Monday, January 17, 2011

Organized Medicine Bristles at Proposed 'Sleep Regulations'

From Medscape Medical News

Robert Lowes

January 12, 2011 — Sleep deprivation can addle someone just as much as drinking a 6-pack of beer, and therefore regulations to protect patients from yawning surgeons are justified, asserts a recent perspective article in the New England Journal of Medicine (NEJM).

The authors suggest that surgeons who have been awake for 22 of the last 24 hours could be required by law to disclose their condition to patients scheduled for elective surgery, who could then decide whether to turn to a fresher physician or reschedule.

Physicians differ on the need for regulations around sleep deprivation.

Not so fast, replies organized medicine. Yes, fatigue can fuzz up thinking and degrade technical skills. However, mandating disclosure of sleep deprivation would usurp a physician's professional judgment as to whether he or she is fit to operate, and could give litigious patients one more reason to file a malpractice suit, physicians argue.

"It opens a whole can of worms," Jim Fasules, MD, senior vice president for advocacy at the American College of Cardiology, told Medscape Medical News.

The debate over a regulatory solution for the problem of sleep fatigue is not as theoretical as a recommendation in an editorial. The consumer advocacy group Public Citizen and 2 organizations representing medical students and residents have asked the US Occupational Safety and Health Administration (OSHA) to limit work shifts for all residents to 16 hours. Because residency training helps mold the culture of medicine, OSHA restrictions on work hours could reverberate throughout the profession, and not entirely for the good, some physicians contend. For one thing, they fear the growth of a shift mentality that subordinates patient care to physician comfort.

"This is a 365-day-a-year, 24/7 career choice, to become a neurosurgeon," said H. Hunt Batjer, MD, chair of neurological surgery at Northwestern University in Evanston, Illinois, and a former chair of the American Board of Neurological Surgery.

In their NEJM article, lead author Michael Nurok, MD, PhD, and coauthors concentrate on the common scenario of surgeons who have been up all night, only to face an elective surgery scheduled for the morning. The results are often not pretty. The authors cite research showing that the risk for complications rises 83% for patients who undergo an elective daytime operation performed by someone who had less than a 6-hour opportunity for sleep between procedures while they were on call the night before.

One simple way to safeguard patients, write the authors, is to avoid scheduling elective procedures for physicians the day after they have been on night call. Otherwise, sleep-deprived physicians should not be allowed to proceed with an elective procedure unless they first obtain the patient's informed consent with regard to the risks they face. The patient should then have the right to undergo the surgery with that physician, reschedule it, or choose another physician.

Mandatory Disclosure Called "Oppressive and Insidious"

Accompanying the article by Dr. Nurok and coauthors is a rebuttal by 3 leaders of the American College of Surgeons (ACS): executive director David Hoyt, MD; president L.D. Britt, MD, MPH; and Carlos Pellegrinni, MD, chair of the group's board of regents. They agree that sleep deprivation is a problem, but reject the idea of mandatory disclosure because it "eliminates the necessary judgmental latitude surgeons should possess to determine the fitness for providing optimal patient care." For example, a fatigued surgeon might decline to undertake a liver transplant but go ahead with a simpler operation such as a colostomy.

"Professionals of this caliber are likely to view the authors' recommendation that surgeons be required to disclose the number of hours they have slept as oppressive and insidious," write the ACS leaders, who wonder whether surgeons also will be asked to reveal marital or financial woes that might mar their operating room performance.

The solution they propose is training surgeons to recognize how fatigue degrades their cognitive and physical capabilities, and then decide whether to voluntarily disclose sleep deprivation to a patient or go another route.

However, the authors of the NEJM editorial point out a conundrum that runs counter to the ACS recommendation: Sleep deprivation degrades one's ability to recognize how the condition impairs judgment.

"Sleep-deprived clinicians are therefore not likely to assess accurately the risks posed when they perform procedures in such a state," they write. Hence, the need for mandatory disclosure.

"It Doesn't Require a Legislative Fiat"

In an interview with Medscape Medical News, Dr. Batjer said that in his career, coping with sleep deprivation has not been fraught with the problems raised in the NEJM article.

"If I'm up all night and I don't feel good about embarking on a procedure the next day, I talk to the patient about it," said Dr. Batjer. "I would never put someone in the operating room if I felt that I or someone else weren't good to go."

I would never put someone in the operating room if I felt that I or someone else weren't good to go.

And recharging his battery is not all that hard, he added.

"If I've been on call, and done a case, and I have a ruptured aneurysm to do in the morning, I lie down in my office for 15 minutes and come back fresh," Dr. Batjer said. "It doesn't require a legislative fiat."

