannot prescribe for more than a 7-day amount.”
That 7-day limit helps keep excess opioids out of households, he noted, making it harder for patients to share their medication with friends and family, which has proven to be the most common source for opioids during the onset of substance use disorders. In the first 12 months of use, friends and family members accounted for 55% of reported sources of opioids, according to the U.S. 2010 National Survey on Drug Use and Health.
Providers may also want to consider screening pain patients for psychological disorders, Dr. Salsitz said, as many psychological conditions are associated with a high risk of developing a substance use disorder. Patients with major depression, dysthymia, or panic disorder were 3.43, 6.51, and 5.37 times more likely, respectively, than those without to initiate a prescription for and regularly use opioids, according to a study cited by Dr. Salsitz (Arch Intern Med. 2006 Oct 23;166[19]:2087-93).
One of the largest barriers preventing providers from implementing these methods, however, is a lack of resources, particularly in rural areas with increasing rates of opioid substance use disorders and limited provider options.
While these limitations do pose a problem, physicians should not feel they can’t provide proper care, according to Dr. Salsitz. “I think that each individual provider, wherever they are located, can do a reasonable job.”
Global Academy and this news organization are owned by the same company.
[email protected]
On Twitter @eaztweets
Standard care of chronic noncancer pain should start moving away from chronic opioid treatment, which can put patients in greater danger of developing a substance use disorder, according to evidence presented at a meeting held by the American Pain Society and Global Academy for Medical Education.
As the effects of the U.S. opioid epidemic continue to gain public attention – recently spurring a declaration of a state of emergency –
Use of opioid therapy for pain conditions such as osteoarthritis, fibromyalgia, and migraine – once a common treatment approach – has been shown to be a dangerous breeding ground for opioid substance use disorders, and physicians would do well to re-evaluate their treatment methods, according to Edwin Salsitz, MD, assistant clinical professor at Mount Sinai Beth Israel Hospital, New York.
“Each prescriber is going to have to review this, digest it, reflect on it, and decide what they are going to do,” said Dr. Salsitz in an interview. “Base it on the Centers for Disease Control and Prevention’s guideline as a good starting point, and then individualize it for yourself and your patients.”
One of the major steps toward lowering the rate of opioid addiction through prescription is avoiding opioids as a treatment for acute pain.
“The first recommendation [of the CDC guideline] is nonpharmaceutical therapy, including physical therapy, massage therapy, acupuncture, and cognitive-behavioral therapy – and there’s a whole lot of evidence for these types of therapy,” said Dr. Salsitz. “The second option is that if you’re going to use medications, use those that aren’t opioids, like Tylenol, Motrin, and antidepressants.”
If opioids are necessary, said Dr. Salsitz, immediate-release opioids in limited prescriptions are a good way to lower the risk of addiction.
“The extended-release opioids have many more milligrams than the immediate-release opioids,” according to Dr. Salsitz. “For example, in New York state, we have a law now that says for acute pain, you cannot prescribe for more than a 7-day amount.”
That 7-day limit helps keep excess opioids out of households, he noted, making it harder for patients to share their medication with friends and family, which has proven to be the most common source for opioids during the onset of substance use disorders. In the first 12 months of use, friends and family members accounted for 55% of reported sources of opioids, according to the U.S. 2010 National Survey on Drug Use and Health.
Providers may also want to consider screening pain patients for psychological disorders, Dr. Salsitz said, as many psychological conditions are associated with a high risk of developing a substance use disorder. Patients with major depression, dysthymia, or panic disorder were 3.43, 6.51, and 5.37 times more likely, respectively, than those without to initiate a prescription for and regularly use opioids, according to a study cited by Dr. Salsitz (Arch Intern Med. 2006 Oct 23;166[19]:2087-93).
One of the largest barriers preventing providers from implementing these methods, however, is a lack of resources, particularly in rural areas with increasing rates of opioid substance use disorders and limited provider options.
While these limitations do pose a problem, physicians should not feel they can’t provide proper care, according to Dr. Salsitz. “I think that each individual provider, wherever they are located, can do a reasonable job.”
Global Academy and this news organization are owned by the same company.
[email protected]
On Twitter @eaztweets
FROM PAIN CARE FOR PRIMARY CARE
Study shows more changes, less stopping of PsA systemic drugs
Among psoriatic arthritis (PsA) patients who started a systemic disease-modifying antirheumatic drug (DMARD) in the United States during 2004-2015, treatment modification rates went up and discontinuation rates decreased over the 11-year period, according to results from a large study of national claims data.
The increased rate of treatment modification may not be surprising given the “significant advancement in PsA treatment and expanding pharmacotherapy options in the past decade,” wrote researchers led by Moa P. Lee, PharmD, of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital and Harvard Medical School, Boston (Arthritis Care Res. 2017 Aug 13. doi: 10.1002/acr.23337).
The researchers reviewed records between July 1, 2004, and Sept. 30, 2015, from the Clinformatics Datamart data set, which contains demographic and longitudinal claims information for all United Healthcare beneficiaries. They observed an increasing trend in treatment modifications over the 11-year study period (P = .03) and found that 5% of all patients discontinued treatment, with the discontinuation rates decreasing over time (P less than .001).
Of the 9,222 PsA patients who initiated DMARDs, 43% received a biologic agent (bDMARD) and 57% received a conventional synthetic agent (csDMARD). Patients who were initiated on bDMARDs had an average age of 48 years, compared with 52 years in csDMARD initiators. Biologic DMARD initiators also had generally fewer comorbidities.
The most frequently used DMARD overall was methotrexate, which constituted 81% of csDMARD initiations. The most commonly prescribed bDMARDs were etanercept and adalimumab (49% vs. 34%, respectively).
When the researchers evaluated 12-month follow-up data after the first DMARD initiation, they found that 20% of bDMARD initiators had their initial DMARD regimen modified, compared with 31% of csDMARD initiators. Treatment modifications occurred more quickly after starting a csDMARD (median of 102 days) when compared against bDMARD initiators (148 days), and the rate of modification was also higher for patients who first started a csDMARD (adjusted incidence rate of 39.3 cases per 100 patient-years vs. 21.1 cases per 100 person-years for bDMARDs).
The most common modification made by csDMARD initiators was the addition of a bDMARD to methotrexate, particularly etanercept or adalimumab, in 16%. For bDMARD initiators, the most common modification was adding methotrexate in 7%, followed by switches between etanercept and adalimumab in 6%.
“In a rapidly evolving field of PsA treatment, further studies that elucidate more comprehensive real-world trends in the use of available treatment, including more recent novel therapies for PsA, may be needed,” the researchers concluded.
There was no specific funding source for the study. The researchers reported having no financial disclosures relevant to the study.
Among psoriatic arthritis (PsA) patients who started a systemic disease-modifying antirheumatic drug (DMARD) in the United States during 2004-2015, treatment modification rates went up and discontinuation rates decreased over the 11-year period, according to results from a large study of national claims data.
The increased rate of treatment modification may not be surprising given the “significant advancement in PsA treatment and expanding pharmacotherapy options in the past decade,” wrote researchers led by Moa P. Lee, PharmD, of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital and Harvard Medical School, Boston (Arthritis Care Res. 2017 Aug 13. doi: 10.1002/acr.23337).
The researchers reviewed records between July 1, 2004, and Sept. 30, 2015, from the Clinformatics Datamart data set, which contains demographic and longitudinal claims information for all United Healthcare beneficiaries. They observed an increasing trend in treatment modifications over the 11-year study period (P = .03) and found that 5% of all patients discontinued treatment, with the discontinuation rates decreasing over time (P less than .001).
Of the 9,222 PsA patients who initiated DMARDs, 43% received a biologic agent (bDMARD) and 57% received a conventional synthetic agent (csDMARD). Patients who were initiated on bDMARDs had an average age of 48 years, compared with 52 years in csDMARD initiators. Biologic DMARD initiators also had generally fewer comorbidities.
The most frequently used DMARD overall was methotrexate, which constituted 81% of csDMARD initiations. The most commonly prescribed bDMARDs were etanercept and adalimumab (49% vs. 34%, respectively).
When the researchers evaluated 12-month follow-up data after the first DMARD initiation, they found that 20% of bDMARD initiators had their initial DMARD regimen modified, compared with 31% of csDMARD initiators. Treatment modifications occurred more quickly after starting a csDMARD (median of 102 days) when compared against bDMARD initiators (148 days), and the rate of modification was also higher for patients who first started a csDMARD (adjusted incidence rate of 39.3 cases per 100 patient-years vs. 21.1 cases per 100 person-years for bDMARDs).
The most common modification made by csDMARD initiators was the addition of a bDMARD to methotrexate, particularly etanercept or adalimumab, in 16%. For bDMARD initiators, the most common modification was adding methotrexate in 7%, followed by switches between etanercept and adalimumab in 6%.
