The companionship of animals has provided humans with a powerful healing bond for thousands of years. No wonder animal assisted therapy (AAT) has become a way to enhance an individual’s physical, social, emotional and spiritual well being. This emphasis on psychological, spiritual and physical healing distinguishes the use of animals in AAT from the use of service animals trained to perform specific tasks for a person with a disability, such as blindness, hearing loss and other impairments. But even in these more narrowly defined interactions, animals can have healing benefits far beyond the technical or mechanical help they provide for a person’s disability. Although dogs and horses are the most commonly used animals in therapy, other animals include cats, rabbits, birds, fish, gerbils, elephants, dolphins and lizards.

The relationship-centered nature of AAT provides an opportunity for both patient and animal to give and receive love and affection. This makes AAT well suited for care of veterans and their families who are struggling to cope with the effects of wartime military service. The American Humane Association (AHA) began its animal-assisted therapy program in 1945, using dogs to comfort and motivate injured World War II soldiers. The US military now uses AAT to treat post-traumatic stress disorder (PTSD) in returning soldiers from the wars in Iraq and Afghanistan. Research suggests that the physical and social interactions with animals increases the secretion of stress-relieving chemicals such as oxytocin, leading to reductions in soldiers’ symptoms from traumatic brain injuries, amputations and PTSD.

Having a parent deployed indefinitely to an active combat zone is one of the most stressful events in childhood. AHA now works with the National Military Family Association supporting camps for children of deployed military parents. By providing a calming presence and offering nonjudgmental, loving affection, therapy dogs can help children talk about the fear, anger and uncertainty they feel.

Most children are attracted to animals and can often express themselves better with them than with other children or adults, especially children who have experienced physical or mental neglect, abuse or trauma. I use a toy dog from my own childhood as a puppet to communicate with young children about emotionally charged issues. I ask them to bring one or more of their toy animals from home and we talk together, letting our toy animals do the talking. The results are heart-warming and often give me significant insights into the child’s feelings and relationships- insights that are often very different from the parents’ perspective.

Integrating animals into therapy can sometimes lead to results not attainable by conventional interventions alone. For this reason, doctors, hospitals and nursing homes find the calming effect of animals can help treat a wide range of clinical disorders, including high blood pressure, cerebral palsy, elevated cholesterol, depression, anxiety, attention deficit disorder, epilepsy and deafness.

Animals are used most often to help with emotional and stress-related problems. In this context, they are often referred to as comfort animals. Animals can help patients generate positive emotions, resolve feelings of loneliness, promote socialization, enhance trust, stimulate mental and social activity, improve overall well being and provide a distraction from stressful medical procedures and chemotherapy. Because animals are non-judgmental, people with physical deformities may find it easier to socialize with animals than with people.

AAT can include animals living with a patient or family, volunteers and therapists bringing animals into hospitals, nursing homes, schools and libraries as well as patients’ traveling to sites where the animals are maintained. Animals must be up to date on routine vaccinations and be in good health. To ensure safety, experienced therapists are required in therapy using large animals such as horses and dolphins.

To avoid causing harm, patients must be carefully assessed for potential risks of AAT, including fear of animals and severe mental health disorders. Known and unknown allergies may also require pre-medication and adjustments in type and duration of exposure to animals. Patients with immune suppression from HIV/AIDS, chemotherapy, radiation, high-dose steroids and other immune-suppressive medications must be cleared by their physician before participating in AAT.

AAT currently has no state or national certification. Individual hospitals, nursing homes, hospices and other institutions have their own rules regarding the therapeutic use of animals in their facilities. Organizations like Pet Partners offer courses to facilitate the training of animals and their human partners. The Pet Partners website lists courses and conferences around the country as well as the necessary qualifications to become an AAT instructor.

Resources-

American Humane Association http://www.americanhumane.org/interaction/programs/animal-assisted-therapy/

Pet Partners
http://www.petpartners.org

Aubrey Fine (ed), Handbook on Animal Assisted Therapy, 2010, Academic Press

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The presence of oral disease and dental disorders can cause stress from low self-image, which can have a negative effect on well-being and personal happiness. Stress, chronic anxiety and depression can lead to self-neglect, including neglect of dental hygiene. For many people, dental self-care is not a high priority. It is especially common for stressful economic times to be associated with lapses in the proper oral hygiene habits of regular brushing and flossing of teeth and professional dental exams. Turning to sugar-laden comfort foods for stress relief can also lead to dental caries (tooth decay).

Emotional disorders and stress at home or work can lead to the excess production of dental plaque, which in turn can lead to periodontal (gum) disease, leading to gingivitis and bleeding gums. A highly emotional response to financial hardship, in particular, has been shown to increase gum disease. Periodontal disease is the leading cause of tooth loss and Kentucky ranks first or second among the national leaders in tooth loss.  A healthy diet, regular brushing, flossing, anti-bacterial mouth rinses and regular dental evaluations can save teeth.

Stress can increase the frequency of canker sores. Also known as aphthous ulcers, these painful lesions are not contagious and occur inside the mouth. Students often have canker sores during their school year but fewer sores during holidays and over summer vacation. Cold sores, also called fever blisters are contagious, painful blisters around the lips, nose or chin caused by the herpes virus. Stress is a common trigger for these herpes-virus blisters. Though canker sores and cold sores resolve with or without medication, their resolution and their prevention can be helped by stress reduction.