Another opponent of sleep fiats is Michael Marks, MD, from Norwalk, Connecticut, a member of the Board of Councilors of the American Academy of Orthopaedic Surgeons.

"The biggest problem with legislation and regulations is their one-size-fits-all approach," Dr. Marks told Medscape Medical News. "Something that might work in an urban environment might not work in a rural environment, where there are fewer physicians.

"And 98% of physicians will do the right thing for their patients. [The NEJM editorial authors] are trying to create legislation to deal with the 2% who are outliers. That's not how things should be done in our society."

Petition Stresses Harm to Residents, Not Patients

Although there are no state or federal laws on the horizon to require disclosure of sleep deprivation, OSHA has been asked to address the issue of sleep deprivation among residents by more tightly restricting their hours.

Right now, residency programs operate under duty-hour requirements set by the Accreditation Council for Graduate Medical Education (ACGME). In 2003, the council limited resident work weeks to 80 hours and shifts to 24 hours. Beginning this July, a new ACGME rule kicks in, prohibiting first-year residents from working shifts longer than 16 hours and mandating a minimum of 8 hours off-duty afterward.

This change does not go far enough for Public Citizen, the American Medical Student Association, and the Committee of Interns and Residents, a union representing 13,000 residents. Last September, along with a number of individual physicians, including Charles Czeisler, MD, PhD, a coauthor of the NEJM editorial, they asked OSHA to impose a shift limit of 16 hours on all residents regardless of year. In addition, they requested a minimum of 10 hours off after a day shift, and 12 hours off after a night shift.

The petition does not stress the effect of sleep deprivation on patient care so much as its effect on the well-being of residents, who may work 30 hours straight. Exhausted physicians-in-training, it states, risk needle sticks, pregnancy complications, depression, and falling asleep while driving home.

"In order to fulfill OSHA's mission to 'send every worker home whole and healthy every day,' you must act now to address the dangers that extreme work hours pose for resident physicians," the petition states.

The coalition contends that schedule restrictions make sense because the federal government regulates the hours of other industries. The Federal Aviation Administration, for example, does not permit pilots to fly more than 34 hours per week, or 8 hours in a single day. In addition, other developed nations, such as members of the European Union, have instituted shifts that max out at 13 hours, with 11 hours off afterward.

Slaves to the Clock?

The petition asking OSHA to regulate resident duty hours has sparked uniform opposition from the American Medical Association, the American College of Physicians, and a coalition of 20 surgical societies, including the ACS.

For starters, organized medicine contends that the job of setting standards for residency training already belongs to the ACGME, and that OSHA would be a poor substitute because of its unfamiliarity with medical education and patient care. OSHA itself cited this reasoning when it rejected a similar request from Public Citizen in 2001 to regulate resident duty hours.

Physician groups also raise the issue of more patient hand-offs. Shorter shifts mean patients will be turned over more frequently from resident to resident, disrupting the continuity of care. The petitioners counter that studies of residency shift-shortening turn up evidence to the contrary — that patient care improves.

Another issue is inadequate training. The argument here is that rookie physicians need as much exposure as they can get to a myriad of medical conditions. "You could rob them of experience," said the American College of Cardiology's Dr. Fasules about shorter shifts. "Are we going to need to increase the length of residency programs? If so, where does that money come from?"

Are we going to need to increase the length of residency programs? If so, where does that money come from?

Dr. Marks of the American Academy of Orthopaedic Surgeons makes the same point: "It used to be said [in residency training] that when you were on call every other night, you missed half the cases," he said.

Long hours in and of themselves have training value, some would say, because they harden physicians for future rigors.

"Residents need to learn to prioritize and think on their feet," said Dr. Batjer. "If there is a terrorist attack, or a plane crash, with multiple casualties, physicians may have to be on their feet for more than 16 hours. They'll work as long as it takes to manage the situation."

Public Citizen and its fellow petitioners respond that lifelong learning combined with life balance is "at least as important as any experience to be gained between the 80th and 100th hour of a [residency] work week." They also discount the "toughen them up" rationale for long hours, saying physician work weeks after residency training are getting shorter, and on-call schedules lighter.

In yet another salvo against the Public Citizen petition, the 20 surgical societies told OSHA in a letter last month that current restrictions on resident hours are fostering a "shift mentality" and a "loss of professional responsibility to the patient." More restrictions, they warned, could further undermine patient care.

Dr. Fasules provides a hyperbolic, but apt, example.

"I'm in the middle of a 10-hour surgery," he said. "I look up at the clock and I say, 'I've reached my limit. I have to leave now.'

"You're a slave to the clock instead of the patient."