“In a rapidly evolving field of PsA treatment, further studies that elucidate more comprehensive real-world trends in the use of available treatment, including more recent novel therapies for PsA, may be needed,” the researchers concluded.
There was no specific funding source for the study. The researchers reported having no financial disclosures relevant to the study.
Among psoriatic arthritis (PsA) patients who started a systemic disease-modifying antirheumatic drug (DMARD) in the United States during 2004-2015, treatment modification rates went up and discontinuation rates decreased over the 11-year period, according to results from a large study of national claims data.
The increased rate of treatment modification may not be surprising given the “significant advancement in PsA treatment and expanding pharmacotherapy options in the past decade,” wrote researchers led by Moa P. Lee, PharmD, of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital and Harvard Medical School, Boston (Arthritis Care Res. 2017 Aug 13. doi: 10.1002/acr.23337).
The researchers reviewed records between July 1, 2004, and Sept. 30, 2015, from the Clinformatics Datamart data set, which contains demographic and longitudinal claims information for all United Healthcare beneficiaries. They observed an increasing trend in treatment modifications over the 11-year study period (P = .03) and found that 5% of all patients discontinued treatment, with the discontinuation rates decreasing over time (P less than .001).
Of the 9,222 PsA patients who initiated DMARDs, 43% received a biologic agent (bDMARD) and 57% received a conventional synthetic agent (csDMARD). Patients who were initiated on bDMARDs had an average age of 48 years, compared with 52 years in csDMARD initiators. Biologic DMARD initiators also had generally fewer comorbidities.
The most frequently used DMARD overall was methotrexate, which constituted 81% of csDMARD initiations. The most commonly prescribed bDMARDs were etanercept and adalimumab (49% vs. 34%, respectively).
When the researchers evaluated 12-month follow-up data after the first DMARD initiation, they found that 20% of bDMARD initiators had their initial DMARD regimen modified, compared with 31% of csDMARD initiators. Treatment modifications occurred more quickly after starting a csDMARD (median of 102 days) when compared against bDMARD initiators (148 days), and the rate of modification was also higher for patients who first started a csDMARD (adjusted incidence rate of 39.3 cases per 100 patient-years vs. 21.1 cases per 100 person-years for bDMARDs).
The most common modification made by csDMARD initiators was the addition of a bDMARD to methotrexate, particularly etanercept or adalimumab, in 16%. For bDMARD initiators, the most common modification was adding methotrexate in 7%, followed by switches between etanercept and adalimumab in 6%.
“In a rapidly evolving field of PsA treatment, further studies that elucidate more comprehensive real-world trends in the use of available treatment, including more recent novel therapies for PsA, may be needed,” the researchers concluded.
There was no specific funding source for the study. The researchers reported having no financial disclosures relevant to the study.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point:
Major finding: 20% of bDMARD initiators had their initial DMARD regimen modified, compared with 31% of csDMARD initiators.
Data source: Data from a national claims database on 9,222 psoriatic arthritis patients who initiated DMARDs.
Disclosures: There was no specific funding source for the study. The researchers reported having no financial disclosures relevant to the study.
Why you should use sunscreens indoors
It may be surprising that there are dermatologic risks of UV exposure from lamps and other indoor light sources that we use daily. Is long-term daily exposure to presumably low-irradiance lights of clinical significance to photodermatoses? Recent findings suggest that skin protection must be practiced indoors to adequately protect the skin against UV rays.
Photodermatoses, such as lupus, actinic prurigo, and xeroderma pigmentosum, are only a few of the skin diseases that are triggered by UV exposure; however, chronic low-dose exposures to UV light, such as those associated with indoor lighting, may also be triggers of such conditions. Melasma, for example, can be triggered by heat or UV light. Chronic exposure to ambient light may darken the skin, necessitating daily UV protection in both indoor and outdoor settings.
A study examining light sources in the environment of a child with xeroderma pigmentosum suggested that indoor lights emit unexpected amounts of UV light as measured by a spectral radiometer. This finding illustrated that cumulative, chronic doses of indoor lighting may be of clinical significance.
Interior lighting is also implicated in worsening of melasma and other photosensitive dermatoses. Incandescent bulbs have little to no UV irradiance. However, fluorescent lighting has been shown to increase lifetime UV exposure by 3% based on the distance the lamp is from the skin. If the lamp is close – particularly desk lamps, bed lamps, and overhead lamps – the light and heat emitted can worsen photoexacerbated dermatitidis. Avoiding close contact with the light or adding acrylic or plastic diffusers to the light can help reduce exposure.
Halogen bulbs are filled with an inert gas and a halogen, such as iodine. These bulbs are usually made of quartz because quartz is more resistant to the high heat emitted by these bulbs. But the quartz, however, does not block UV radiation, which is why manufacturers add UV-blocking agents and heat-resistant glass to block the UV; however, the amount blocked is usually unknown. As with fluorescent bulbs, the distance from the bulb is essential to protect against both the UV and heat emitted. Light-emitting diodes (LEDs) generate a light from a semiconductor material that converts blue light into white light with the use of phosphorus; LEDs do not emit UV rays and, therefore, are a safer light source for the skin.
In addition to the use of lamps, the light that passes through glass is easy to underestimate. Unlike UVB rays, UVA rays pass through glass and affect the skin. The percentage of UVA rays that pass through glass depends on the type of glass and the coating on the glass. There are three types of window glass: clear, reflective, and tinted. Clear glass allows 75% of UVA through,while reflective and tinted glass allow only 25%-50% of UVA rays to pass through. Low-emissivity glass (Low-E) is made to reduce heat transfer and is similar to clear glass. The most protective glass is laminated or UV-coated glass that filters out 95%-99% of all UVA rays. Unfortunately, most residential and commercial buildings do not have UVA protection. The use of blinds, shades, and tinted glass, and increasing the distance from windows and doors are the best methods of protection from chronic daily UVA exposures.
In most cars, windshield is made of laminated glass (two layers of glass with a layer of plastic in between), which blocks all UVB and approximately 50% of UVA rays. However, side and rear windows are often clear glass, which does not prevent UVA rays from penetrating through. Patients with photosensitive dermatoses and all melasma patients are encouraged to tint the side windows of their vehicles to reduce UVA exposures to 15%-30%. Tinting, however, must be in compliance with federally mandated standard of 70% minimum visible light transmittance. In my practice, daily UV protection is recommended for all patients, even within an automobile or in an office. Daily cumulative exposure can cause chronic skin damage and early signs of photoaging.
Other sources of indoor exposures include TV monitors, computers, tablets, and UV sterilization devices in the workplace. Older cathode ray tube screens emit UV radiation; however, newer liquid crystal display (LCD) or flat panel monitors most commonly on laptops, desktops, and mobile devices do not emit UV radiation. They do emit blue light – although a small fraction compared to that emitted by the sun. The amount of time spent in front of these screens and their proximity can pose a problem as blue light can increase reactive oxygen species, which is the most common contributor to premature aging. These devices also emit heat, which can exacerbate erythema ab igne and other heat-sensitive skin conditions.
The risks of indoor UV and blue light exposures are commonly overlooked. Skin protection with broad-spectrum sunscreen both inside and outside should be used daily for maximum protection. Care should also be taken to limit exposure times and increase distance of these objects from the skin and eyes.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
It may be surprising that there are dermatologic risks of UV exposure from lamps and other indoor light sources that we use daily. Is long-term daily exposure to presumably low-irradiance lights of clinical significance to photodermatoses? Recent findings suggest that skin protection must be practiced indoors to adequately protect the skin against UV rays.
Photodermatoses, such as lupus, actinic prurigo, and xeroderma pigmentosum, are only a few of the skin diseases that are triggered by UV exposure; however, chronic low-dose exposures to UV light, such as those associated with indoor lighting, may also be triggers of such conditions. Melasma, for example, can be triggered by heat or UV light. Chronic exposure to ambient light may darken the skin, necessitating daily UV protection in both indoor and outdoor settings.
A study examining light sources in the environment of a child with xeroderma pigmentosum suggested that indoor lights emit unexpected amounts of UV light as measured by a spectral radiometer. This finding illustrated that cumulative, chronic doses of indoor lighting may be of clinical significance.
Interior lighting is also implicated in worsening of melasma and other photosensitive dermatoses. Incandescent bulbs have little to no UV irradiance. However, fluorescent lighting has been shown to increase lifetime UV exposure by 3% based on the distance the lamp is from the skin. If the lamp is close – particularly desk lamps, bed lamps, and overhead lamps – the light and heat emitted can worsen photoexacerbated dermatitidis. Avoiding close contact with the light or adding acrylic or plastic diffusers to the light can help reduce exposure.
Halogen bulbs are filled with an inert gas and a halogen, such as iodine. These bulbs are usually made of quartz because quartz is more resistant to the high heat emitted by these bulbs. But the quartz, however, does not block UV radiation, which is why manufacturers add UV-blocking agents and heat-resistant glass to block the UV; however, the amount blocked is usually unknown. As with fluorescent bulbs, the distance from the bulb is essential to protect against both the UV and heat emitted. Light-emitting diodes (LEDs) generate a light from a semiconductor material that converts blue light into white light with the use of phosphorus; LEDs do not emit UV rays and, therefore, are a safer light source for the skin.
