Wednesday, August 24, 2011

The Role of Obesity, Salt and Exercise on Blood Pressure in Children and Adolescents

From Expert Review of Cardiovascular Therapy Stella Stabouli; Sofia Papakatsika; Vasilios Kotsis Posted: 08/16/2011; Expert Rev Cardiovasc Ther. 2011;9(6):753-761. © 2011 Expert Reviews Ltd. Abstract and Introduction Definition of Pediatric HTN Childhood Obesity & BP Regulation Dietary Salt Intake & BP in Childhood Exercise & Prevention of HTN in Children & Adolescents Expert Commentary Five-year View Abstract The increasing trends of blood pressure (BP) in children and adolescents pose great concern for the burden of hypertension-related cardiovascular disease. Although primary hypertension in childhood is commonly associated with obesity, it seems that other factors, such as dietary sodium and exercise, also influence BP levels in children and adolescents. Several studies support that sympathetic nervous system imbalance, impairment of the physiological mechanism of pressure natriuresis, hyperinsulinemia and early vascular changes are involved in the mechanisms causing elevated BP in obese children and adolescents. Under the current evidence on the association of salt intake and BP, dietary sodium restriction appears to be a rational step in the prevention of hypertension in genetically predisposed children and adolescents. Finally, interventional studies show that regular aerobic exercise can significantly reduce BP and restore vascular changes in obese with hypertensive pediatric patients. This article aims to summarize previous studies on the role of obesity, salt intake and exercise on BP in children and adolescents. Introduction The prevalence of primary hypertension (HTN) in children and adolescents has been reported to have increased during the last few decades. HTN awareness is currently increased, due to the easier detection and improved classification of HTN in the young. Despite the difficulty in estimating the exact percentage of children with elevated blood pressure (BP), pediatric primary HTN is present in 1–5% of children and adolescents of all age groups. Differences in race/ethnicity, variance in secondary HTN, sex-related changes, environmental and nutritional influences are all confounding factors in the estimation of prevalence. The most important aspect of identifying HTN in the pediatric population is 'BP tracking', that means the association of high BP in childhood with elevated BP in adulthood. With this concept, factors that affect BP in childhood, are likely to further influence the burden of HTN and cardiovascular disease in adults. The documented increasing prevalence of childhood obesity has accounted for the trends of elevated BP in children and adolescents. However, in the recent National Health and Nutrition Examination Survey (NHANES; 1988/1994 and 1999/2000), adjustment for obesity explain only 29% of the increase in systolic BP (SBP) and 12% in diastolic BP (DBP), suggesting that other factors, such as increased salt intake and low physical activity, may also affect BP trends over time. This article aims to summarize previous studies on the role of obesity, salt intake and exercise on BP in children and adolescents.

Friday, August 12, 2011

US Gets Less for Its Healthcare Buck Than Other Nations

From Medscape Medical News

Robert Lowes

August 11, 2011 — Despite outspending 18 other developed nations on healthcare as a percentage of gross domestic product (GDP) in 2005, the United States posted the highest mortality rate among its peers, according to a study published online last month in the Journal of the Royal Society of Medicine Short Reports.
Although the United States reduced its mortality rate from 1979 to 2005, 15 of the other developed countries, including the United Kingdom, did the same thing at a faster clip.
In short, the American healthcare system is one of the least cost-effective, whereas the system in the United Kingdom is the second most cost-effective, doing more with less, write Colin Pritchard, PhD, a professor of psychiatric social work at Bournemouth University in Bournemouth, United Kingdom; and Mark Wallace, BSc, who teaches economics, politics, and philosophy at the Latymer School in London.
Pritchard and Wallace paid particular attention to the United Kingdom's performance because they conducted their study in response to frequent references to the "apparent failings" of the National Health Service during the ongoing healthcare reform debate in the United States.
 The other countries in the study are Austria, Australia, Canada, Finland, France, Germany, Greece, Ireland, Italy, Japan, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, and Switzerland.

