Choosing Gratitude

By Kara Frame, MD

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I don’t remember the exact lecture or rotation, but somewhere along the course of my medical school education, I was taught this powerful lesson: a person is capable of changing how she thinks.  Of course, people have natural tendencies- leaning more positive or tending toward a more pessimistic outlook- but to some degree these preferences are pliable rather than fixed.

 

In a very rudimentary way, it can be explained like this: our brains are facile, constantly remodeling themselves.  And, if a thought becomes repetitive, it reinforces the nerve pathway that it triggers, essentially making the pathway stronger. The reverse can also be true, if we de-emphasize a certain pathway (thought process) it may become less prominent. This lesson resonated with me and the concept seems to resurface in my conscious at different intervals in my life.

 

As a family doctor, the idea has helped me offer hope to patients, many of whom, unfortunately, struggle with depression and anxiety.  Of course, I would never mean to suggest to them or to you that their disease can just be willed away, that simply reframing their thinking will make all of their problems disappear.  That way of thinking suggests the disease is completely within their control, something they might have caused or are responsible for, which is grossly false and is partly responsible for the stigma they often feel when it comes to mental health conditions. It minimizes their experiences.  However, when I talk about the multi-pronged treatment that I often recommend for depression or anxiety, it typically includes medication, good therapy, and lifestyle interventions.  The last part can be overwhelming but it can also be empowering.  When you are battling depression and/or anxiety, so much feels out of control.  You might feel at times as if you are “going crazy” or losing your mind.  It often comes with a sense of hopelessness.  So, the idea that there may be things within your control can be uplifting.

 

Eating well, being physically active, being rested, generally taking care of ourselves: these are the pillars of health that can be difficult to maintain even when we are not depressed, so trying to do this under the weight of depression can become impossible.  Therefore, I encourage my patients to start very small.  To choose one thing to focus on first and then we build over time from there.  Still, just wanting to exercise more or eat “better” doesn’t often get the desired results, so we often have to back up a few steps.

 

No one can make a change until she understands what is stopping her in the first place.  And, for many of us, that something that is in the way is often our own thinking.  “I am so out of shape, what’s the point?” “I can’t even walk to the mailbox-there’s no way I can run.” “I have already eaten half the bag, what difference does it make if I eat the whole thing now?”  These are all paraphrased examples of the negative self-talk, I have heard from patients.  When they start to think about change, some version of these negative thoughts will run through their heads. And, once these negative thoughts are recognized, the work of re-framing them can begin.  If we recognize the repetitive thinking as it begins, we can then stop it and shift to something different, replacing the negative with more positive and actionable thoughts.

 

As for us doctors, we are not above the negativity.  In fact, we are often more susceptible. It is generally accepted that doctors have a higher rate of burnout than the general public, and we certainly are at risk for depression.  People talk about the jadedness that often envelops physicians somewhere along their training- people who began a profession with total optimism and a desire to help too often becoming filled with negativity and, sometimes, contempt.  I have seen this in residents, young doctors going through the gauntlet that is residency.  There are times when it can become overwhelming and even the most positive can begin to falter.  And, I have seen this in seasoned physicians with many years of practice under their belts.

 

For my own part, I have been pretty fortunate.  I have been lucky to train, both in medical school and in residency, at places that were very supportive.  And now, I work in a program that places a very high value on personal wellness.  And yet, there have been times when I found myself slipping into negativity, too.  Something I subconsciously considered myself to be above happening to me, just as I had witnessed in other friends, colleagues, and learners.  I have always considered myself to be a positive person, so don’t like it when this new pessimism starts slithering in.  I try to practice what I preach and make an effort to change.  By consciously focusing on the countless things I am grateful for, at least once each day, there is less time for the negative chatter.  When I start this practice, sometimes it is hard to think of much, but as I become more practiced, numerous things pop into my head each day.  By choosing gratitude I also shift back toward optimism.
As I am writing this, I recognize that I am vastly oversimplifying a very complicated process, a process that often has many starts and stops, times of progression and regression.  Yet, in a time where there is a lot of uncertainty, when many feel lost and as if there is nothing in their control, I find it comforting to be reminded that we can do something pretty big: we have the power to change the way we think.

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Kara Frame, MD is an Assistant Professor (Clinical) in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

How Did I Get Here?

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By Jake Whetzel, MD

Recently our residency program has wrapped up another interview season, meeting to review our applicants (and potential future friends and colleagues) to complete our rank list to submit for the Match in March. It is nearly impossible to meet and get to know each applicant as a resident due to rotation schedules limiting your availability to participate in the interviews, or you get caught up in a conversation with one interesting applicant and might miss out on the chance to meet another. Our process allows us to revisit each application and hear from others in the program who had a chance to interact with these future physicians and hear how diverse our applicant pool was, with people coming from all parts of the country, each with different backgrounds and experiences, all ready to become a Family Physician. Being only a couple years removed from going through a similar process, I can still relate to the stress and excitement of choosing my future career. Reviewing our most recent group of applicants has caused me to reflect on my journey to Family Medicine and answer the question – How did I get here?