Stress, worry, anxiety and anger can also lead to bruxism- clenching and grinding of the teeth during sleep or while awake. This grinding of the teeth can eventually lead to problems with the TMJ (temporomandibular joint). TMJ problems can cause popping or clicking of the jaw when opening the mouth or chewing. It can also cause facial pain or tenderness in the face, jaw joint, neck, shoulders, and around the ear during chewing, speaking, or opening the mouth. A custom-made dental bite guard may be required to prevent damage to the teeth and the TMJ from frequent grinding. Individuals may be unaware of their teeth grinding and jaw clenching. Signs include flattening of the tips of the teeth and dental sensitivity from loss of dental enamel.

There are many ways to help prevent stress from having an adverse impact on your dental health. You can probably find something on this short list that fits your lifestyle and personal preferences. To begin, try to reduce your exposure to the circumstances, patterns of thinking, habits, people or other sources of your stress. Deal thoughtfully, methodically and rationally with external stressors like financial hardship. Seek financial, emotional or pastoral counseling rather than self-medicating with drugs, alcohol and overconsumption of unhealthy foods. To reduce mental and emotional stress, connect more with your body through your preferred physical activity- walking, jogging, swimming, yoga or sports. Practice daily skilled relaxation, meditation or prayer. Spend some time each evening reading inspirational material that uplifts your spirits. Get a massage. Hug a loved one. Play with children and animals. Get out in nature. Do something for others who are less fortunate. Participate in social and community activities that reduce feelings of isolation and loneliness. Count your blessings.

Listed below are several resources that offer self-directed approaches to stress management. They do not take the place of professional help should your burden of stress feel overwhelming or get worse over time. Speak with your dental or medical provider for a professional stress management referral if your self-care strategies are not helping.

You dental health and your overall health may depend on how effectively you manage your stress.

Resources-
Dr. James Gordon, founder of the Center for Mind Body Medicine guides a ‘soft belly meditation’
http://vimeo.com/37976492

Zen master Thich Nhat Hanh’s ‘single pointed meditation’ is led by Peg Baim of the Benson-Henry Institute for Mind Body Medicine
http://www.youtube.com/watch?v=gAIYm6wpzw4

Stressed out? Your Dentist Can Tell
http://www.deltadentalins.com/oral_health/stressed_out.html

How stress affects your oral health
http://www.webmd.com/oral-health/healthy-teeth-2/stress-teeth 

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Our breath has the dual nature of being regulated by both voluntary and involuntary mechanisms. We really take the involuntary, automatic quality of the breath for granted. Thank goodness we don’t have to remember to breathe each breath. Breathing happens automatically while we are busy doing and thinking about other things, from physical activity to sleep. We usually think “I am breathing” but in a very real sense, we are being breathed by our own automatic, involuntary physiology. We can also exert voluntary control over the breath, allowing us to whistle, blow out birthday candles or stop a panic attack.

Our breath, thoughts and emotions are deeply interconnected. Calm and peaceful thoughts and emotions are usually reflected in calm, peaceful breathing. Agitation, anxiety, fear, worry and panic are sometimes associated with irregular, rapid or shallow breathing. This can develop into a full-blown ‘hyperventilation’ attack. Being helped to slow down one’s breathing and breathe more deeply and regularly not only returns the breathing to normal but also relieves some of the distressful thoughts and emotions that triggered the episode. The breath influences our thoughts and emotions. Our thoughts and emotions influence the breath.

Due to the interconnectedness of thoughts, emotions and breathing, we can intentionally and skillfully use the breath to cultivate calmness and peacefulness. No wonder that awareness of the breath is one of the world’s oldest forms of meditation and contemplative practice. Wherever we go, the breath is always with us. It is free. It doesn’t require special equipment to use the breath for meditation.

There are many ways in which the breath is used in meditation. A particularly relaxing and simple, meditative use of the breath is diaphragmatic breathing or abdominal breathing- also known as ‘soft belly’.  Most of us have little experience breathing with a soft abdomen as our society sends a message to both men and women that a big belly is undesirable. Yet a soft belly was our normal condition when we were babies and is also our normal condition as adults when we are calm, peaceful and rested.

Here’s how to practice ‘soft belly’ meditation-
Closing the eyes is recommended for more focused attention on the practice. You use less energy breathing in through the nose and out through the mouth. Breathing out through the mouth also seems to help soften the abdomen.

If the abdomen is soft, with each deep in-breath your lungs fill with air, your diaphragm moves down and your abdomen expands. With each out-breath, the lungs empty themselves of air, your diaphragm rises and your abdomen contracts. Breathing this way helps to more fully expand the lungs, mobilize the diaphragm and stimulate the vagus nerve, causing a shift of your nervous system from the stress-related, sympathetic, fight-or-flight mode to the restorative, parasympathetic mode. Not everyone can easily soften the abdomen. It can help to place your hands over your abdomen and notice the movements described here. Usually very quickly, the hands are no longer needed as an aide.

This practice improves expansion and oxygenation of the lungs and relaxes tense muscles all over your body. If you find it helpful, you might say to yourself “soft” as you breathe in and “belly” as you breathe out. When you find your attention distracted by thoughts, emotions, sounds or physical sensations, simply bring your attention back to the belly.