In 1980, public and private healthcare expenditures in the United States as a percent of GDP amounted to 8.8%, ranking it second behind Sweden at 9%. By 2005, the United States had vaulted to first place with 15.3%, Switzerland placing a distant second at 11.6%.
The United States also ranked number 1 in average GDP healthcare expenditures — 12.2% — during the entire 25-year time frame.
The authors extrapolated mortality rates per million (PM) from data compiled by the World Health Organization for 2 time frames — 1979 to 1981, and 2003 to 2005 — with separate rates for individuals aged 15 to 74 years, 15 to 34 years, 35 to 54 years, and 55 to 74 years.
The mortality rate in the United States for the comprehensive 15- to 74-year-old age group decreased from 9158 deaths PM to 6660 PM, or by 27% during the roughly quarter-century span, but the nation nevertheless posted the highest mortality rate in 2005 among the 19 developed nations.
All but Portugal, Spain, and Switzerland saw their mortality rate decrease at a slower pace.
The United Kingdom had the fifth highest mortality rate — 5471 PM.
Likewise, the United States topped the mortality-rate list for the 55- to 74-year-old age groups, whereas the United Kingdom came in at number 6.
Too Many Guns in the United States?
The authors calculated a cost-effectiveness ratio for each country by dividing the level of reduced mortality rates — in the case of the United States, 9158 PM minus 6660 PM or 2498 PM — by average GDP healthcare spending from 1980 to 2005. According to this measure, the United States ranked third from the bottom for the 15- to 74-year-old age group with a ratio of 1:205 vs 1:557 for the United Kingdom, which ranked second behind Ireland. The same pecking order for the 3 countries held true in the 55- to 74-year-old age group.
Several characteristics of the United States might help explain the country's high mortality rate among the 19 nations, according to Pritchard and Wallace. They point to the country's "considerable variation" on a range of socioeconomic and health factors, especially regarding ethnic groups. In addition, the availability of firearms here "impacts upon mortality rates such as homicide and suicide, far more than any other Western country."
The authors attempt to answer the question of why the United States performs so poorly on healthcare cost-effectiveness when the market forces of a largely private healthcare system are assumed to foster efficiency. The US system, Pritchard and Wallace write, has "inherent market failures" such as adverse selection, in which individuals with greater health risks are more likely to obtain coverage from private insurers than individuals with lesser risks, driving premiums upward and discouraging the "better bets" from getting coverage in the first place. Another market failure stems from private insurers charging everyone higher premiums to hedge against "a few individuals that require unexpectedly very expensive medical treatment."
Nations with mostly public healthcare systems, such as the United Kingdom, avoid these pitfalls, according to the authors.
The study authors have disclosed no relevant financial relationships.
J R Soc Med Sh Rep. 2011;2:60. Full text

Wednesday, August 10, 2011

How Can I Remember All That I've Learned in Preclinical Classes?

From Medscape Med Students > Ask the Experts

Alex Millman, MD
Posted: 12/15/2010

Do you have any tips for remembering all the stuff I learned in the first 2 years, and for integrating it into clinical practice?
            Response from Alex Millman, MD
Resident Physician, University of California, San Francisco
Trying to remember the material learned during the preclinical years of medical school is a perennial challenge for physicians in training. The quantity of information is daunting, and it can certainly feel as though your brain is overflowing with facts that are difficult to relate to clinical practice. If you find yourself in this situation, remember these 2 important points: (1) everyone in medicine has confronted this issue at some point in his or her career; and (2) you know more than you think you do.
The transition from the preclinical to the clinical years presents a new set of challenges for all medical students. Not only are you confronted with the complexities of functioning on a team, navigating long hours, and caring for patients, you also are learning new aspects of clinical medicine while simultaneously trying to preserve your "book knowledge." How does one do this effectively?
The first 2 years of medical school provide a foundation -- a starting place from which clinical knowledge will grow. Although it may be difficult to find time to review old material during clerkships, clinical practice provides an important tool for learning: the patient.
Learning from the context of patient care is truly the most effective way for reviewing topics and expanding your knowledge base. I find it easiest to remember things when related to an experience with a patient. Caring for patients provides necessary opportunities for experiential learning by actually demonstrating the pathophysiology learned during the preclinical years.
For example, I have read about the different physical exam maneuvers that accentuate the murmur of aortic stenosis compared with that of outflow tract obstruction. However, it was not until I treated a patient with aortic stenosis that I was able to truly commit the difference to memory. Moreover, caring for patients motivates you to read more about their diseases and treatments. Associating one's learning with an actual patient provides a considerably stronger framework for remembering facts than simply sitting down and reading about random topics for 2 hours.
Medical student presentations can also serve as excellent mechanisms for reviewing preclinical material and for expanding your knowledge base. As a medical student on a clinical team, you will likely be expected to make at least 1 presentation on a particular disease topic during the course of your rotation. This gives you a chance to become a "mini-expert" on a topic while reviewing material you might have forgotten.
For example, if you have a patient with a type of renal tubular acidosis (RTA), it would behoove you to refresh yourself on the mechanisms behind different types of RTAs. Discussing the pathophysiology behind the disease and pairing it with additional information about diagnosis and therapeutics will help you review and expand your knowledge base simultaneously. In fact, these types of topic reviews also allow you to educate other members of the medical team (so be sure to listen to others' presentations as well). Remember, medical students are closest to the basic science years. Other members of the team appreciate a chance to refresh their own knowledge as well.
Although it may seem daunting to remember and apply knowledge from the first 2 years of medical school to the clinical arena, there are methods for effectively doing so. By continuously revisiting old topics in the context of patient care, you will be able to review your basic science foundation while concurrently learning more about clinical medicine. Although clinical practices are consistently in flux, developing the skills to build upon your understanding of the basic mechanisms of disease is essential to becoming a successful physician.