 

This blog has included a number of pieces last summer/fall that asked writers to answer the question – Why (not) Family Medicine? This was a slightly different version of a question that always seemed to come up during the interview process – Why Family Medicine? To me, the answer is probably the same for both. A career in medicine probably first developed in my mind around middle school, and was based on some great interactions I had with providers early on in my life. I was so impressed with their knowledge and ability to reassure us if things were fine or “fix” things if they weren’t. Initially, I remember thinking Radiology would be kinda cool. It seemed that this just involved looking at pictures and trying to solve the puzzle. As life progressed through high school and college, my thoughts shifted and started to include more about what type of lifestyle I wanted, what would give me fulfillment in life and where I wanted to live. The first and last questions were easy. I knew I wanted to live in a small town, evident within about a week of moving to the “city” of Helena, MT (population estimated just over 30,000 in July 2015) for undergrad. I also knew that I needed to be located in close proximity to mountains that I could escape to when I would need to decompress. And Montana will always be home.

 

Next came the decisions to find a career in medicine that allowed me to return home, a lifestyle so that I could enjoy it, and provide fulfillment in my life. This is where I came to Family Medicine. I would argue basic healthcare is a human right and that any small town community without a provider is underserved in this aspect, whether the next physician is only twenty miles away or one hundred. Without a local provider, chances are people just won’t go to see one until it’s an emergency. This may be due to inconvenience of travel, lack of funds or lack of trust in an outsider. The reason most of us are in primary care is to prevent these “train-wrecks” from occurring. To be truly beneficial to a community like these, I believe you have to be a local. They want someone who is a member of their community, a familiar face they can trust and turn to when they need it the most. When choosing a career, I felt that Family Medicine gave me the best chance at filling this void for a small town. I wanted to be able to take care of all the community members and develop those trusting relationships so that when a patient needs their care to be escalated, they can believe that the decision is in their best interest and consistent with their wishes.

 

One of the greatest things about Family Medicine is that no two paths are the same. Your career can lead you to urgent care, to academics, or to a hospitalist position. Family Medicine provides you with a base to mold your own choice that allows you to hopefully find that dream job that not only gives you the opportunity to make a major difference in other people’s lives, but also gives you a sense of fulfillment in your life. To the future physicians waiting for the Match, I wish you luck and hope that you are able to find that path to your own version of professional success.

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Jake Whetzel, MD is a second year Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

On the Edge of the Future: Imperatives to Succeed in Health care’s Grand Transformation

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By Paul Grundy, MD, MPH, FACOEM, FACPM

Making health care smarter

The current health system transformation has been referred to as health care’s “moon shot” – that defining moment when a grand vision is fulfilled and the world changes.  Cognitive computing systems play a major role in achieving this moon shot.

Cognitive computing systems learn and interact naturally with people to extend what neither humans nor machines could do on their own. They enhance humans’ ability to make decisions by penetrating the complexity of Big Data.

Traditional computers, while powerful, are limited by their programming. They are programmed to review every possible answer or action needed to perform a function or set of tasks. They can only do what they have previously been told to do.

Cognitive computing systems, by contrast, are “trained” using artificial intelligence and machine learning algorithms. They mine the world’s data, make correlations, identify patterns and present actionable, patient-specific information and recommendations to physicians at the point of care. This enables physicians to focus on the diagnosis and the patient relationship when the patient is in front of them rather than spending that time on research. In this sense, cognitive computing is the X-ray of diagnosis: It reveals hidden details of the patient’s condition to enable more informed and accurate decisions.

Consider this example of how cognitive computing will contribute to a patient’s long-term health as well as the healing relationship of trust between the doctor and patient.

A patient with chronic heart failure (CHF) visits his primary care physician seeking a plan of treatment. After the patient meets with his physician he is handed off to the office’s care manager, who calls up the patient’s record and is provided with a personalized plan of care based on a multitude of factors, including the patient’s current health status, family history, genetic predisposition, socio-economic factors and other information. The patient is encouraged by the care manager to download an app for his smartphone that will let his provider track his progress against the plan.

Each day, the app collects information such as the patient’s weight and the answers to his questions about common symptoms. If he has questions about some aspect of his health, his plan of care or his medications, the app either answers the question, or escalates the question to an e-visit with a care manager. In addition, persistent health reminders encourage patients to adopt the right behaviors and develop healthy habits that lead to better health and lower costs.

Based on that patient’s history and current remote data, as well as population health data for thousands of other CHF patients and information from the clinical literature, the app may spontaneously send an alert recommending that the patient consult his doctor.  In that case, it offers to set up an appointment via integration with the office’s scheduling system.

As you can see from this scenario, population health management supported by cognitive computing lets health care organizations identify the right type and scope of care to treat patients in a minimally-invasive fashion and in the most cost-effective setting.

 

 

Outlook for the future

It is not difficult to imagine what health care will look like in the future, because we have already made great strides toward achieving a transformed health care system. The fabric of the care team will continue to advance. New technologies and new structures will drive more efficiency and accountability across healthcare, and give us the confidence that we are making a meaningful difference in patients’ lives.

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Paul Grundy, MD, MPH, FACOEM, FACPM, is the Chief Medical Officer and Global Director of Healthcare Transformation for IBM Healthcare and Life Sciences. He is also a founder of the Patient-Centered Primary Care Collaborative (https://pcpcc.org/), and is an Adjunct Professor in the Department of Family and Preventive Medicine at the University of Utah School of Medicine.