Even 1 minute of ‘soft belly’ breathing can help calm a busy mind. Devoting five or ten minutes without interruption helps develop skillful practice. Over time, you can extend the practice to suit your schedule and your needs, aiming for two or three times a day.
Traditionally, these practices are recommended for 15-20 minutes before the morning and evening meals. Using a timer with a very quiet alarm may help you manage your time. Practicing ‘soft belly’ at bedtime can help you fall asleep. With regular practice, you will have a new self care tool for use in times of stress- breathing in ‘soft’, breathing out ‘belly.’

Practiced regularly, ‘soft belly’ can help manage stress-related chronic disease symptoms, improve immune functioning, decrease pain and anxiety, improve mood, and cultivate a friendlier relationship with your thoughts and emotions. Techniques such as ‘soft belly’ meditation can help you see every aspect of your life more clearly and calmly and feel more in control. Practicing these techniques when you are not feeling overwhelmed can help you better master your physical, mental and emotional responses at difficult times.

Remember- to master any skill requires practice, practice, practice.

Resources-
The Relaxation and Stress Reduction Workbook by Davis, Eshelman, McKay

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Journal writing is a simple, inexpensive, convenient form of self-care. Research shows that emotionally expressive journal writing can lower high blood pressure, reduce arthritis pain, asthma severity and cancer pain, promote wound healing and enhance immune function in HIV/AIDS.

Journaling can also relieve the stress and emotional suffering of insomnia, anxiety, depression, grief, cancer survivorship, anger, loneliness, traumatic events, eating disorders and addiction to tobacco, drugs and alcohol.

Beyond its use in alleviating these forms of pain and suffering, journal writing can increase your sense of mental, emotional and spiritual well being, build resilience, enhance emotional intelligence, nurture creativity, improve communication and relationships, identify purpose, meaning, clarify deepest values and ignite a personal passion for your unique life path by cultivating acceptance, gratitude, happiness, forgiveness and compassion.

For instance, try writing down everything you are grateful for. Keep the list and add to it over several days. Over time, gratitude can be felt at surprisingly unexpected moments as you have learned to see the gratitude in the present, at the time it arises. The seeds of gratitude were always there. They take root, sprout and grow when they are watered, fertilized and cultivated by your attention.

Journal writing should not be considered a substitute for professional help when your level of distress is severe. Physical pain and emotional suffering may sometimes require professional help from medical or mental health providers or from trusted clergy or pastoral counselors. And like medication, even journal writing can have side effects. Writing only about the details of traumatic events could make you feel worse. If there is a question about your response to journaling, speak with a trusted medical, mental health or spiritual counselor.

Most people, however, experience journal writing as a positive and therapeutic experience. In fact, the remarkable thing about therapeutic journal writing is its ability to provide insight into life’s problems and reduction of physical pain and relief from mental, emotional and spiritual suffering, sometimes as effectively as prescribed medication and professional counseling.

Psychologist James W Pennebaker points out that it is often best not to write about one’s illness directly. He recommends starting by writing about a teacher or book that positively influenced your life. He also suggests writing a letter to yourself as a child to help mobilize self-nurturing feelings. The goal here is not the production of a written product but the interior experience that results from it. You may wish to save your writing but you can also destroy what you’ve written, since the emotional awareness of the act of writing was the goal, not the written product itself.

In Writing to Heal: A Guided Journal for Recovering from Trauma and Emotional Upheaval, Pennebaker suggests this simple exercise for anyone bothered by a stressful event or past turmoil. 1) Write for 20 minutes per day for four days 2) Write about a major conflict or stressor in your life, something personal and important 3) Write without stopping until you feel a good stopping point; don’t worry about spelling and grammar like you did in school 4) Write for your eyes only 5) If writing makes you feel worse- stop.
Notice how different this is from most diary entries or journaling.  The usual diary habit of recording the day’s events in a log-type manner would be very different from this emotional writing about stressful events.
Whether typing or handwriting, just start with a blank page and begin writing. You might try writing daily as a commitment to the practice or simply keep a journal handy and write as needed. Grief is a particularly unpredictable emotion, with waves coming and going without warning. Writing down and capturing these waves in the moment, as they occur, can be extremely helpful in grief recovery.
The goal is to identify your feelings and write them- cultivating your emotional intelligence. For ages, people have begun writing with ‘Dear Diary’, illustrating the relationship that may develop between you and your trusted journal.
Rachel Remen MD taught me the Heart Journal, or 3 Question Journal, which she learned from the work of Angeles Arrien. At bedtime each night, reflecting back on your day, ask yourself three questions- What surprised me today? What touched my heart today? What inspired me today? Write down your answers, or simply let them relax your body, quiet your mind and open your heart as you fall asleep.
When I journal like this regularly, my days become more alive with surprises and inspirations and moments that touch my heart.