In addition to the use of lamps, the light that passes through glass is easy to underestimate. Unlike UVB rays, UVA rays pass through glass and affect the skin. The percentage of UVA rays that pass through glass depends on the type of glass and the coating on the glass. There are three types of window glass: clear, reflective, and tinted. Clear glass allows 75% of UVA through,while reflective and tinted glass allow only 25%-50% of UVA rays to pass through. Low-emissivity glass (Low-E) is made to reduce heat transfer and is similar to clear glass. The most protective glass is laminated or UV-coated glass that filters out 95%-99% of all UVA rays. Unfortunately, most residential and commercial buildings do not have UVA protection. The use of blinds, shades, and tinted glass, and increasing the distance from windows and doors are the best methods of protection from chronic daily UVA exposures.
In most cars, windshield is made of laminated glass (two layers of glass with a layer of plastic in between), which blocks all UVB and approximately 50% of UVA rays. However, side and rear windows are often clear glass, which does not prevent UVA rays from penetrating through. Patients with photosensitive dermatoses and all melasma patients are encouraged to tint the side windows of their vehicles to reduce UVA exposures to 15%-30%. Tinting, however, must be in compliance with federally mandated standard of 70% minimum visible light transmittance. In my practice, daily UV protection is recommended for all patients, even within an automobile or in an office. Daily cumulative exposure can cause chronic skin damage and early signs of photoaging.
Other sources of indoor exposures include TV monitors, computers, tablets, and UV sterilization devices in the workplace. Older cathode ray tube screens emit UV radiation; however, newer liquid crystal display (LCD) or flat panel monitors most commonly on laptops, desktops, and mobile devices do not emit UV radiation. They do emit blue light – although a small fraction compared to that emitted by the sun. The amount of time spent in front of these screens and their proximity can pose a problem as blue light can increase reactive oxygen species, which is the most common contributor to premature aging. These devices also emit heat, which can exacerbate erythema ab igne and other heat-sensitive skin conditions.
The risks of indoor UV and blue light exposures are commonly overlooked. Skin protection with broad-spectrum sunscreen both inside and outside should be used daily for maximum protection. Care should also be taken to limit exposure times and increase distance of these objects from the skin and eyes.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
It may be surprising that there are dermatologic risks of UV exposure from lamps and other indoor light sources that we use daily. Is long-term daily exposure to presumably low-irradiance lights of clinical significance to photodermatoses? Recent findings suggest that skin protection must be practiced indoors to adequately protect the skin against UV rays.
Photodermatoses, such as lupus, actinic prurigo, and xeroderma pigmentosum, are only a few of the skin diseases that are triggered by UV exposure; however, chronic low-dose exposures to UV light, such as those associated with indoor lighting, may also be triggers of such conditions. Melasma, for example, can be triggered by heat or UV light. Chronic exposure to ambient light may darken the skin, necessitating daily UV protection in both indoor and outdoor settings.
A study examining light sources in the environment of a child with xeroderma pigmentosum suggested that indoor lights emit unexpected amounts of UV light as measured by a spectral radiometer. This finding illustrated that cumulative, chronic doses of indoor lighting may be of clinical significance.
Interior lighting is also implicated in worsening of melasma and other photosensitive dermatoses. Incandescent bulbs have little to no UV irradiance. However, fluorescent lighting has been shown to increase lifetime UV exposure by 3% based on the distance the lamp is from the skin. If the lamp is close – particularly desk lamps, bed lamps, and overhead lamps – the light and heat emitted can worsen photoexacerbated dermatitidis. Avoiding close contact with the light or adding acrylic or plastic diffusers to the light can help reduce exposure.
Halogen bulbs are filled with an inert gas and a halogen, such as iodine. These bulbs are usually made of quartz because quartz is more resistant to the high heat emitted by these bulbs. But the quartz, however, does not block UV radiation, which is why manufacturers add UV-blocking agents and heat-resistant glass to block the UV; however, the amount blocked is usually unknown. As with fluorescent bulbs, the distance from the bulb is essential to protect against both the UV and heat emitted. Light-emitting diodes (LEDs) generate a light from a semiconductor material that converts blue light into white light with the use of phosphorus; LEDs do not emit UV rays and, therefore, are a safer light source for the skin.
In addition to the use of lamps, the light that passes through glass is easy to underestimate. Unlike UVB rays, UVA rays pass through glass and affect the skin. The percentage of UVA rays that pass through glass depends on the type of glass and the coating on the glass. There are three types of window glass: clear, reflective, and tinted. Clear glass allows 75% of UVA through,while reflective and tinted glass allow only 25%-50% of UVA rays to pass through. Low-emissivity glass (Low-E) is made to reduce heat transfer and is similar to clear glass. The most protective glass is laminated or UV-coated glass that filters out 95%-99% of all UVA rays. Unfortunately, most residential and commercial buildings do not have UVA protection. The use of blinds, shades, and tinted glass, and increasing the distance from windows and doors are the best methods of protection from chronic daily UVA exposures.
In most cars, windshield is made of laminated glass (two layers of glass with a layer of plastic in between), which blocks all UVB and approximately 50% of UVA rays. However, side and rear windows are often clear glass, which does not prevent UVA rays from penetrating through. Patients with photosensitive dermatoses and all melasma patients are encouraged to tint the side windows of their vehicles to reduce UVA exposures to 15%-30%. Tinting, however, must be in compliance with federally mandated standard of 70% minimum visible light transmittance. In my practice, daily UV protection is recommended for all patients, even within an automobile or in an office. Daily cumulative exposure can cause chronic skin damage and early signs of photoaging.
Other sources of indoor exposures include TV monitors, computers, tablets, and UV sterilization devices in the workplace. Older cathode ray tube screens emit UV radiation; however, newer liquid crystal display (LCD) or flat panel monitors most commonly on laptops, desktops, and mobile devices do not emit UV radiation. They do emit blue light – although a small fraction compared to that emitted by the sun. The amount of time spent in front of these screens and their proximity can pose a problem as blue light can increase reactive oxygen species, which is the most common contributor to premature aging. These devices also emit heat, which can exacerbate erythema ab igne and other heat-sensitive skin conditions.
The risks of indoor UV and blue light exposures are commonly overlooked. Skin protection with broad-spectrum sunscreen both inside and outside should be used daily for maximum protection. Care should also be taken to limit exposure times and increase distance of these objects from the skin and eyes.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Potential pitfalls of social media
Cassandra presents to the office anxious because of social media posts her peers have made regarding current events that she feels are inflammatory.
Jenna expresses suicidal thoughts in response to comments made by peers from several schools in the area about the nature of her friendship with a boy.
Social media was developed to increase connections between people, even despite geographic distances. It has helped create communities of people with similar interests or beliefs, as well as to help reconnect us with people. It can provide educational opportunities and enhance technical skills. These are all potential benefits, but risks exist as well.
Cyberbullying and harassment
Cyberbullying is defined as “willful and repeated harm inflicted through the use of computers, cell phones, or other electronic devices,” and can include sending denigrating messages or images.3 Studies have shown varying rates of victimization from cyberbullying, ranging from 6% to 72%, and perpetration ranging from 3% to 44%.4 Bullying in general has been associated with increased school drop-out rates, suicidal ideation, bringing weapons to school, and aggression. The sizable audience that social media can reach can amplify bullying’s impact.
Privacy concerns
Determining the appropriate amount of information to share and knowing that it is truly being shared with the person identified on the other end also can be a challenge. In addition, the digital footprint left by navigating different social media sites may have unforeseen effects on youth regarding inappropriate posts. They also may be particularly vulnerable to other predatory individuals. Other privacy concerns involve what information parents, guardians, or other family members may share online.
Addiction
While social media has the possible benefit of creating a broader social network, particularly for someone who may be anxious in more traditional settings, it also can reinforce isolation from “real-world” experiences and the sense that no one else “gets” him or her. Without knowing who is on the other end of the keyboard, tablet, or smartphone, it can be difficult to ascertain if others in the community are reinforcing maladaptive behaviors and further withdrawal.
Self esteem
Images promulgated online often are highly idealized and edited, and are meant to exhibit a specific point of view. Exposure to these images can have a negative impact on self-esteem.
Another study of preteen girls (10- to 12-year-olds) indicated that increased time spent on social media sites such as MySpace and Facebook led to greater internalization of a thin ideal, increased body image concerns, and decreased self-esteem.5 Further data suggest that youth who are in need of more mental health support may engage in increased amounts of social media use. In a Canadian study, daily use of more than 2 hours per day was associated with increased reports of emotional distress as well as suicidal ideation.6
So, given all of this information, how to address this in an appointment?