Five Discovery Skills that Distinguish Great Innovators

Executive Summary:

In The Innovator's DNA, authors Jeff Dyer , Hal Gergersen, and Clayton M. Christensen build on the idea of disruptive innovation to outline the five discovery skills that distinguish the Steve Jobses and Jeff Bezoses of the world from the run-of-the-mill corporate managers. Key concepts include:
  • Academic and medical research supports the idea that innovative tendencies are not genetic. Rather, they can be developed.
  • The authors identify five discovery skills that distinguish successful innovators: associating, questioning, observing, networking, and experimenting.
Clayton M. Christensen is the Robert and Jane Cizik Professor of Business Administration at Harvard Business School.
In their new book, The Innovator's DNA, authors Jeff Dyer, Hal Gergersen, and Clayton M. Christensen build on the idea of disruptive innovation to explain how and why the Steve Jobses and Jeff Bezoses of the world are so successful. This excerpt from Chapter One summarizes the five discovery skills that distinguish innovative entrepreneurs and executives from run-of-the-mill managers.

What Makes Innovators Different?

The Innovator's DNA: Mastering the Five Skills of Disruptive Innovators So what makes innovators different from the rest of us? Most of us believe this question has been answered. It's a genetic endowment. Some people are right brained, which allows them to be more intuitive and divergent thinkers. Either you have it or you don't.
But does research really support this idea? Our research confirms others' work that creativity skills are not simply genetic traits endowed at birth, but that they can be developed. In fact, the most comprehensive study confirming this was done by a group of researchers, Merton Reznikoff, George Domino, Carolyn Bridges, and Merton Honeymon, who studied creative abilities in 117 pairs of identical and fraternal twins. Testing twins aged fifteen to twenty-two, they found that only about 30 percent of the performance of identical twins on a battery of ten creativity tests could be attributed to genetics.  In contrast, roughly 80 percent to 85 percent of the twins' performance on general intelligence (IQ) tests could be attributed to genetics.
So general intelligence (at least the way scientists measure it) is basically a genetic endowment, but creativity is not.
Nurture trumps nature as far as creativity goes.
Six other creativity studies of identical twins confirm the Reznikoff et al. result: roughly 25 percent to 40 percent of what we do innovatively stems from genetics. That means that roughly two-thirds of our innovation skills still come through learning—from first understanding the skill, then practicing it, and ultimately gaining confidence in our capacity to create.
This is one reason that individuals who grow up in societies that promote community versus individualism and hierarchy over merit—such as Japan, China, Korea, and many Arab nations—are less likely to creatively challenge the status quo and turn out innovations (or win Nobel prizes).
To be sure, many innovators in our study seemed genetically gifted. But more importantly, they often described how they acquired innovation skills from role models who made it "safe" as well as exciting to discover new ways of doing things.
If innovators can be made and not just born, how then do they come up with great new ideas?
Our research on roughly five hundred innovators compared to roughly five thousand executives led us to identify five discovery skills that distinguish innovators from typical executives.