Proponents of stricter duty hours would reply, however, that if a physician is nodding off during surgery, the patient is ill served.

OSHA has yet to issue a decision on the residency hours petition, but David Michaels, PhD, MPH, assistant secretary of labor for OSHA, has already stated that he is "very concerned" about residents working extremely long hours, and that he is willing to hold training programs accountable.

"We know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents," Dr. Michaels said in a written statement last fall. "It is clear that long work hours can lead to tragic mistakes, endangering workers, patients and the public.

"Hospitals and medical training programs are not exempt from ensuring that their employees' health and safety are protected."

N Engl J Med. 2010;363:2672-2673, 2577-2579. Abstract Abstract

Monday, January 10, 2011

The 'Luxury Prime': How Luxury Changes People

Q&A with: Roy Y.J. Chua
Published: February 1, 2010
Author: Sarah Jane Gilbert

Executive Summary:

What effect does luxury have on human cognition and decision making? According to new research, there seems to be a link between luxury and self interest, an insight that may help curb corporate excesses. Roy Y.J. Chua of Harvard Business School discusses findings from his work conducted with Xi Zou of London Business School. Key concepts include:

* People who were made to think about luxury before a decision-making task were more likely to endorse self-interested decisions that might potentially harm others.
* Although luxury does not necessarily induce people to harm others, it may cause them to be less considerate.
* Limiting corporate excesses and luxuries might be a step toward getting executives to behave more responsibly toward society.

Roy Chua is an assistant professor in the Organizational Behavior unit at Harvard Business School.

Are people who travel in town cars and on corporate jets different—on a psychological level—from you and me? Does the availability of luxury goods "prime" individuals to be less concerned about or considerate toward others? The answer from new research seems to be yes.

HBS professor Roy Y.J. Chua and Xi Zou, an assistant professor at London Business School, suggest that luxury goods have an important effect on human behavior that is only now becoming clear—and that may have implications for addressing the continuation of objectionable choices among, for example, high-flying executives on Wall Street.

According to Chua, their research found that "people who were made to think about luxury prior to a decision-making task have a higher tendency to endorse self-interested decisions that might potentially harm others." Their findings are detailed in the HBS working paper "The Devil Wears Prada? Effects of Exposure to Luxury Goods on Cognition and Decision Making" [PDF].

"Will the same business meeting reach different decisions when it is held at a luxury resort as opposed to a modest conference room?" the authors write. "Will CEOs who bequeath themselves expensive office facilities and luxurious corporate jets make different business decisions than those who do not? In this age of Wall Street excesses, these are pertinent questions that could further our understanding of why some [people] continue to place their own interests over others', even in difficult economic times."

Chua, whose research draws on human psychology to better understand important social processes in business organizations, explained more about the findings in an e-mail Q&A.

Sarah Jane Gilbert: You conducted two experiments to explore a psychological link between the notion of luxury and self-interest. What did you find?

Roy Chua: In the first experiment, participants were asked to answer a series of business-related decision-making questions that were designed to tap the extent to which people place self-interests (profit maximization for one's firm) above society interests. An example involved asking participants how likely they are to endorse the manufacturing of a new model of car that could bring in enormous profit but could potentially pollute the environment. Before answering these questions, half of the participants were asked to evaluate luxury products, while the other half evaluated cheaper equivalents. We found that people who were made to think about luxury prior to the decision-making task have a higher tendency to endorse self-interested decisions that might potentially harm others.

These results led us to wonder whether "luxury-primed" individuals are simply self-interested or are indeed more prone to harm others. Thus, we conducted a second experiment that was similar to the first one in that the participants were either primed with luxury or not. The difference is that after the prime, we asked them to do a word recognition exercise.
The task was to write down the first word that came to their mind when given a string of scrambled letters. These strings of scrambled letters were each constructed by interleaving a pro-social word with an anti-social word of equal length. Examples of the pro-social words used were nice, giving, and helpful; examples of anti-social words were rude, stingy, and selfish. We found that luxury-primed participants identified significantly fewer pro-social words than non-luxury-primed participants. However, there was no significant difference in the identification of anti-social words.

This pattern of findings suggests that luxury-primed individuals were not more likely to have anti-social cognition, but were less likely to have pro-social thoughts. In other words, when thinking about luxury, people tend to focus more on themselves and less on others.

Q: Did anything in your research surprise you?

A: The findings are not so much surprising as illuminating. We expected a relationship between luxury and self-interests. However, self-interested behaviors are often conflated with those that do harm to others (e.g., selling low-quality products that might be harmful to consumers). Our second study to some extent clarifies the psychological dynamics that arise from luxury.