Resources:

James W Pennebaker, Writing and Health- Some Practical Advice

http://homepage.psy.utexas.edu/homepage/faculty/pennebaker/Home2000/WritingandHealth.html

Rachel Remen, Keeping a Heart Journal

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High blood pressure (hypertension) is defined as a pressure equal to or greater than 140/90. It can lead to stroke, kidney failure and heart failure.  Pre-hypertension is defined as a pressure greater than or equal to 120/80 and may also increase the risk of developing serious disease.
Compared to the typical American diet, DASH (Dietary Approaches to Stop Hypertension) is lower in saturated fat, cholesterol, total fat, sweets, sugary beverages and red meats. It is higher in fruits, vegetables, fat-free or low-fat dairy products, whole grains, fish, poultry, beans, seeds, and nuts. Though the DASH Eating Plan is designed to treat or prevent hypertension, it also can help prevent or control obesity, diabetes, osteoporosis, cancer, heart disease and stroke.
Excessive dietary sodium raises blood pressure and reducing sodium intake can help lower high blood pressure. DASH encourages foods low in sodium (salt) and high in nutrients that lower blood pressure- especially potassium, calcium and magnesium. Since the DASH Eating Plan can begin lowering blood pressure in just two weeks, discuss the addition of DASH with your primary care provider, especially if you take medication for hypertension.
The typical American diet contains about 4,000 milligrams of sodium daily (about 1½ teaspoon of salt). Reducing daily sodium intake to 2,300 milligrams (about 1 teaspoon of salt) can lower blood pressure. Limiting daily sodium to only 1,500 milligrams (about 2/3 teaspoon) can lower blood pressure even further and is advised in people who already have hypertension, diabetes or chronic kidney disease as well as African Americans and middle-aged and older adults. Sodium intake can be reduced by using sodium-free spices or flavorings in place of salt, not adding salt when cooking rice, pasta or hot cereal, rinsing canned foods to remove added salt and buying foods labeled “no salt added,” “sodium-free” and “low sodium”.
DASH emphasizes whole grains, fruits, vegetables, low-fat dairy products, fish, nuts, seeds and legumes. Whole grains have more fiber and nutrients than refined grains. When choosing bread, cereal, rice and pasta, select whole wheat, brown rice, whole (‘old-fashioned’) oats and look for ‘whole grain’ on the label.
Many vegetables provide fiber, vitamins, and blood pressure-lowering minerals such as potassium and magnesium. Serve steamed or lightly stir-fried vegetables over brown rice or whole-wheat noodles. Many fruits provide fiber, potassium and magnesium. Have fruit as a snack between meals and as a dessert after your meal. I recommend stewed unsweetened fruit (prunes, apricots, apples, cranberries) as a sweet snack or dessert. Despite having no added sugars, stewed fruit is incredibly sweet and satisfying.
Dairy products are major sources of calcium. Choose dairy products that are low fat or fat-free. Add fruit to unsweetened yogurt for a healthier dessert. Fish, such as salmon, herring and tuna are high in heart-healthy omega-3 fatty acids and should be favored over beef, pork and other meats. Nuts, seeds and legumes are good sources of magnesium and potassium, as well as other healthy micronutrients. In particular, soybean products, such as tofu and tempeh, contain high quality protein suitable as a meat substitute.
     Compared to the 35-40 percent fat intake of the average American diet, the DASH Eating Plan limits total fat to 27 percent or less of daily calories, with a focus on the healthier monounsaturated rather than saturated fat. Monounsaturated oils include olive, canola, peanut, sunflower and sesame. DASH limits daily saturated fat to less than 6 percent of total calories by limiting use of meat, butter, cheese, whole milk, cream, eggs, lard, solid shortenings, and palm and coconut oils.
Weight loss can be a positive side benefit of the DASH Eating Plan, especially if you cut back on sugar with its ‘empty calories’- calories that are not accompanied by healthful nutrients. When you eat sweets, choose those that are fat-free or low-fat, such as sorbets, hard candy, graham crackers or low-fat cookies. Avoid the sugar of pop by limiting your beverages to water, low fat milk and unsweetened fruit juice diluted half and half with water. Combining the DASH Eating Plan with physical activity makes it more likely that you’ll reduce both your weight and your blood pressure.
Drinking too much alcohol can increase blood pressure. Although I never advise non-drinkers to begin drinking alcohol for their health, the DASH Eating Plan recommends that men limit alcohol to two or fewer drinks a day and women to one or less.
If you have hypertension, discuss the DASH Eating Plan with your provider and make food part of your treatment plan.

Resources-

NHLBI- What is the DASH Eating Plan?

http://www.nhlbi.nih.gov/health/health-topics/topics/dash
NHLBI- Flavor that food
http://www.nhlbi.nih.gov/hbp/prevent/sodium/flavor.htm Mayo Clinic- Sample menus for the DASH Eating Plan
http://www.mayoclinic.com/health/dash-diet/HI00046Mayo Clinic- DASH Diet: Healthy eating tot lower your blood pressure
http://www.mayoclinic.com/health/dash-diet/HI00047

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This classic mindfulness instruction is being shown by modern research to have many health benefits. Mindfulness meditation usually focuses on the breath, bodily posture, physical movement, thoughts and emotions. The goal is to enrich life by living in the only time we truly have- the present moment- rather than spending so much time, mentally and emotionally, in the past and future.

We often eat mindlessly, paying more attention to the television, movie, newspaper or conversation than to the life-sustaining act of eating. We use antacids and digestive aids to control symptoms created by unhealthy eating habits. But eating can also be a meditative practice- providing nourishment physically, mentally, emotionally, socially and spiritually. For adults and children, mindful eating can be a friendly introduction to meditative practice.