Dr. Strange is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and University of Vermont Robert Larner College of Medicine, both in Burlington. She works with children and adolescents. She has no relevant financial disclosures.
Resources:
1. The Kaiser Family Foundation: Generation M2: Media in the Lives of 8- to 18-Year-Olds
2. The Pew Research Center: Internet & Technology, “Teens, Social Media and Technology Overview 2015.”
3. The Cyberbullying Research Center. Cyberbullying Fact Sheet 2009.
4. Cyberbullying: An Update and Synthesis of the Research, in “Cyberbullying Prevention and Response: Expert Perspectives,” (New York: Routledge, 2012, pp. 13-35).
5. J. Early Adolesc. 2014. Vol 34(5) 606-20.
6. Cyberpsychol Behav Soc Netw. 2015 Jul;18(7):380-5.
Cassandra presents to the office anxious because of social media posts her peers have made regarding current events that she feels are inflammatory.
Jenna expresses suicidal thoughts in response to comments made by peers from several schools in the area about the nature of her friendship with a boy.
Social media was developed to increase connections between people, even despite geographic distances. It has helped create communities of people with similar interests or beliefs, as well as to help reconnect us with people. It can provide educational opportunities and enhance technical skills. These are all potential benefits, but risks exist as well.
Cyberbullying and harassment
Cyberbullying is defined as “willful and repeated harm inflicted through the use of computers, cell phones, or other electronic devices,” and can include sending denigrating messages or images.3 Studies have shown varying rates of victimization from cyberbullying, ranging from 6% to 72%, and perpetration ranging from 3% to 44%.4 Bullying in general has been associated with increased school drop-out rates, suicidal ideation, bringing weapons to school, and aggression. The sizable audience that social media can reach can amplify bullying’s impact.
Privacy concerns
Determining the appropriate amount of information to share and knowing that it is truly being shared with the person identified on the other end also can be a challenge. In addition, the digital footprint left by navigating different social media sites may have unforeseen effects on youth regarding inappropriate posts. They also may be particularly vulnerable to other predatory individuals. Other privacy concerns involve what information parents, guardians, or other family members may share online.
Addiction
While social media has the possible benefit of creating a broader social network, particularly for someone who may be anxious in more traditional settings, it also can reinforce isolation from “real-world” experiences and the sense that no one else “gets” him or her. Without knowing who is on the other end of the keyboard, tablet, or smartphone, it can be difficult to ascertain if others in the community are reinforcing maladaptive behaviors and further withdrawal.
Self esteem
Images promulgated online often are highly idealized and edited, and are meant to exhibit a specific point of view. Exposure to these images can have a negative impact on self-esteem.
Another study of preteen girls (10- to 12-year-olds) indicated that increased time spent on social media sites such as MySpace and Facebook led to greater internalization of a thin ideal, increased body image concerns, and decreased self-esteem.5 Further data suggest that youth who are in need of more mental health support may engage in increased amounts of social media use. In a Canadian study, daily use of more than 2 hours per day was associated with increased reports of emotional distress as well as suicidal ideation.6
So, given all of this information, how to address this in an appointment?
Dr. Strange is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and University of Vermont Robert Larner College of Medicine, both in Burlington. She works with children and adolescents. She has no relevant financial disclosures.
Resources:
1. The Kaiser Family Foundation: Generation M2: Media in the Lives of 8- to 18-Year-Olds
2. The Pew Research Center: Internet & Technology, “Teens, Social Media and Technology Overview 2015.”
3. The Cyberbullying Research Center. Cyberbullying Fact Sheet 2009.
4. Cyberbullying: An Update and Synthesis of the Research, in “Cyberbullying Prevention and Response: Expert Perspectives,” (New York: Routledge, 2012, pp. 13-35).
5. J. Early Adolesc. 2014. Vol 34(5) 606-20.
6. Cyberpsychol Behav Soc Netw. 2015 Jul;18(7):380-5.
Cassandra presents to the office anxious because of social media posts her peers have made regarding current events that she feels are inflammatory.
Jenna expresses suicidal thoughts in response to comments made by peers from several schools in the area about the nature of her friendship with a boy.
Social media was developed to increase connections between people, even despite geographic distances. It has helped create communities of people with similar interests or beliefs, as well as to help reconnect us with people. It can provide educational opportunities and enhance technical skills. These are all potential benefits, but risks exist as well.
Cyberbullying and harassment
Cyberbullying is defined as “willful and repeated harm inflicted through the use of computers, cell phones, or other electronic devices,” and can include sending denigrating messages or images.3 Studies have shown varying rates of victimization from cyberbullying, ranging from 6% to 72%, and perpetration ranging from 3% to 44%.4 Bullying in general has been associated with increased school drop-out rates, suicidal ideation, bringing weapons to school, and aggression. The sizable audience that social media can reach can amplify bullying’s impact.
Privacy concerns
Determining the appropriate amount of information to share and knowing that it is truly being shared with the person identified on the other end also can be a challenge. In addition, the digital footprint left by navigating different social media sites may have unforeseen effects on youth regarding inappropriate posts. They also may be particularly vulnerable to other predatory individuals. Other privacy concerns involve what information parents, guardians, or other family members may share online.
Addiction
While social media has the possible benefit of creating a broader social network, particularly for someone who may be anxious in more traditional settings, it also can reinforce isolation from “real-world” experiences and the sense that no one else “gets” him or her. Without knowing who is on the other end of the keyboard, tablet, or smartphone, it can be difficult to ascertain if others in the community are reinforcing maladaptive behaviors and further withdrawal.
Self esteem
Images promulgated online often are highly idealized and edited, and are meant to exhibit a specific point of view. Exposure to these images can have a negative impact on self-esteem.
Another study of preteen girls (10- to 12-year-olds) indicated that increased time spent on social media sites such as MySpace and Facebook led to greater internalization of a thin ideal, increased body image concerns, and decreased self-esteem.5 Further data suggest that youth who are in need of more mental health support may engage in increased amounts of social media use. In a Canadian study, daily use of more than 2 hours per day was associated with increased reports of emotional distress as well as suicidal ideation.6
So, given all of this information, how to address this in an appointment?
Dr. Strange is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and University of Vermont Robert Larner College of Medicine, both in Burlington. She works with children and adolescents. She has no relevant financial disclosures.
Resources:
1. The Kaiser Family Foundation: Generation M2: Media in the Lives of 8- to 18-Year-Olds
2. The Pew Research Center: Internet & Technology, “Teens, Social Media and Technology Overview 2015.”
3. The Cyberbullying Research Center. Cyberbullying Fact Sheet 2009.
4. Cyberbullying: An Update and Synthesis of the Research, in “Cyberbullying Prevention and Response: Expert Perspectives,” (New York: Routledge, 2012, pp. 13-35).
5. J. Early Adolesc. 2014. Vol 34(5) 606-20.
6. Cyberpsychol Behav Soc Netw. 2015 Jul;18(7):380-5.
Mindfulness and child health
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, PhD, learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some deep breaths, and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, PhD, learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some deep breaths, and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, PhD, learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some deep breaths, and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Physicians shift on support of single-payer system
, according to a recent survey by physician recruiting firm Merritt Hawkins.
A single-payer system was “strongly supported” by 42% and “somewhat supported” by 14% of the 1,033 physicians who responded to the email survey, which was sent out on Aug. 3. Compared with the 41% who expressed opposition to a single payer – 35% “strongly opposed” and 6% “somewhat opposed” – the total of 56% supporting it was more than enough to cover the margin of error of ±3.1%. The remaining 3% of physicians said that they neither support nor oppose a single-payer system, Merritt Hawkins reported.
In a survey the company conducted in 2008, just 42% of physicians supported a single-payer system and 58% opposed it. “Physicians appear to have evolved on single payer,” Travis Singleton, senior vice president of Merritt Hawkins, said in a statement. “Whether they are enthusiastic about it, are merely resigned to it, or are just seeking clarity, single payer is a concept many physicians appear to be embracing.”
, according to a recent survey by physician recruiting firm Merritt Hawkins.
A single-payer system was “strongly supported” by 42% and “somewhat supported” by 14% of the 1,033 physicians who responded to the email survey, which was sent out on Aug. 3. Compared with the 41% who expressed opposition to a single payer – 35% “strongly opposed” and 6% “somewhat opposed” – the total of 56% supporting it was more than enough to cover the margin of error of ±3.1%. The remaining 3% of physicians said that they neither support nor oppose a single-payer system, Merritt Hawkins reported.
In a survey the company conducted in 2008, just 42% of physicians supported a single-payer system and 58% opposed it. “Physicians appear to have evolved on single payer,” Travis Singleton, senior vice president of Merritt Hawkins, said in a statement. “Whether they are enthusiastic about it, are merely resigned to it, or are just seeking clarity, single payer is a concept many physicians appear to be embracing.”
, according to a recent survey by physician recruiting firm Merritt Hawkins.