First and foremost, innovators count on a cognitive skill that we call "associational thinking" or simply "associating." Associating happens as the brain tries to synthesize and make sense of novel inputs. It helps innovators discover new directions by making connections across seemingly unrelated questions, problems, or ideas. Innovative breakthroughs often happen at the intersection of diverse disciplines and fields. Author Frans Johanssen described this phenomenon as "the Medici effect," referring to the creative explosion in Florence when the Medici family brought together creators from a wide range of disciplines—sculptors, scientist, poets, philosophers, painters, and architects. As these individuals connected, they created new ideas at the intersection of their respective fields, thereby spawning the Renaissance, one of the most innovative eras in history. Put simply, innovative thinkers connect fields, problems, or ideas that others find unrelated.
The other four discovery skills trigger associational thinking by helping innovators increase their stock of building-block ideas from which innovative ideas spring. Specifically, innovators engage the following behavioral skills more frequently:

Questioning. Innovators are consummate questioners who show a passion for inquiry. Their queries frequently challenge the status quo, just as [Apple Inc. co-founder Steve] Jobs did when he asked, "Why does a computer need a fan?" They love to ask, "If we tried this, what would happen?" Innovators, like Jobs, ask questions to understand how things really are today, why they are that way, and how they might be changed or disrupted.
Collectively, their questions provoke new insights, connections, possibilities, and directions.
We found that innovators consistently demonstrate a high Q/A ratio, where questions (Q) not only outnumber answers (A) in a typical conversation, but are valued at least as highly as good answers.

Observing. Innovators are also intense observers. They carefully watch the world around them—including customers, products, services, technologies, and companies—and the observations help them gain insights into and ideas for new ways of doing things. Jobs's observation trip to Xerox PARC provided the germ of insight that was the catalyst for both the Macintosh's innovative operating system and mouse, and Apple's current OSX operating system.

Networking. Innovators spend a lot of time and energy finding and testing ideas through a diverse network of individuals who vary wildly in their backgrounds and perspectives. Rather than simply doing social networking or networking for resources, they actively search for new ideas by talking to people who may offer a radically different view of things.
For example, Jobs talked with an Apple Fellow named Alan Kay, who told him to "go visit these crazy guys up in San Rafael, California." The crazy guys were Ed Catmull and Alvy Ray, who headed up a small computer graphics operation called Industrial Light & Magic (the group created special effects for George Lucas's movies). Fascinated by their operation, Jobs bought Industrial Light & Magic for $10 million, renamed it Pixar, and eventually took it public for $1 billion. Had he never chatted with Kay, he would never have wound up purchasing Pixar, and the world might never have thrilled to wonderful animated films like Toy Story,WALL-E, and Up.

Experimenting. Finally, innovators are constantly trying out new experiences and piloting new ideas. Experimenters unceasingly explore the world intellectually and experientially, holding convictions at bay and testing hypotheses along the way.
They visit new places, try new things, seek new information, and experiment to learn new things.
Jobs, for example, has tried new experiences all his life—from meditation and living in an ashram in India to dropping in on a calligraphy class at Reed College.
All these varied experiences would later trigger ideas for innovations at Apple Computer.

Collectively, these discovery skills—the cognitive skill of associating and the behavioral skills of questioning, observing, networking, and experimenting—constitute what we call the innovator's DNA, or the code for generating innovative business ideas.

Monday, August 8, 2011

AHA/ASA Issue Scientific Statement on Vascular Dementia

  From Medscape Education Clinical Briefs

News Author: Megan Brooks
CME Author: Désirée Lie, MD, MSEd
 07/28/2011Stroke. Published online July 21, 2011.