Luxury does not necessarily induce one to do harm to others, but simply causes one to be less concerned or considerate toward them.

Q: How do your findings help us to understand corporate greed? Do you think there is a different mindset now for companies and executives to change and become more socially and morally responsible?

A: In the midst of the current global economic crisis, people are outraged by highly paid executives living in the lap of luxury while continuing to make self-serving decisions and ignoring the plight of others. To date, more than a year since the crisis started, despite much public outrage and threats to more strongly regulate the financial industry, there do not seem to be any substantive changes in their mindset. Bankers are still planning large bonuses for themselves.

One commonly proffered explanation is that these executives lack a moral compass, leading them to care only about themselves to the extent of hurting others. Our findings offer another perspective—the fact that these executives are surrounded by luxury did not help their decision-making to be more "other-oriented." Yet their seemingly "immoral" decisions stem not so much from a real desire to hurt others but more from over self-indulgence.

Perhaps besides limiting the size of bonuses, limiting corporate excesses and luxuries might be a step toward getting executives to behave more responsibly.

Q: Since your research is work in progress, do you have plans to expand your study to uncover additional findings? What would you include in future studies?

A: Yes, this is still very much work in progress. While our findings established the effects of exposure to luxury, we believe more work is required. Future research should tease out the nuances in the psychological effects of "luxury prime" (which we have shown to promote self-interest) and "money prime" (which has been shown to promote self-sufficiency and independence).

Toward this end, Xi Zou and I have recently completed a new study in which participants tested perfumes as part of an ostensible marketing research project. Participants were divided into two groups: In the first group, participants read about perfumes as luxury products, and in the second group, participants read about perfumes as becoming daily necessities. Both groups tested the same perfumes. We found that luxury-primed participants behaved in a more self-interested manner in that they were less likely to make contributions toward the public good. Priming luxury did not have any effect on self-sufficiency measures, suggesting that priming luxury is different from priming money.

Future research should also examine the mechanisms through which luxury goods activate self-interests. We posit that several potential mechanisms may be involved in the process. Exposure to luxury goods may activate a social norm that it is appropriate to pursue interests beyond a basic comfort level, even at the expense of others. It may be this activated social norm affects people's judgment and decision-making. Alternatively, exposure to luxury may directly increase people's personal desire, causing them to focus on their own benefits such as prioritizing profits over social responsibilities.

Although these two mechanisms lead to the same observed results, they have distinct social implications. As social scientists, we think it is important to understand the "why" beneath the effects we found, and so we are currently planning more studies.

About the author

Sarah Jane Gilbert is a product manager for Harvard Business School's Knowledge and Library Services.

7 days program to Stress management

By: frank tibss

"Have One Week, Will Relax" Your 7 days program to Stress management

They say there's more than one way to skin a cat. The same goes when you start tearing your hair out with all the frustration, grief, anxiety, and yes, stress. It's a state of mental conditioning that is like taking that bitter pill down your throat, causing you to lose your sense of self, and worse your sanity. Just thinking about it can drive anyone off the edge.

And they say that the proactive ones are already living off the edge.

As one stressed-out person to another, I know how it feels, and believe me there are many variants when it comes to stress. Coping with life, and carrying the problems that may or may not belong to you can scratch away the little joy and happiness that you can carry once you head out that door. You can't blame them for being like that; they have their own reasons, so much like we have our reasons to allow stress to weigh us down. They say that stress is all in the mind, well, what's bugging you anyway?

There are several ways to manage stress, and eventually remove it out of your life one of these days. So I'll try to divide it into a seven-day course for you and I promise it's not going to be too taxing on the body, as well as on the mind.

1. Acknowledge stress is good
Make stress your friend! Based on the body's natural "fight or flight" response, that burst of energy will enhance your performance at the right moment. I've yet to see a top sportsman totally relaxed before a big competition. Use stress wisely to push yourself that little bit harder when it counts most.

2. Avoid stress sneezers
Stressed people sneeze stress germs indiscriminately and before you know it, you are infected too!

Protect yourself by recognizing stress in others and limiting your contact with them. Or if you've got the inclination, play stress doctor and teach them how to better manage themselves.

3. Learn from the best
When people around are losing their head, who keeps calm? What are they doing differently? What is their attitude? What language do they use? Are they trained and experienced?
Figure it out from afar or sit them down for a chat. Learn from the best stress managers and copy what they do.

4. Practice socially acceptable heavy breathing
This is something I've learned from a gym instructor: You can trick your body into relaxing by using heavy breathing. Breathe in slowly for a count of 7 then breathe out for a count of 11. Repeat the 7-11 breathing until your heart rate slows down, your sweaty palms dry off and things start to feel more normal.