A single-payer system was “strongly supported” by 42% and “somewhat supported” by 14% of the 1,033 physicians who responded to the email survey, which was sent out on Aug. 3. Compared with the 41% who expressed opposition to a single payer – 35% “strongly opposed” and 6% “somewhat opposed” – the total of 56% supporting it was more than enough to cover the margin of error of ±3.1%. The remaining 3% of physicians said that they neither support nor oppose a single-payer system, Merritt Hawkins reported.
In a survey the company conducted in 2008, just 42% of physicians supported a single-payer system and 58% opposed it. “Physicians appear to have evolved on single payer,” Travis Singleton, senior vice president of Merritt Hawkins, said in a statement. “Whether they are enthusiastic about it, are merely resigned to it, or are just seeking clarity, single payer is a concept many physicians appear to be embracing.”
QI enthusiast to QI leader: Luci Leykum, MD
Editor’s Note: This ongoing series highlights the professional pathways of quality improvement leaders. This month features the story of Luci Leykum, MD, division chief, general and hospital medicine at the University of Texas Health Science Center, San Antonio.
Luci Leykum, MD, MBA, MSc, FACP, SFHM, became familiar with inpatient medicine at age 9 years, when her grandfather contracted non-AB hepatitis from a postoperative blood transfusion. In the ensuing years, Dr. Leykum visited her grandfather during his frequent hospitalizations, keeping a close watch on the physicians charged with his care.
“It was when HIV and what we now think is hep C were just emerging, and there was a lot to figure out,” Dr. Leykum recalled of these formative experiences. Her interests in problem-solving, human relationships, and physiology led to enrollment years later as a medical student at Columbia University’s College of Physicians and Surgeons, where her keen observation skills led to a life-changing, “how did we get here?” moment.
Shortly before Dr. Leykum entered residency in 1999, New York Hospital and Columbia Presbyterian Hospital announced that they were merging. The timing was ideal for someone with Dr. Leykum’s acumen in business and medicine, and, as a resident, she began working with the chief medical officer for quality at the new, combined health system to identify quality improvement opportunities.
From there, the projects began pouring in: tracking phone hold times for residents; updating policies to reduce staff exposure to blood-borne pathogens and other infectious diseases; and monitoring flow through the hospitalization process. “In the progression of a few years, I was able to see important aspects of how the system came together,” said Dr. Leykum, “and how decisions were made around standards and metrics for the system as a whole and for its multiple individual hospital facilities.”
In 2004, two years out of residency, Dr. Leykum relocated to San Antonio to accept a clinician investigator position with the South Texas Veterans Health Care System/University of Texas Health Science Center San Antonio (UTHSCSA). Research, she said, has allowed her to delve deeper into the underlying mechanisms that impact systems of health care. She sees the complementary sides of quality improvement and research.
“Through our quality improvement initiatives, we can evaluate and improve specific aspects of care, in specific contexts or systems,” Dr. Leykum explained. “In our research projects, we look for new insights that can be more broadly applied across contexts. With funding, you are able to look at things with a scope, depth, or time horizon beyond what you typically have with a QI project.”
Since joining the UTHSCSA/VA system, Dr. Leykum has participated in more than 15 externally funded studies, 6 as principal investigator. She joined SHM’s research committee in 2009, serving as chair for 6 years, and is currently working with the committee to implement the Improving Hospital Outcomes through Patient Engagement (i-HOPE) Study.
I-HOPE, funded through the Patient-Centered Outcomes Research Institute, is a project to develop a patient- and stakeholder-partnered research agenda to improve the care of hospitalized patients. Dr. Leykum is also involved in implementing a collaborative care model at University Health System, a patient-partnered, interprofessional model that “focuses on improving interconnections, relationships, and sense making,” in the hospital system, she explained. “It was motivated strongly by our desire to improve our partnerships with patients and other providers in the hospital as a strategy to improve care.”
In addition to the many professional responsibilities she manages as division chief of general and hospital medicine at UTHSCSA – a position she has held for hospital medicine since 2006 and for the combined division since 2016 – Dr. Leykum continues to play an integral role in multiple academic and research initiatives for SHM.
She encourages anyone considering a concentration in QI and research to seek opportunities to actively learn these skills and, more importantly, let other people know their interests.
“The value of talking with colleagues at other places is so high,” she said. “When you actively reach out, you find that most people are happy to share their knowledge. Networking is one of the best parts of the SHM annual meeting – there’s an energy and excitement in learning about what others are doing. Wander into the poster and special interest sessions and see what people are working on, get email addresses, and participate on committees.”
Editor’s Note: This ongoing series highlights the professional pathways of quality improvement leaders. This month features the story of Luci Leykum, MD, division chief, general and hospital medicine at the University of Texas Health Science Center, San Antonio.
Luci Leykum, MD, MBA, MSc, FACP, SFHM, became familiar with inpatient medicine at age 9 years, when her grandfather contracted non-AB hepatitis from a postoperative blood transfusion. In the ensuing years, Dr. Leykum visited her grandfather during his frequent hospitalizations, keeping a close watch on the physicians charged with his care.
“It was when HIV and what we now think is hep C were just emerging, and there was a lot to figure out,” Dr. Leykum recalled of these formative experiences. Her interests in problem-solving, human relationships, and physiology led to enrollment years later as a medical student at Columbia University’s College of Physicians and Surgeons, where her keen observation skills led to a life-changing, “how did we get here?” moment.
Shortly before Dr. Leykum entered residency in 1999, New York Hospital and Columbia Presbyterian Hospital announced that they were merging. The timing was ideal for someone with Dr. Leykum’s acumen in business and medicine, and, as a resident, she began working with the chief medical officer for quality at the new, combined health system to identify quality improvement opportunities.
From there, the projects began pouring in: tracking phone hold times for residents; updating policies to reduce staff exposure to blood-borne pathogens and other infectious diseases; and monitoring flow through the hospitalization process. “In the progression of a few years, I was able to see important aspects of how the system came together,” said Dr. Leykum, “and how decisions were made around standards and metrics for the system as a whole and for its multiple individual hospital facilities.”
In 2004, two years out of residency, Dr. Leykum relocated to San Antonio to accept a clinician investigator position with the South Texas Veterans Health Care System/University of Texas Health Science Center San Antonio (UTHSCSA). Research, she said, has allowed her to delve deeper into the underlying mechanisms that impact systems of health care. She sees the complementary sides of quality improvement and research.
“Through our quality improvement initiatives, we can evaluate and improve specific aspects of care, in specific contexts or systems,” Dr. Leykum explained. “In our research projects, we look for new insights that can be more broadly applied across contexts. With funding, you are able to look at things with a scope, depth, or time horizon beyond what you typically have with a QI project.”
Since joining the UTHSCSA/VA system, Dr. Leykum has participated in more than 15 externally funded studies, 6 as principal investigator. She joined SHM’s research committee in 2009, serving as chair for 6 years, and is currently working with the committee to implement the Improving Hospital Outcomes through Patient Engagement (i-HOPE) Study.
I-HOPE, funded through the Patient-Centered Outcomes Research Institute, is a project to develop a patient- and stakeholder-partnered research agenda to improve the care of hospitalized patients. Dr. Leykum is also involved in implementing a collaborative care model at University Health System, a patient-partnered, interprofessional model that “focuses on improving interconnections, relationships, and sense making,” in the hospital system, she explained. “It was motivated strongly by our desire to improve our partnerships with patients and other providers in the hospital as a strategy to improve care.”
In addition to the many professional responsibilities she manages as division chief of general and hospital medicine at UTHSCSA – a position she has held for hospital medicine since 2006 and for the combined division since 2016 – Dr. Leykum continues to play an integral role in multiple academic and research initiatives for SHM.
She encourages anyone considering a concentration in QI and research to seek opportunities to actively learn these skills and, more importantly, let other people know their interests.
“The value of talking with colleagues at other places is so high,” she said. “When you actively reach out, you find that most people are happy to share their knowledge. Networking is one of the best parts of the SHM annual meeting – there’s an energy and excitement in learning about what others are doing. Wander into the poster and special interest sessions and see what people are working on, get email addresses, and participate on committees.”
Editor’s Note: This ongoing series highlights the professional pathways of quality improvement leaders. This month features the story of Luci Leykum, MD, division chief, general and hospital medicine at the University of Texas Health Science Center, San Antonio.
Luci Leykum, MD, MBA, MSc, FACP, SFHM, became familiar with inpatient medicine at age 9 years, when her grandfather contracted non-AB hepatitis from a postoperative blood transfusion. In the ensuing years, Dr. Leykum visited her grandfather during his frequent hospitalizations, keeping a close watch on the physicians charged with his care.
“It was when HIV and what we now think is hep C were just emerging, and there was a lot to figure out,” Dr. Leykum recalled of these formative experiences. Her interests in problem-solving, human relationships, and physiology led to enrollment years later as a medical student at Columbia University’s College of Physicians and Surgeons, where her keen observation skills led to a life-changing, “how did we get here?” moment.