Study Highlights

  • The overall prevalence of dementia in developed countries is 5% to 10% in persons 65 years and older. The prevalence of Alzheimer's disease doubles every 4.3 years, with vascular dementia doubling every 5.3 years.
  • VCI embraces the spectrum of severity from prodrome to full-blown manifestations of cognitive impairment including stroke, and from pure Alzheimer's disease to vascular dementia.
  • Criteria for a diagnosis of VCI should be based on the presence of 2 factors: demonstrated cognitive disorder (such as dementia) by neuropsychological testing, and a history of stroke or evidence of vascular disease by neuroimaging testing.
  • It is often difficult to determine if the cognitive impairment is the result of vascular factors or deterioration in Alzheimer's disease.
  • Magnetic resonance imaging and other neuroimaging techniques are useful for detection of VCI and provide evidence that subcortical forms with white matter hyperintensities and small deep infarcts are common.
  • Risk factors for vascular dementia and VCI can be nonmodifiable and modifiable.
  • Nonmodifiable factors include increasing age. There is a suggestion that ethnicity may be a risk factor, with a higher incidence in blacks and Hispanics vs whites.
  • Genetic factors are involved in Alzheimer's disease, but their role in VCI is unclear at present.
  • Modifiable risk factors include education, diet, physical activity, body mass index, and social support.
  • Although lower education has been cited as a risk for VCI, there may be confounders explaining the link.
  • Antioxidants have been suggested as being protective for VCI, but prospective randomized trials do not support a benefit.
  • High intake of fish has been found to be inversely related to the risk for VCI.
  • The role of vitamin D, folic acid, and the B vitamins remains unclear. However, antioxidants and B vitamins are not considered useful in the prevention of VCI, even when homocysteine levels are improved.
  • Long-term physical activity has been shown to be protective for VCI and for preservation of brain health.
  • Obesity and smoking have both been implicated in the risk for VCI.
  • The current recommendations to reduce the risk for VCI are smoking cessation, moderate alcohol intake, weight control, and moderate physical activity.
  • The Mediterranean diet has been found to be helpful in the prevention of cognitive decline.
  • In persons at risk for VCI, other recommendations to reduce risk include treatment of atrial fibrillation, hypertension, hyperglycemia, and hypercholesterolemia, but it is unclear if treatment of inflammation would affect risk.
  • The longer the treatment of hypertension, the greater the benefit in the prevention of VCI. Compared with the oldest old, the youngest old experience the greatest benefits.
  • In general, prevention of chronic vascular disease may help to reduce the burden of VCI, dementia, and recurrent stroke.
  • For treatment, donepezil can be useful for cognitive enhancement in patients with vascular dementia.
  • Galantamine may be beneficial for mixed Alzheimer's disease and vascular dementia.
  • Rivastigmine and memantine are not considered useful in vascular dementia at present.
  • Antiaggregant therapy has not been found to be effective.
  • Cognitive rehabilitation and cognitive stimulation have not been proven to be useful so far; more studies are needed.
  • Acupuncture was found to be useful in 1 rodent study, but a Cochrane review found inconclusive results in human studies.
  • Recent recommendations for stroke prevention from the AHA are a useful guide for VCI prevention in risk management.
  • The authors concluded that early detection of VCI with use of neuropsychological batteries, neuroimaging, and preventive strategies — especially prevention of cardiovascular disease — were important approaches to improve outcomes.

Clinical Implications

  • Risk factors for VCI are similar to those for cardiovascular disease, and risk reduction involves similar approaches.
  • Donepezil and galantamine may be beneficial for VCI, but rivastigmine and memantine, cognitive stimulation, and cognitive rehabilitation have not been found to be helpful.

Sunday, August 7, 2011

The Three Foundations of a Great Life, Great Leadership, and a Great Organization

Michael C. Jensen is the Jesse Isidor Straus Professor of Business Administration, Emeritus, at Harvard Business School.

Executive Summary:

This is the commencement speech that HBS professor Michael Jensen delivered to the 2011 graduates of the McDonough School of Business at Georgetown University. Drawing from his own experiences, he discusses the three foundations of a great personal life, great leadership, and a great organization.
Those three foundations are integrity, authenticity, and being committed to something bigger than oneself.
Key concepts include:
  • As integrity declines, workability declines. As workability declines, value (or more generally, the opportunity for performance) declines.
  • The actionable pathway to authenticity is to be authentic about your inauthenticities.
  • Being committed to something bigger than oneself is the source of both personal and corporate passion and energy.


I argue here that the three factors my co-authors and I identify as constituting the foundation for being a leader and the effective exercise of leadership can also be seen as the foundations not only for great leadership, but also for a high quality personal life and an extraordinary organization.
One can see this as a "value free" approach to values because,
1) integrity as we define it (being whole and complete) is a purely positive proposition,
2) authenticity is also a purely positive proposition (being and acting consistent with who you hold yourself out to be for others and who you hold yourself to be for yourself), and
3) being committed to something bigger than oneself is also a purely positive proposition (that says nothing about what that commitment should be other than it be bigger than oneself).