Mindful eating brings a 3-dimensional, meditative awareness to the preparation, serving and eating of your food. Looking deeply into the history of your food, you can see the sunshine, rain, topsoil, farmers, truckers, grocers and all those involved in bringing this food to your plate. Though religions honor this connection through mealtime prayers and thanksgiving, one does not have to be religious to appreciate this universal interdependence underlying our food supply.

Mindful eating can be your gateway to the practice of mindfulness in other daily activities. It can help you cultivate a deeper level of appreciation for life, bringing more joy to life and enhancing relationships with yourself, other people and the earth. When driving, cycling or walking on the road, your life may actually depend on how aware you are in the present moment. Mindful eating may help you travel life’s highway more safely.

Approaching a mindful meal as a mini-meditation retreat, you may begin to cultivate relaxation, joy, happiness and compassion simply from eating mindfully and meditatively.

Tips for mindful eating
-Mindful eating does not require meditative experience or a lot of time. “When eating, just eat”. Simply pay attention to eating and drinking. Begin with one meal a day for one bite, one minute, 5 minutes or the entire meal. Eventually it may become a habit at all meals.
-You can practice mindful, meditative eating alone, with others, at home or eating out.
-Begin by paying attention to your hunger and satiety levels. Eat only when you are hungry, not simply because it is ‘time’ to eat.
-As you sit with your plate, wait at least one mindful, grateful breath or one minute before beginning to eat or drink.
-Take only the amount of food that is good for you. If you are trying to control portion size, research suggests using a smaller plate.
-Appreciate the hard work and loving intention of all those involved in the life history of your food, noticing any compassion and loving connection that arises in you.
-Be aware of the nutritional quality of your food and how your food choices impact your health, the health of farm families and the environment.
-Be aware of the quality of life of farm animals.
-Holding some food between your fingers, notice its color, shape, texture and aroma.
-Raising the cup or utensil, be aware of movement of your hand and arm, appreciative of the body’s function and wisdom.
-Pause between sips and bites, setting down utensils and cup.
-Chew each mouthful slowly, aiding the digestive process.
-Notice while mindfully eating and drinking there is no room in your mouth for worry, fear, anxiety, depression or other distressing thoughts and emotions. If these arise in your mind, simply bring awareness back to sipping and chewing. If you persistently recognize emotions associated with your eating habits, it may be worthy of journaling, self reflection or discussion with a professional counselor.
-As you chew, notice changes in food texture, temperature and taste.
-Bring full awareness to each sip as you drink liquids.
-After swallowing, be aware of how far down your esophagus you can feel your food or drink.
-Enjoy each bite of food and the presence of friends eating with you.
-Remember your intention to be aware of eating in this present moment, avoiding memories of the past and plans for the future.
-Eating in silence can add a meditative dimension to your experience.
-Limit talking to pleasant, friendly conversation rather than emotionally charged topics.
-Yoga tradition advises remaining seated while eating.
-End your meal when you notice your hunger is gone.
-After your meal, notice the physical sensations of satiety and the gratitude that you have enough to eat.
My own life has benefited greatly from mindful eating. I wish the same for you.

Resources-
Thich Nhat Hanh’s Mindful Eating Meditation
http://deerparkmonastery.org/mindfulness-practice/eating-meditation
Savor: Mindful Eating, Mindful Life by Lilian Cheung and Thich Nhat Hanh
http://www.amazon.com/Savor-Mindful-Eating-Life/dp/0061697702
The Art of Eating Meditation by Jay Michaelson
http://www.metatronics.net/eat/
The Meditation Diet Method by Leo Babauta,
http://zenhabits.net/mind-full

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Second, relieve suffering!

Third, contain cost!

“Primum non nocere”, the historic ethical mantra of medicine, is getting a much-needed 21^st century update in the form of the Choosing Wisely Campaign. Twenty five medical specialty societies, representing over 500,000 US physicians, have already created specialty-specific “Top 5 Lists” of tests and procedures that are sometimes overused, can potentially cause harm to patients and may add avoidable cost to our bloated national health care expenditures. In 2013, an additional 25 medical specialty societies will submit their “Top 5 Lists” of tests and procedures after careful review of comparative effectiveness studies.

This campaign began in 2002 with a seminal article in the Archives of Internal Medicine titled “Medical Professionalism in the New Millenium: A Physician Charter.” The AIM editor said of this charter, co-authored by the American Board of Internal Medicine, the American College of Physicians- American Society of Internal Medicine Foundation and the European Foundation of Internal Medicine, “I hope that we will look back upon its publication as a watershed event in medicine.”

The American Board of Internal Medicine and the Council of Medical Specialty Societies jointly sponsor a biennial Putting the Charter into Practice grant to promote adherence to the Physician Charter’s emphasis on putting patients’ interests first and using limited financial resources wisely. In 2009, this grant was awarded to the National Physicians Alliance. The Alliance’s list of guiding principles begins- “We place the best interests of our patients above all others and avoid conflicts of interest and financial entanglements. The health of our patients is our first concern.” The Alliance’s home page displays the mission- “Committed to Advancing the Core Values of the Medical Profession: Service, Integrity, and Advocacy.” Their initial grant project, “Promoting Good Stewardship in Clinical Practice”, asked primary care physicians in internal medicine, family practice and pediatrics to identify a list of 5 overused tests or procedures commonly used in their specialty. These lists were field-tested nationwide and chosen for their basis in evidence from comparative effectiveness studies, their inherent risks to patients and their cost.