Shortly before Dr. Leykum entered residency in 1999, New York Hospital and Columbia Presbyterian Hospital announced that they were merging. The timing was ideal for someone with Dr. Leykum’s acumen in business and medicine, and, as a resident, she began working with the chief medical officer for quality at the new, combined health system to identify quality improvement opportunities.
From there, the projects began pouring in: tracking phone hold times for residents; updating policies to reduce staff exposure to blood-borne pathogens and other infectious diseases; and monitoring flow through the hospitalization process. “In the progression of a few years, I was able to see important aspects of how the system came together,” said Dr. Leykum, “and how decisions were made around standards and metrics for the system as a whole and for its multiple individual hospital facilities.”
In 2004, two years out of residency, Dr. Leykum relocated to San Antonio to accept a clinician investigator position with the South Texas Veterans Health Care System/University of Texas Health Science Center San Antonio (UTHSCSA). Research, she said, has allowed her to delve deeper into the underlying mechanisms that impact systems of health care. She sees the complementary sides of quality improvement and research.
“Through our quality improvement initiatives, we can evaluate and improve specific aspects of care, in specific contexts or systems,” Dr. Leykum explained. “In our research projects, we look for new insights that can be more broadly applied across contexts. With funding, you are able to look at things with a scope, depth, or time horizon beyond what you typically have with a QI project.”
Since joining the UTHSCSA/VA system, Dr. Leykum has participated in more than 15 externally funded studies, 6 as principal investigator. She joined SHM’s research committee in 2009, serving as chair for 6 years, and is currently working with the committee to implement the Improving Hospital Outcomes through Patient Engagement (i-HOPE) Study.
I-HOPE, funded through the Patient-Centered Outcomes Research Institute, is a project to develop a patient- and stakeholder-partnered research agenda to improve the care of hospitalized patients. Dr. Leykum is also involved in implementing a collaborative care model at University Health System, a patient-partnered, interprofessional model that “focuses on improving interconnections, relationships, and sense making,” in the hospital system, she explained. “It was motivated strongly by our desire to improve our partnerships with patients and other providers in the hospital as a strategy to improve care.”
In addition to the many professional responsibilities she manages as division chief of general and hospital medicine at UTHSCSA – a position she has held for hospital medicine since 2006 and for the combined division since 2016 – Dr. Leykum continues to play an integral role in multiple academic and research initiatives for SHM.
She encourages anyone considering a concentration in QI and research to seek opportunities to actively learn these skills and, more importantly, let other people know their interests.
“The value of talking with colleagues at other places is so high,” she said. “When you actively reach out, you find that most people are happy to share their knowledge. Networking is one of the best parts of the SHM annual meeting – there’s an energy and excitement in learning about what others are doing. Wander into the poster and special interest sessions and see what people are working on, get email addresses, and participate on committees.”
The Search for Meaning After Surviving Cancer
Until now, research on meaning in cancer patients has focused mostly on patients with advanced cancer, who may be facing existential issues like the desire for hastened death. But as more people survive cancer, a sense of meaning is also an important issue for them, say researchers from VU University in Amsterdam. Those patients may be facing “fundamental uncertainties,” such as possible recurrence, long-term adverse effects of treatment, and physical, personal, and social losses. Helping them come to terms with those stressors can have benefits: higher psychological well-being, more successful adjustment, better quality of life.
Related: Social Interaction May Enhance Patient Survival After Chemotherapy
Noting the results of meaning-centered group psychotherapy (MCGP) for patients with advanced cancer, the researchers decided to compare MCGP with supportive group therapy (SGP) and usual care. Their study included 170 survivors who were diagnosed in the past 5 years, were treated with curative intent, and had completed their main treatment (surgery, radiotherapy, chemotherapy). Patients also had to have an expressed need for psychological care and at least 1 psychosocial condition, such as depressed mood, anxiety, or coping issues.
The researchers adapted the original MCGP intervention with different terminologies and topics more relevant for survivors (MCGP-CS [cancer survivors]). For instance, the topic “a good and meaningful death” was replaced by “carrying on in life despite limitations.” Topics included “The story of our life as a source of meaning: things we have done and want to do in the future.” The researchers also added mindfulness exercises to help patients with introspection.
Related: Women Living Longer With Metastatic Breast Cancer
The intervention consisted of 8 once-weekly sessions using didactics, group discussions, experimental exercises, and homework assignments. The SGP sessions, also 8 once-weekly meetings, did not pay specific attention to meaning. The psychotherapists leading the sessions, while maintaining an “unconditionally positive regard and empathetic understanding,” were trained to avoid group discussions on meaning-related topics. The primary outcome, measured before and after the intervention, then at 3 and 6 months, was personal meaning; secondary outcomes included psychological well-being, adjustment to cancer, optimism, and quality of life.
The researchers found “evidence for the efficacy of MCGP-CS to improve personal meaning among cancer survivors,” in both the short and longer terms. MCGP-CS participants scored significantly higher on goal-orientedness, psychological well-being, and adjustment to cancer. At 6 months, the intervention group also had lower scores for psychological distress and depressive symptoms.
Source:
van der Spek N, Vos J, van Uden-Kraan CF, et al. 2017;47(11):1990-2001.
doi: 10.1017/S0033291717000447.
Until now, research on meaning in cancer patients has focused mostly on patients with advanced cancer, who may be facing existential issues like the desire for hastened death. But as more people survive cancer, a sense of meaning is also an important issue for them, say researchers from VU University in Amsterdam. Those patients may be facing “fundamental uncertainties,” such as possible recurrence, long-term adverse effects of treatment, and physical, personal, and social losses. Helping them come to terms with those stressors can have benefits: higher psychological well-being, more successful adjustment, better quality of life.
Related: Social Interaction May Enhance Patient Survival After Chemotherapy
Noting the results of meaning-centered group psychotherapy (MCGP) for patients with advanced cancer, the researchers decided to compare MCGP with supportive group therapy (SGP) and usual care. Their study included 170 survivors who were diagnosed in the past 5 years, were treated with curative intent, and had completed their main treatment (surgery, radiotherapy, chemotherapy). Patients also had to have an expressed need for psychological care and at least 1 psychosocial condition, such as depressed mood, anxiety, or coping issues.
The researchers adapted the original MCGP intervention with different terminologies and topics more relevant for survivors (MCGP-CS [cancer survivors]). For instance, the topic “a good and meaningful death” was replaced by “carrying on in life despite limitations.” Topics included “The story of our life as a source of meaning: things we have done and want to do in the future.” The researchers also added mindfulness exercises to help patients with introspection.
Related: Women Living Longer With Metastatic Breast Cancer
The intervention consisted of 8 once-weekly sessions using didactics, group discussions, experimental exercises, and homework assignments. The SGP sessions, also 8 once-weekly meetings, did not pay specific attention to meaning. The psychotherapists leading the sessions, while maintaining an “unconditionally positive regard and empathetic understanding,” were trained to avoid group discussions on meaning-related topics. The primary outcome, measured before and after the intervention, then at 3 and 6 months, was personal meaning; secondary outcomes included psychological well-being, adjustment to cancer, optimism, and quality of life.
The researchers found “evidence for the efficacy of MCGP-CS to improve personal meaning among cancer survivors,” in both the short and longer terms. MCGP-CS participants scored significantly higher on goal-orientedness, psychological well-being, and adjustment to cancer. At 6 months, the intervention group also had lower scores for psychological distress and depressive symptoms.
Source:
van der Spek N, Vos J, van Uden-Kraan CF, et al. 2017;47(11):1990-2001.
doi: 10.1017/S0033291717000447.
Until now, research on meaning in cancer patients has focused mostly on patients with advanced cancer, who may be facing existential issues like the desire for hastened death. But as more people survive cancer, a sense of meaning is also an important issue for them, say researchers from VU University in Amsterdam. Those patients may be facing “fundamental uncertainties,” such as possible recurrence, long-term adverse effects of treatment, and physical, personal, and social losses. Helping them come to terms with those stressors can have benefits: higher psychological well-being, more successful adjustment, better quality of life.
Related: Social Interaction May Enhance Patient Survival After Chemotherapy
Noting the results of meaning-centered group psychotherapy (MCGP) for patients with advanced cancer, the researchers decided to compare MCGP with supportive group therapy (SGP) and usual care. Their study included 170 survivors who were diagnosed in the past 5 years, were treated with curative intent, and had completed their main treatment (surgery, radiotherapy, chemotherapy). Patients also had to have an expressed need for psychological care and at least 1 psychosocial condition, such as depressed mood, anxiety, or coping issues.
The researchers adapted the original MCGP intervention with different terminologies and topics more relevant for survivors (MCGP-CS [cancer survivors]). For instance, the topic “a good and meaningful death” was replaced by “carrying on in life despite limitations.” Topics included “The story of our life as a source of meaning: things we have done and want to do in the future.” The researchers also added mindfulness exercises to help patients with introspection.