full video is available at

Friday, August 5, 2011

Air Cleaners Do Not Thwart Most Effects of Secondhand Smoke

From Medscape Medical News

Emma Hitt, PhD

August 4, 2011 — Air cleaners significantly reduce particulate matter (PM) levels but are not enough to reduce exposure to secondhand smoke in inner-city children with asthma residing with a smoker, a new study has found.
Arlene M. Butz, ScD, MSN, CPNP, with the Division of General Pediatrics at The Johns Hopkins University School of Medicine, in Baltimore, Maryland, and colleagues reported the findings in the August issue of the Archives of Pediatrics & Adolescent Medicine.
"Despite parental awareness that second-hand smoke exacerbates asthma, 40% to 67% of inner-city children with asthma reside in a household with at least 1 smoker," the study authors note.
According to the researchers, PM concentrations of secondhand smoke exposures have previously been found to be reduced with the use of air cleaners.
The current study sought to test the ability of an air cleaner only (n = 41), an air cleaner plus a health coach (n = 41), or delayed air cleaners (control; n = 44) in reducing PM, air nicotine, and urine cotinine concentrations. The number of symptom-free days was also evaluated.
Eligible children were aged 6 to 12 years, with clinician-diagnosed asthma, symptom frequency, and/or controller medication use signifying persistent asthma. A smoker, who smoked more than 5 cigarettes per day and resided in the home at least 4 days per week, was also present.
Reductions in mean fine and coarse PM (PM2.5 and PM2.5-10) concentrations from baseline to 6 months were significantly higher in both air cleaner groups vs the control group (PM2.5 concentrations, P = .003; and PM2.5-10 concentrations, P = .02 for differences between both air cleaner groups and control).

However, the presence of secondhand smoke, as measured by air nicotine and urine cotinine concentrations, was comparable among the groups.
Use of a health coach did not further reduce PM concentrations.
Air cleaner groups, when combined, had a significant increase in symptom-free days during the past 2 weeks (1.36 vs 0.24 symptom-free days for control group children from baseline to follow-up), representing an increase of 14% to 18% symptom-free days, and yielding an additional 33 symptom-free days per year.
"Use of air cleaners in homes of children with asthma was associated with a significant reduction in indoor PM concentrations and increase in symptom-free days," the study authors note. "However, the reduced indoor PM levels were not sufficiently decreased to meet EPA [Environmental Protection Agency] standards for outdoor air quality," they add.

Arch Pediatr Adolesc Med. 2011;165:741-748.

Wednesday, August 3, 2011

Burned Out? How Doctors Recover Their Spark

From Medscape Business of Medicine

Shelly M. Reese


When Steve Hyman, MD, from Nashville, Tennessee, looks back, he doesn't like the person he used to be.
"I was a lot meaner then," says Hyman, an anesthesiologist. "I was a lot less tolerant. I had a chronic depression and I didn't know what the problem was." Attributing his malaise to his workplace, he switched practices. It didn't help.
It wasn't until Dr. Hyman cut back his work schedule to 3 days a week and started using his new found spare time to indulge a forgotten passion for piano that he was able to pinpoint the root of his problem: burnout.
Today Dr. Hyman happily splits his time between medicine and music. Three days a week he is in the operating room. The rest of the time he is a concert pianist performing recitals and playing with regional orchestras.

Dr. Hyman wasn't able to avoid burnout, but he was fortunate to find a way out of the abyss. It's something that other doctors can do as well.                                                                                                          

Burnout: "A Loss of Ideals and Hope"     
Stress and burnout are often lumped together, but they are distinct processes.
Unlike stress, which is associated with overengagement, burnout is characterized by disengagement, blunted emotions, depression, exhaustion that affects motivation and drive, and demoralization.  
Stress produces a sense of urgency and hyperactivity. 
Burnout produces a sense of helplessness and hopelessness.

Archibald Hart, PhD, psychologist, author, and Dean Emeritus of the Fuller Theological Seminary School of Psychology in Pasadena, California, noted that "Burnout can best be understood as a loss of ideals and hope."
Stress is omnipresent. Underwater mortgages, the economy, job losses, and the mundane stressors of daily living affect many people. Every industry has its own cache of challenges. Doctors may have to contend with healthcare reform, EMRs, reduced rates, medical school loans, and pressure to see more patients.

What puts physicians at greater risk for burnout isn't necessarily the work-a-day stresses they face but the nature of their role as caregivers, says Neelum Aggarwal, MD, a Chicago neurologist who frequently lectures on stress and burnout. "We have to interact with many people many times a day," she says, "and the element of having to provide care for someone -- the personal responsibility for someone else's health -- that's an unconscious element that feeds into everything."
It's a role that many physicians -- unlike professionals in most other fields -- internalize, notes John-Henry Pfifferling, PhD, director of the Center for Professional Well-Being in Durham, North Carolina. "The greatest risk for burnout comes when the doctor identifies being a doctor as who they are."