This unprecedented campaign has been precipitated by the convergence of several factors, include spiraling health care costs, an unacceptable number of adverse reactions to medical procedures (potentially including lifelong disability and death), growing consumer demand for transparency and involvement in medical decision-making, isolated examples of unethical overuse of medical procedures for monetary gain and, perhaps most importantly, the long-overdue movement toward scientific, evidence-based decisions surrounding appropriate indications for testing, procedures and prescribing. Increasingly, we know when certain tests and procedures are likely to be safe and cost-effective versus when the risk and cost of the procedure may outweigh the benefits.

For too long, the medical liability climate has caused physicians to practice defensive medicine by ordering tests they don’t really need in order to prevent being accused of failure to adequately investigate patient symptoms and diagnose serious disease. Patients have also had a long-standing inflated opinion of the necessity and value of many costly and risky medical tests and procedures. The Choosing Wisely Campaign and its emphasis on Things Physicians and Patients Should Question promote mutually respectful conversations between physicians and patients in order to prevent harm to patients, contain health care costs and enhance the prospect for a safe, effective, ethical and humane medicine.

A partial list of tests and procedures included in this campaign thus far include- antibiotic use for sinusitis, allergy testing, bone-density tests, cancer care at the end of life, pre-operative chest x-rays, use of pain and anemia medications in the presence of kidney disease, dialysis and other management issues in severe kidney disease, indications for initial and follow-up colonoscopies, early elective obstetric delivery, cardiac testing and other tests in cancer patients, Pap smears, pulmonary testing in asthma, testing for Alzheimer disease, imaging for headache, back pain and ovarian cysts and treatment of heartburn, reflux, migraines, erectile dysfunction and peripheral arterial disease.

Grants from the Robert Wood Johnson Foundation (RWJF) will help educate both physicians and patients. Practicing physicians will be educated about the recommendations of these medical societies and helped to communicate these recommendations to their patients. Patients will be educated through an RWJF grant to Consumer Reports, which has developed several initiatives to raise awareness among consumers. These include Best Buy Drugs (emphasizing prescription medications), Care About Your Care (to reduce hospital readmissions), Choosing Wisely Campaign (targeting safe, appropriate use of overused and potentially harmful procedures), Engage with Health (aimed at businesses and their employees), High Value Care (an extension of the American College of Physicians’ High Value, Cost-Conscious Care Initiative), and Physician Ratings (in collaboration with the RWJF’s Aligning Forces for Quality).

Consumer Reports’ newest campaign is Preventing Overdiagnosis (Winding Back the Harms of Too Much Medicine). It will be launched in September 2013. It focuses on the routine use of screening tests and the early detection of conditions that may never cause clinically significant disease.

The Choosing Wisely Campaign and its Things Physicians and Patients Should Question are helping patients, medical societies and consumer groups collaborate in new ways. They will help us all promote good stewardship in medicine by avoiding harm, containing costs and improving doctor-patient communication that characterizes the therapeutic relationship so essential to good medicine.

Resources-

ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002 Feb;136(3):243-246

Good Stewardship Working Group. The “top 5” lists in primary care: Meeting the responsibility of professionalism. Arch Intern Med. 2011 Aug 8;171(15):1385-90

National Physicians Alliance     http://npalliance.org

Choosing Wisely Campaign   http://www.choosingwisely.org

Things Physicians and Patients Should Question  http://www.choosingwisely.org/doctor-patient-lists/

Consumer Reports Campaigns   http://consumerhealthchoices.org/campaigns/

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Job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. While many of us need a certain amount of stress to fuel our productivity, too much of it can be harmful to both physical and emotional health.

Short-term stress causes hormone changes that were life-saving thousands of years ago when our nervous systems adapted to deadly threats with a ‘fight-or-flight response.’ Chronic stress that is sustained over time, including job stress, can lead to harmful effects on physical and emotional health. Co-workers and supervisors can be a source of conflict and stress. Overworking to gain recognition or promotion can interfere with family and friendships. Anxiety over job security is epidemic in uncertain economic climates.

Common health consequences of job stress can include job-related injuries and pain, sleep disturbance, exhaustion, unhealthy eating and exercise habits, weight gain and weight loss, high blood pressure, diabetes, elevated cholesterol, cynicism, depression and suicide, digestive disturbances, impaired immunity and premature death. Workers’ pulse and blood pressure have been shown to increase simply from rumors of impending layoffs. Work-related injuries can increase during corporate downsizing. These effects are more common among blue-collar workers who have little control over decisions about their work. All these health impacts can be expected to increase in the older workers that make up an increasing part of the workforce.

Employers are increasingly paying attention as workers describe their jobs as stressful, view their jobs as the number one stressor in their lives (more than family or finances) and believe there is more job stress than a generation ago. Employers are especially concerned that highly stressed workers are more likely to be absent, consider quitting and cost the company more in health care payouts.

Employers are also seeing more research showing that striving for a healthy working environment benefits both workers and company profits. Work site programs to combat job stress can include education in healthy eating, physical activity, emotional wellbeing, time management, assertiveness training, communication and social skills. Almost half of large US companies have general stress management programs and employee assistance programs that address individual needs of workers.