Related: Women Living Longer With Metastatic Breast Cancer
The intervention consisted of 8 once-weekly sessions using didactics, group discussions, experimental exercises, and homework assignments. The SGP sessions, also 8 once-weekly meetings, did not pay specific attention to meaning. The psychotherapists leading the sessions, while maintaining an “unconditionally positive regard and empathetic understanding,” were trained to avoid group discussions on meaning-related topics. The primary outcome, measured before and after the intervention, then at 3 and 6 months, was personal meaning; secondary outcomes included psychological well-being, adjustment to cancer, optimism, and quality of life.
The researchers found “evidence for the efficacy of MCGP-CS to improve personal meaning among cancer survivors,” in both the short and longer terms. MCGP-CS participants scored significantly higher on goal-orientedness, psychological well-being, and adjustment to cancer. At 6 months, the intervention group also had lower scores for psychological distress and depressive symptoms.
Source:
van der Spek N, Vos J, van Uden-Kraan CF, et al. 2017;47(11):1990-2001.
doi: 10.1017/S0033291717000447.
Morning rituals
“How we spend our days is, of course, how we spend our lives.” – Annie Dillard
It’s 4:40 a.m. and I’ve got two items checked off my list. As I stir my coffee, made the same way each day, I’m engaged in my morning ritual. It begins at 4:30 a.m. and ends with me ready for whatever comes that day.
In our life-hacking world, morning rituals are hotter than my mug of Italian roast. Blog posts, magazine articles, podcasts, and books, such as the New York Times best-selling “Make Your Bed,” (New York: Hachette Book Group, 2017) written by a former Navy SEAL, all argue that the secret to a successful day, and life, lies in the start. But do morning rituals apply to us doctors?
Dr. William Osler, the father of modern medicine, had the answer a century ago: “The day [can] be predicted from the first waking hour. The start is everything,” he advised Yale medical students in his “Way of Life” address. “Live with day-tight compartments,” and focus on “what lies clearly at hand.” He encouraged them to develop focus so they might avoid “indecision and worry,” and fluster and flurry. Today, we call it “mindfulness,” so we might avoid “burnout.”
Dr. Osler, who read Ben Franklin, no doubt would have been familiar with Franklin’s recommendations: 5 a.m.: “Rise, wash, and address Powerful Goodness [prayer]! Contrive day’s business and take the resolution of the day; prosecute the present study, and breakfast.” Tested by over 200 years of self-help seekers, this is a good start. Through years of research and experimentation, I’ve refined this to the five morning activities that matter most:
2. Reflect on yesterday. Your brain is coming online in the few minutes after waking; while booting, review what happened yesterday. According to an article on-line in the Harvard Business Review (hbr.org), top CEOs make a habit of reviewing their actions and decisions to deconstruct both successes and failures. Replaying your day, like reviewing game film, is key to getting better.
3. Exercise. Physical activity improves memory, and cognition and aerobics are particularly effective. I vary both my activities and length of time in the gym. Ten minutes, if done all-out, might be all you need.
4. Preview and plan. In the excellent “How to Have a Good Day,” (New York: Penguin Random House, 2016) author Caroline Webb recommends an approach from three angles: “Aim, Attitude, and Attention.” Aim: What are the most important activities today? Who will you meet? What might you say to be successful? Attitude is key and often overlooked. Perhaps you have a patient you’d prefer not to see or a colleague with whom you need to have a difficult conversation. Reflect on how your attitude will impact the outcome. Lastly, attention must be paid. It’s as relevant today as when Dr. Osler recommended it. What must you focus on today to be successful?
5. Breathe deeply. Developing the habit of mindful breathing can help you become more resilient and focused. Spend 10-30 minutes breathing deeply and mindfully. You can take this time to pray as Franklin did or for priming as self-help guru Tony Robbins recommends today. Whichever you choose, be deliberate and consistent.
I’m invariably energized when I finish my morning routine. Even on my worst procrastination days, I have the satisfaction of getting at least five things done. Much of today will be out of my control: Patients will arrive late and surgeries might run over. But this morning was all mine. By faithfully carrying out this ritual I’m not only ready each day, I’m better each day.
What’s your morning ritual?
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
“How we spend our days is, of course, how we spend our lives.” – Annie Dillard
It’s 4:40 a.m. and I’ve got two items checked off my list. As I stir my coffee, made the same way each day, I’m engaged in my morning ritual. It begins at 4:30 a.m. and ends with me ready for whatever comes that day.
In our life-hacking world, morning rituals are hotter than my mug of Italian roast. Blog posts, magazine articles, podcasts, and books, such as the New York Times best-selling “Make Your Bed,” (New York: Hachette Book Group, 2017) written by a former Navy SEAL, all argue that the secret to a successful day, and life, lies in the start. But do morning rituals apply to us doctors?
Dr. William Osler, the father of modern medicine, had the answer a century ago: “The day [can] be predicted from the first waking hour. The start is everything,” he advised Yale medical students in his “Way of Life” address. “Live with day-tight compartments,” and focus on “what lies clearly at hand.” He encouraged them to develop focus so they might avoid “indecision and worry,” and fluster and flurry. Today, we call it “mindfulness,” so we might avoid “burnout.”
Dr. Osler, who read Ben Franklin, no doubt would have been familiar with Franklin’s recommendations: 5 a.m.: “Rise, wash, and address Powerful Goodness [prayer]! Contrive day’s business and take the resolution of the day; prosecute the present study, and breakfast.” Tested by over 200 years of self-help seekers, this is a good start. Through years of research and experimentation, I’ve refined this to the five morning activities that matter most:
2. Reflect on yesterday. Your brain is coming online in the few minutes after waking; while booting, review what happened yesterday. According to an article on-line in the Harvard Business Review (hbr.org), top CEOs make a habit of reviewing their actions and decisions to deconstruct both successes and failures. Replaying your day, like reviewing game film, is key to getting better.
3. Exercise. Physical activity improves memory, and cognition and aerobics are particularly effective. I vary both my activities and length of time in the gym. Ten minutes, if done all-out, might be all you need.
4. Preview and plan. In the excellent “How to Have a Good Day,” (New York: Penguin Random House, 2016) author Caroline Webb recommends an approach from three angles: “Aim, Attitude, and Attention.” Aim: What are the most important activities today? Who will you meet? What might you say to be successful? Attitude is key and often overlooked. Perhaps you have a patient you’d prefer not to see or a colleague with whom you need to have a difficult conversation. Reflect on how your attitude will impact the outcome. Lastly, attention must be paid. It’s as relevant today as when Dr. Osler recommended it. What must you focus on today to be successful?
5. Breathe deeply. Developing the habit of mindful breathing can help you become more resilient and focused. Spend 10-30 minutes breathing deeply and mindfully. You can take this time to pray as Franklin did or for priming as self-help guru Tony Robbins recommends today. Whichever you choose, be deliberate and consistent.
I’m invariably energized when I finish my morning routine. Even on my worst procrastination days, I have the satisfaction of getting at least five things done. Much of today will be out of my control: Patients will arrive late and surgeries might run over. But this morning was all mine. By faithfully carrying out this ritual I’m not only ready each day, I’m better each day.
What’s your morning ritual?
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
“How we spend our days is, of course, how we spend our lives.” – Annie Dillard
It’s 4:40 a.m. and I’ve got two items checked off my list. As I stir my coffee, made the same way each day, I’m engaged in my morning ritual. It begins at 4:30 a.m. and ends with me ready for whatever comes that day.
In our life-hacking world, morning rituals are hotter than my mug of Italian roast. Blog posts, magazine articles, podcasts, and books, such as the New York Times best-selling “Make Your Bed,” (New York: Hachette Book Group, 2017) written by a former Navy SEAL, all argue that the secret to a successful day, and life, lies in the start. But do morning rituals apply to us doctors?
Dr. William Osler, the father of modern medicine, had the answer a century ago: “The day [can] be predicted from the first waking hour. The start is everything,” he advised Yale medical students in his “Way of Life” address. “Live with day-tight compartments,” and focus on “what lies clearly at hand.” He encouraged them to develop focus so they might avoid “indecision and worry,” and fluster and flurry. Today, we call it “mindfulness,” so we might avoid “burnout.”
Dr. Osler, who read Ben Franklin, no doubt would have been familiar with Franklin’s recommendations: 5 a.m.: “Rise, wash, and address Powerful Goodness [prayer]! Contrive day’s business and take the resolution of the day; prosecute the present study, and breakfast.” Tested by over 200 years of self-help seekers, this is a good start. Through years of research and experimentation, I’ve refined this to the five morning activities that matter most:
2. Reflect on yesterday. Your brain is coming online in the few minutes after waking; while booting, review what happened yesterday. According to an article on-line in the Harvard Business Review (hbr.org), top CEOs make a habit of reviewing their actions and decisions to deconstruct both successes and failures. Replaying your day, like reviewing game film, is key to getting better.