5. Give stressy thoughts the red light
It is possible to tangle yourself up in a stress knot all by yourself. "If this happens, then that might happen and then we're all up the creek!" Most of these things never happen, so why waste all that energy worrying needlessly?

Give stress thought-trains the red light and stop them in their tracks. Okay so it might go wrong - how likely is that, and what can you do to prevent it?

6. Know your trigger points and hot spots
Presentations, interviews, meetings, giving difficult feedback, tight deadlines.. My heart rate is cranking up just writing these down!

Make your own list of stress trigger points or hot spots. Be specific. Is it only presentations to a certain audience that get you worked up? Does one project cause more stress than another? Did you drink too much coffee?

Knowing what causes you stress is powerful information, as you can take action to make it less stressful. Do you need to learn some new skills? Do you need extra resources? Do you need to switch to decaf?

7. Burn the candle at one end
Lack of sleep, poor diet and no exercise wreaks havoc on our body and mind. Kind of obvious, but worth mentioning as it's often ignored as a stress management technique. Listen to your mother and don't burn the candle at both ends!

So having stress can be a total drag, but that should not hinder us to find the inner peace of mind that we have wanted for a long time. In any case, one could always go to the Bahamas and bask under the summer sun.

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Change Your Point of View

By: Art Franks

Enjoy Your Life: Change Your Point of View

"Two men look out through the same bars: One sees the mud, and one sees the stars."- Frederick Langbridge, A Cluster of Quiet Thoughts

If you've placed second in a writing contest, will you jump for joy and push for better results the next time or will you be discouraged and find an excuse not to join again?

In life, you are always filled with choices. You may opt to have a pessimist's view and live a self-defeated life or you may decide to take the optimist's route and take a challenging and fulfilling life.

So why nurture an optimist's point of view? And why now?

Well, optimism has been linked to positive mood and good morale; to academic, athletic, military, occupational and political success; to popularity; to good health and even to long life and freedom from trauma.

On the other hand, the rates of depression and pessimism have never been higher. It affects middle-aged adults the same way it hits younger people. The mean age of onset has gone from 30 to 15. It is no longer a middle-aged housewife's disorder but also a teen-ager's disorder' as well.

Here's how optimists are in action and researches that back up why it really pays to be an optimist:

Optimists expect the best

The defining characteristic of pessimists is that they tend to believe bad events, which will last a long time and undermine everything they do, are their own fault.

The truth is optimists are confronted with the same hard knocks of this world. What differs is the way they explain their misfortune---it's the opposite way. They tend to believe defeat is just a temporary setback, that its causes are confined to this one case.

Optimists tend to focus on and plan for the 'problem' at hand. They use 'positive reinterpretation.' In other words, they most likely reinterpret a negative experience in a way that helps them learn and grow. Such people are unfazed by bad situation, they perceive it is a challenge and try harder.

They won't say "things will never get better," "If I failed once, it will happen again" and "If I experience misfortune in one part of my life, then it will happen in my whole life."

Positive expectancies of optimists also predict better reactions during transitions to new environments, sudden tragedies and unlikely turn of events. If they fall, they will stand up. They see opportunities instead of obstacles.

People respond positively to optimists

Optimists are proactive and less dependent on others for their happiness. They find no need to control or manipulate people. They usually draw people towards them. Their optimistic view of the world can be contagious and influence those they are with.

Optimism seems a socially desirable trait in all communities. Those who share optimism are generally accepted while those who spread gloom, panic and hysteria are treated unfavorably.

In life, these people often win elections; get voted most congenial and sought for advice.

When the going gets tough, optimists get tougher

Optimists typically maintain higher levels of subjective well-being during times of stress than do people who are less optimistic. In contrast, pessimists are likely to react to stressful events by denying that they exist or by avoiding dealing with problems. Pessimists are more likely to quit trying when difficulties arise.

They persevere. They just don't give up easily, they are also known for their patience. Inching their way a step closer to that goal or elusive dream.

Optimists are healthier and live longer

Medical research has justified that simple pleasures and a positive outlook can cause a measurable increase in the body's ability to fight disease.

Optimists' health is unusually good. They age well, much freer than most people from the usual physical ills of middle age. And they get to outlive those prone to negative thoughts.

So why not be an optimist today? And think positively towards a more fulfilled life.

Why not look forward to success in all your endeavors? Why not be resilient? Like everybody else you are bound to hit lows sometimes but don't just stay there. Carry yourself out of the mud and improve your chances of getting back on the right track. And why not inspire others to remove their dark-colored glasses and see life in the bright side?

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