Stress management programs emphasize balancing work and personal life commitments, maintaining a supportive group of friends, attitude adjustments, emotional intelligence and simple mind body skills. Just 5 minutes of ‘me time’ on work breaks can manage stress by walking, talking with supportive friends or sitting quietly with eyes closed, feeling the breath coming in and out. These techniques are especially helpful when you encounter emotional challenges.

Workers who talk to their supervisor or employer honestly about job stress are likely to be talking to people with stress of their own.  Together, workers and management can improve the work environment and morale for all employees and even improve the bottom line.

The National Institute for Occupational Safety and Health (NIOSH) points out the need to address both worksite issues and employee factors. Heat, noise, fumes, chemicals and moving machinery are examples of working conditions that are stressful to most people. Such worksite environmental factors can provide the basis for employee disability and injury claims.

However, NIOSH believes a combination of organizational/worksite change and employee stress management is the most effective strategy for managing stress at work, leading to a healthy workplace, defined as reduced stress disorders, satisfied and productive workers and profitable and competitive organizations. Steps NIOSH suggests for employers and employees to take together include-

1) Employee surveys and discussions among managers, labor representatives, and employees concerning job conditions, perceived levels of stress, job satisfaction and specific worksite stressors. Personnel records of absenteeism, illness and health care costs can provide important parameters for measuring the impact of the intervention.
       2) Designing and implementing a stress management intervention.
3) Evaluating the intervention by measuring employee perceptions of change in work conditions, levels of stress, job satisfaction and health.

Judging by recent trends, we can expect more polls showing ‘most livable cities’, ‘best places to work’ and ‘best companies to work for.’ Increasingly well-informed consumers want to support organizations that serve the common good and their employees while serving their bottom line. Employees, employers and customers can all benefit from programs aimed at managing job stress.

Resources

National Institute for Occupational Safety and Health- Job Stress, 1-800-CDC-INFO, or http://www.cdc.gov/niosh/topics/stress/

American Psychological Association www.apa.org/helpcenter/job-stress.aspx

A psychologist in your area can be found through theAmerican Psychological Association (APA) 1-800-964-2000

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This historic ethical mantra of medicine is getting a much-needed 21^st century update in the form of the Choosing Wisely Campaign. Twenty six medical specialty societies, representing over 500,000 US physicians, have created specialty-specific lists of procedures that are sometimes overused, may add avoidable cost to health care and can potentially cause harm. All medical societies have been asked to participate. Those that have thus far contributed to Things Physicians and Patients Should Question include the specialties of allergy, anesthesiology, cardiology, colorectal surgery, critical care medicine, dermatology, emergency medicine, endocrinology, family practice, gastroenterology, geriatrics, hematology, hospice and palliative care, hospital medicine, internal medicine, long-term care, ophthalmology, obstetrics and gynecology, oncology, orthopedics, otolaryngology, nephrology, neurology, pathology, pediatrics, psychiatry, radiology, rheumatology, thoracic surgery, urology and vascular medicine.

This unprecedented campaign has been precipitated by the convergence of several factors. These factors include spiraling health care costs, an unacceptable number of adverse reactions to medical procedures (including lifelong disability and death), growing consumer demand for transparency and involvement in medical decision-making, isolated examples of unethical overuse of medical procedures for monetary gain and, perhaps most importantly, the long-overdue movement toward scientific, evidence-based decisions surrounding appropriate indications for testing and prescribing. Increasingly, we know when certain tests and procedures are likely to be safe and effective versus when the risk of the procedure may outweigh the benefits.

For too long, physicians have felt compelled to practice ‘defensive medicine’ by ordering excessive numbers of tests to prevent being accused of failure to adequately investigate patient symptoms. Patients have also had a long-standing inflated opinion of the necessity and value of medical tests and procedures. The Choosing Wisely Campaign and its emphasis on Things Physicians and Patients Should Question promote mutually respectful conversations between physicians and patients in order to prevent harm to patients, contain health care costs and enhance the prospect for a safe, effective, ethical and humane medicine.

A partial list of tests and procedures included in this campaign thus far include- antibiotic use for sinusitis, allergy testing, bone-density tests, cancer care at the end of life, pre-operative chest x-rays, use of pain and anemia medications in the presence of kidney disease, dialysis and other management issues in severe kidney disease, when to have an initial or follow-up screening colonoscopy, scheduling early delivery in pregnancy, cardiac testing and tests in cancer patients, Pap smears, breathing tests in asthma, testing for Alzheimer disease, treating heartburn, reflux, migraines, erectile dysfunction and blocked leg arteries and x-rays for headache, back pain and ovarian cysts.

Grants from the Robert Wood Johnson Foundation (RWJF) will help educate both physicians and patients. Practicing physicians will be educated about the recommendations of these medical societies and helped to communicate these recommendations to their patients. Patients will be educated through an RWJF grant to Consumer Reports, which has developed several initiatives to raise awareness among consumers. These include Best Buy Drugs (emphasizing prescription medications), Care About Your Care (to reduce hospital readmissions), Choosing Wisely Campaign (targeting safe, appropriate use of overused and potentially harmful procedures), Engage with Health (aimed at businesses and their employees), High Value Care (an extension of the American College of Physicians’ High Value, Cost-Conscious Care Initiative), and Physician Ratings (in collaboration with the RWJF’s Aligning Forces for Quality).