"Delayed Gratification" Puts Doctors at Risk

Part of the problem, Dr. Aggarwal says, is that doctors are in constant motion. They're also very purposeful and, thanks to their protracted medical training, masters when it comes to delayed gratification.
Those qualities, especially if they're mixed with characteristics such as perfectionism, conscientiousness, a need to be in control, and difficulty relaxing, can put physicians at risk, she says.
"When you are always doing, you can't step back and see the big picture," she says. "Often people know something is wrong. They sense it. But the way they try to work through it is, 'Maybe I'm not productive enough or efficient enough' and they go back and try to do more. Figuring out what's wrong really requires stepping back."
The workplace often exacerbates the problem. It's not just long work hours, demanding post call schedules, and administrative demands, notes Pfifferling.
Physicians aren't taught how to work in teams and support each other, and there's a stigma associated with reaching out for help.
What's more, although they're very good about preaching self-care to their patients, they often don't internalize those messages.
"When I talk about burnout I used to start with the medical aspects -- diet and exercise -- for preventing it," says Dr. Aggarwal. "But I realized that just put them back into 'doing' mode.
Now I start with, 'You have to learn to sit and be at peace with yourself.' That hits home with people because most doctors can't just sit quietly."
Dr. Aggarwal herself spends an hour in quiet each morning. Quiet sitting might involve meditation, inspirational reading, listening to relaxing music, or just doing nothing, she says, and it's a skill that doctors need to master before they can move on to more active tactics for combating burnout, such as breathing exercises, walking, improving their diet and -- most important -- adding joyful pursuits back into their lives.

The Importance of Meaningful Pursuits

In February 2008 asked 1200 physicians how they avoid burnout.
The answer: They aren't couch potatoes. Respondents listed participating in sports, travel, and outdoor activities as their top 3 burnout busters .
Many mentioned volunteer and humanitarian commitments as well.
A recent posting on the Medscape discussion board posed the same question. "Exercise every day," advised one physician. "I'm not a gym rat or fitness freak. I'm just talking about a 20-minute walk. Leave the cell phone at home." Another advised, "Buy a small vacation house in Sarasota and go there for 5 days every 4-6 weeks. I did, starting 4 years ago before I sold my practice, and I came back refreshed and recharged."

Diet, exercise, and rest are important components to health, but wellness is a holistic pursuit with physical, emotional, psychological, and spiritual components.

Physicians need to remember -- or discover -- what brings them joy and fulfillment. It might be making dinner with family or friends, listening to music, bowling, traveling, volunteering, or participating in spiritual or religious activities. Whatever pastime they find fulfilling, Dr. Aggarwal says, doctors need to purposefully reintroduce it into their lives.

As easy as it sounds, it can be very difficult to break out of the cycle of perpetual motion, Dr. Hyman says.
"When you have a really strong work ethic and take time off for yourself, you feel guilty about the free time. It takes you a while to get over that," he says. It was only when he brought music back into his life that he was able to accept and embrace the difference between "what I want to be doing and what I do for a living."
Although it definitely falls in the "doing" category, finding a long-term way to deal with burnout means addressing workplace issues as well, says Gabriela Cora, MD, a psychiatrist and author of Leading Under Pressure: Strategies to Avoid Burnout, Increase Energy, and Improve Your Well-Being. That means finding a way to take control over your environment and workload and learning to say "no."

"Don't just look at yourself," she advises, "Look at your practice. Is your nurse practitioner or your office manager stressed out? Look at your turnover. What's the mood? Burnout often happens when there is a lack of processes but also a lack of lifestyle balance. You need a combination of organizational skills and lifestyle strategy to tackle it."

The Cost of Stoicism

Finally, Dr. Hyman says, doctors need to understand that in ignoring the symptoms of burnout, they aren't being stoic; rather, they are doing a disservice to themselves, to the people around them, and to their patients.
"In the field of medicine, particularly for people who trained 20 or 30 years ago, the mindset was that you really needed to forego everything to practice medicine. But when you feel so bad about yourself and your workplace, to go there and be cheerful and give 100% is very difficult," he says.
Fortunately, he says, that's not a problem for him anymore.
"Now when I go to work I'm ready to be there. I like my work and I do a really good job. I don't think the fact that I have other interests and that I don't love my work makes me a bad physician. It doesn't make me less empathetic to my patients. You have to take care of yourself."