3. Exercise. Physical activity improves memory, and cognition and aerobics are particularly effective. I vary both my activities and length of time in the gym. Ten minutes, if done all-out, might be all you need.
4. Preview and plan. In the excellent “How to Have a Good Day,” (New York: Penguin Random House, 2016) author Caroline Webb recommends an approach from three angles: “Aim, Attitude, and Attention.” Aim: What are the most important activities today? Who will you meet? What might you say to be successful? Attitude is key and often overlooked. Perhaps you have a patient you’d prefer not to see or a colleague with whom you need to have a difficult conversation. Reflect on how your attitude will impact the outcome. Lastly, attention must be paid. It’s as relevant today as when Dr. Osler recommended it. What must you focus on today to be successful?
5. Breathe deeply. Developing the habit of mindful breathing can help you become more resilient and focused. Spend 10-30 minutes breathing deeply and mindfully. You can take this time to pray as Franklin did or for priming as self-help guru Tony Robbins recommends today. Whichever you choose, be deliberate and consistent.
I’m invariably energized when I finish my morning routine. Even on my worst procrastination days, I have the satisfaction of getting at least five things done. Much of today will be out of my control: Patients will arrive late and surgeries might run over. But this morning was all mine. By faithfully carrying out this ritual I’m not only ready each day, I’m better each day.
What’s your morning ritual?
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Nurse education boosts proper use of VTE prophylaxis
Online education programs for nurses can improve the administration of prophylaxis for venous thromboembolism (VTE), a new study suggests.
The research was spurred by a documented need to boost the administration of prescribed VTE prophylaxis in hospitalized patients.
Data had shown that patients’ refusal of VTE prophylaxis frequently resulted in nurses not administering the prescribed therapy.
The new research indicates that online education modules helped nurses communicate to patients the need for VTE prophylaxis and therefore improved rates of use.
“We teach in hopes of improving patient care, but there’s actually very little evidence that online professional education can have a measurable impact. Our results show that it does,” said Elliott Haut, MD, PhD, of The Johns Hopkins University School of Medicine in Baltimore, Maryland.
Dr Haut and his colleagues reported these results in PLOS ONE.
For this study, the researchers developed 2 online education modules about the importance of pharmacologic VTE prevention and tactics for better communicating its importance to patients.
One of the modules was “dynamic,” requiring nurses to select responses to clinical scenarios, such as how to respond to a patient who was refusing a prophylactic medication dose. The other module was “static,” involving a PowerPoint slide show with a traditional voice-over explaining the information.
The study included 933 permanently employed nurses on 21 medical or surgical floors at The Johns Hopkins Hospital.
Between April 1, 2014, and March 31, 2015, 445 nurses on 11 of the floors were randomized to the dynamic education arm of the study, and 488 nurses on 10 floors were enrolled in the static arm.
To track non-administration of VTE prophylaxis, the researchers retrieved data from the hospital’s electronic health record system. The team collected data for 1 year and divided it into 3 time periods: baseline, during the educational intervention, and post-education.
Over the entire study period, 214,478 doses of pharmacologic VTE prophylaxis were prescribed to patients on the 21 hospital floors.
After education, non-administration of prescribed VTE prophylaxis decreased from 12.4% to 11.1% (conditional odds ratio [cOR]=0.87, P=0.002).
Nurses who completed the dynamic education module saw a greater reduction in non-administration—from 10.8% to 9.2% (cOR=0.83)—than nurses who completed the static education module—14.5% to 13.5% (cOR=0.92). However, the difference between the study arms was not significant (P=0.26).
“Our study adds to evidence that the way something is taught to professionals has a great influence on whether they retain information and apply it,” said Brandyn Lau, of The Johns Hopkins University School of Medicine.
“Active learning seems to get better results than passive learning, showing that it’s not just what you teach, but also how you teach it.”
“Now that we’ve shown the modules can be effective in improving practice, we want to make [them] available to the more than 3 million nurses practicing in the US,” Dr Haut added. 
Online education programs for nurses can improve the administration of prophylaxis for venous thromboembolism (VTE), a new study suggests.
The research was spurred by a documented need to boost the administration of prescribed VTE prophylaxis in hospitalized patients.
Data had shown that patients’ refusal of VTE prophylaxis frequently resulted in nurses not administering the prescribed therapy.
The new research indicates that online education modules helped nurses communicate to patients the need for VTE prophylaxis and therefore improved rates of use.
“We teach in hopes of improving patient care, but there’s actually very little evidence that online professional education can have a measurable impact. Our results show that it does,” said Elliott Haut, MD, PhD, of The Johns Hopkins University School of Medicine in Baltimore, Maryland.
Dr Haut and his colleagues reported these results in PLOS ONE.
For this study, the researchers developed 2 online education modules about the importance of pharmacologic VTE prevention and tactics for better communicating its importance to patients.
One of the modules was “dynamic,” requiring nurses to select responses to clinical scenarios, such as how to respond to a patient who was refusing a prophylactic medication dose. The other module was “static,” involving a PowerPoint slide show with a traditional voice-over explaining the information.
The study included 933 permanently employed nurses on 21 medical or surgical floors at The Johns Hopkins Hospital.
Between April 1, 2014, and March 31, 2015, 445 nurses on 11 of the floors were randomized to the dynamic education arm of the study, and 488 nurses on 10 floors were enrolled in the static arm.
To track non-administration of VTE prophylaxis, the researchers retrieved data from the hospital’s electronic health record system. The team collected data for 1 year and divided it into 3 time periods: baseline, during the educational intervention, and post-education.
Over the entire study period, 214,478 doses of pharmacologic VTE prophylaxis were prescribed to patients on the 21 hospital floors.
After education, non-administration of prescribed VTE prophylaxis decreased from 12.4% to 11.1% (conditional odds ratio [cOR]=0.87, P=0.002).
Nurses who completed the dynamic education module saw a greater reduction in non-administration—from 10.8% to 9.2% (cOR=0.83)—than nurses who completed the static education module—14.5% to 13.5% (cOR=0.92). However, the difference between the study arms was not significant (P=0.26).
“Our study adds to evidence that the way something is taught to professionals has a great influence on whether they retain information and apply it,” said Brandyn Lau, of The Johns Hopkins University School of Medicine.
“Active learning seems to get better results than passive learning, showing that it’s not just what you teach, but also how you teach it.”
“Now that we’ve shown the modules can be effective in improving practice, we want to make [them] available to the more than 3 million nurses practicing in the US,” Dr Haut added.
Online education programs for nurses can improve the administration of prophylaxis for venous thromboembolism (VTE), a new study suggests.
The research was spurred by a documented need to boost the administration of prescribed VTE prophylaxis in hospitalized patients.
Data had shown that patients’ refusal of VTE prophylaxis frequently resulted in nurses not administering the prescribed therapy.
The new research indicates that online education modules helped nurses communicate to patients the need for VTE prophylaxis and therefore improved rates of use.
“We teach in hopes of improving patient care, but there’s actually very little evidence that online professional education can have a measurable impact. Our results show that it does,” said Elliott Haut, MD, PhD, of The Johns Hopkins University School of Medicine in Baltimore, Maryland.
Dr Haut and his colleagues reported these results in PLOS ONE.
For this study, the researchers developed 2 online education modules about the importance of pharmacologic VTE prevention and tactics for better communicating its importance to patients.
One of the modules was “dynamic,” requiring nurses to select responses to clinical scenarios, such as how to respond to a patient who was refusing a prophylactic medication dose. The other module was “static,” involving a PowerPoint slide show with a traditional voice-over explaining the information.
The study included 933 permanently employed nurses on 21 medical or surgical floors at The Johns Hopkins Hospital.
Between April 1, 2014, and March 31, 2015, 445 nurses on 11 of the floors were randomized to the dynamic education arm of the study, and 488 nurses on 10 floors were enrolled in the static arm.
To track non-administration of VTE prophylaxis, the researchers retrieved data from the hospital’s electronic health record system. The team collected data for 1 year and divided it into 3 time periods: baseline, during the educational intervention, and post-education.
Over the entire study period, 214,478 doses of pharmacologic VTE prophylaxis were prescribed to patients on the 21 hospital floors.
After education, non-administration of prescribed VTE prophylaxis decreased from 12.4% to 11.1% (conditional odds ratio [cOR]=0.87, P=0.002).
Nurses who completed the dynamic education module saw a greater reduction in non-administration—from 10.8% to 9.2% (cOR=0.83)—than nurses who completed the static education module—14.5% to 13.5% (cOR=0.92). However, the difference between the study arms was not significant (P=0.26).
“Our study adds to evidence that the way something is taught to professionals has a great influence on whether they retain information and apply it,” said Brandyn Lau, of The Johns Hopkins University School of Medicine.
“Active learning seems to get better results than passive learning, showing that it’s not just what you teach, but also how you teach it.”
“Now that we’ve shown the modules can be effective in improving practice, we want to make [them] available to the more than 3 million nurses practicing in the US,” Dr Haut added.