Consumer Reports’ newest campaign is Preventing Overdiagnosis (Winding Back the Harms of Too Much Medicine). It will be launched in September 2013. It focuses on the routine use of screening tests and the early detection of conditions that may never cause clinically significant disease. There is presently a heated debate in medical and consumer circles over the recent estimates that as much as a third of breast cancers are ‘overdiagnosed.’ This refers to cancers being diagnosed that are unlikely to ever grow or spread sufficiently to cause disease and illness.

The physical, emotional, social, financial and spiritual stresses surrounding cancer in general and breast cancer in particular make this conversation one of today’s most important, poignant and challenging. The Choosing Wisely Campaign and its Things Physicians and Patients Should Question are helping patients, medical societies and consumer groups collaborate in new ways. They will help us all avoid harm, contain costs and improve the doctor-patient communication that characterizes the therapeutic relationship so essential to good medicine.

Resources-

Choosing Wisely Campaign   http://www.choosingwisely.org
Consumer Reports Campaigns   http://consumerhealthchoices.org/campaigns/About the

The post Things Physicians and Patients Should Question appeared first on Mind Body Studio.

This Hippocratic ideal guides the practice of medicine. Both physicians and patients share this goal of good medicine. This means using appropriate tests to determine a correct diagnosis, using appropriate treatment for the diagnosed condition, avoiding harm caused by testing and treatment, and doing all this as economically as possible.

Both physicians and patients have embraced modern diagnostic technology and modern medical treatments in part because they have helped relieve tremendous suffering and saved countless lives. But unsustainable cost increases have led to our need to control health care spending by choosing wisely how to use the tools of modern medicine. Unavoidable and inevitable side effects to medications and testing have also caused tragic harm to patients. This has led several major medical organizations to consider ways for medicine to be practiced even more wisely, humanely, safely and economically.

The Choosing Wisely Campaign targets medical tests and treatments that are  unnecessary under certain conditions and can also cause serious harm. These tests and treatments that are considered safe under most circumstances but may lead to further testing and treatment which can increase cost and the potential for patient harm. To encourage conversations between patients and doctors, participating medical groups have created recommendations, based on best available medical evidence, to help doctors and patients make wise decisions about the most appropriate care for an individual patient’s individual needs.

So far, nine medical specialty groups have agreed on “Five Things Physicians and Patients Should Question” for their own medical specialty. These groups are- the American Academy of Allergy, Asthma and Immunology; the American Academy of Family Physicians; the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Association; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology. Other medical organizations are in the process of adding their specialty’s list of five.

The initial scientific paper announcing the Choosing Wisely Campaign appeared as part of the “Less is More” series in the Archives of Internal Medicine, one of the family of scholarly medical journals published by the American Medical Association.

With the Choosing Wisely Campaign, these medical groups seek to increase public health and decrease patient harm by educating both physicians and consumers about overused diagnostic and therapeutic interventions.

Below is a partial list of recommendations for adults-

1)   X ray, CAT scan and MRI for low back pain are unnecessary in the first 6 weeks unless there are certain red flags on examination.

2)   Antibiotics are unnecessary for mild to moderate sinus infections.

3)   Routine annual EKGs and other cardiac screening are unnecessary for low-risk patients who have no cardiac symptoms.

4)   Pap smears are unnecessary for women under age 21 or women who have had a hysterectomy, unless they still have a cervix or their hysterectomy was performed for cancer.

5)   DEXA (BMD) scans to screen for osteoporosis are unnecessary in women under age 65 and men under age 70 unless specific risk factors are present.

6)   Healthy adults do not need routine blood and urine testing, although cholesterol screening may be indicated for some people and those with high blood pressure should be screened for diabetes.

7)   If statins are chosen to initiate therapy to lower cholesterol or triglycerides, generic drugs should be used before more expensive brand name drugs.

This is a partial list of recommendations for children-

1)   Antibiotics are not necessary for sore throat/tonsillitis unless there is a positive test for streptococcal infection.

2)   An X ray, CAT scan or MRI is unnecessary after minor head injury unless there has been loss of consciousness or certain symptoms and physical findings suggest increased risk of serious injury.

3)   Middle ear infections (even those with effusion or ‘fluid behind the ear drum’) can be treated by the primary care provider unless certain red flags are present on examination. If an uncomplicated infection does not resolve within 3 months, referral to an ear specialist may be indicated.

4)   It is not necessary, and may be harmful, for children to use over-the-counter cough and cold medication.

5)   Overuse of both oral and inhaled medications for asthma can be harmful and can be prevented by the regular use of a steroid (‘cortisone’) inhaler. A threshold for beginning such inhalers is either 4 wheezing episodes, or 2 episodes requiring oral steroids, within 6 months.

Frank conversations about these interventions can help patients and their providers contain health care costs, avoid causing harm and make rational decisions based on the best available medical evidence of safety and effectiveness.

So that we can all “do no harm”, Consumer Reports Health is partnering with these medical societies to make information about the Choosing Wisely Campaign available to the general public. You can find out more at either- http://choosingwisely.org or http://consumerhealthchoices.org/campaigns/choosing-wisely

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