Boredom as a Health Hazard/Uber as a Cure!

A recent New York Times article featured a photo of Carol Sue Johnson, 73, in her rear view mirror, setting out as a Uber driver. Apparently, an increasing number of older folks are doing gigs for Uber and Lyft.

The main reason is to supplement their income and savings. The average retirement savings for Americans in their 60s is under $200,000. Extra income isn't just for luxuries. And driving for Uber or Lyft is self-scheduled, with no financial penalty for doing a smaller number of hours, appealing features for drivers of all ages. 

But what impressed me most in the New York Times article, and another piece in Time, is how often the older drivers cited the human interest provided by meeting passengers. This makes sense. When I'm in a taxi I often ask drivers about their experience hearing about life's troubles from their passengers. I not infrequently end up telling them that I'm a psychiatrist and that, in a way, they are too. 

Musing on this topic got me thinking about the phrase "bored to death." A search of medical literature led me to a 2010 publication - "Bored to Death" - that reported on the famous Whitehall study of British civil servants. Those who reported higher levels of boredom had poorer health and increased risk of death in subsequent years. The authors speculated that boredom "is almost certainly a proxy for other risk factors." These could include social isolation, poor eating habits, and increased use of alcohol. 

In short, the familiar cliche - "bored to death" - has literal as well as metaphoric truth!

Carol Sue Johnson and the cohort of older Uber/Lyft drivers may well be improving their health by the dual mechanisms of improving their finances and diminishing the risk of boredom.

Mindfulness, Clinical Outcomes, and Patient Safety

Two months ago, when I wrote a post about using the walking we clinicians do in the course of the working day as opportunities for  meditation, I wondered if it was a harebrained idea or a piece of personal eccentricity. But when I came upon "Use Hand Cleaning to Promote Mindfulness in Clinic" published in BMJ earlier this month, I decided there's something to it.

The author is Heather Gilmartin, a nurse fellow in the Colorado VA system. She makes the excellent suggestion that hand washing, a recurrent act of patient care and self care, can be used as a moment of meditation. Here's the practical summary Ms. Gilmartin presents:

A moment of mindfulness

Focus your attention on your thoughts and emotions. Stay present and accept whatever arises, just as it is, without reacting.

Set an intention—be it listening with intent, choosing your words mindfully, or acting with compassion in your next encounter.

Smile to acknowledge this act of kindness to yourself and to your patient.

Alcohol based hand rub

Pause, take a breath, and notice the sound and feel of hand rub being delivered to your palm.
Be present in the moment and experience the sensation of rubbing the foam/gel into your wrists, hands, and fingers until the product evaporates and leaves you clean.

Soap and water

Pause, take a breath, notice that you are turning on the faucet, and regard the feeling of water flowing from your wrists to your fingers.
Be present in the moment and experience the sensation of rubbing soap into your wrists, hands, and fingers, and then washing it all down the drain.

The VA system disseminates innovations well. I anticipate the potential for an epidemic of meditative moments arising from Ms. Gilmartin's modest but well articulated proposal!

Via her article I read an empirical study of the simple idea of using recurrent components of our days as opportunities for "mini-meditative-moments." College students were instructed to wash dishes in their usual manner or to do the ordinarily mindless chore in a mindful manner. The group that meditated as they scrubbed showed increased positive emotion and decreased "nervousness." (The article is at:
"Washing Dishes to Wash the Dishes: Brief Instruction in an Informal Mindfulness Practice.")

Reading the two articles emboldens me to out myself for another practice I've built into my day. I'm vigilant about brushing my teeth twice a day. If tooth brushing takes one minute, in a year it adds up to 12 hours. If it takes two minutes, it's a full day. That's a lot of time to devote to an uninspiring chore. I've taken to applying what Ms. Gilmartin recommends for hand washing to those moments of tooth brushing. It's an N of 1 experiment, but I believe it makes a contribution to overall well being.

I believe that most participants in the US health "system" would agree that the "system" is a mess. There's a massive outpouring of proposals for fixing the broken "system." We need to seek mega-solutions. But micro-improvements, such as what Ms. Gilmartin proposes in her BMJ article, are steps all of us in health care can and should take as part of the larger movement of creating an ever-more ethical environment of care.

A Surgeon Explains and Defends Simultaneous Surgery

In the continuing discussion sparked by the Boston Globe Spotlight Team's reporting on simultaneous surgery, Dr. Alexander Langerman, a head and neck cancer surgeon from Vanderbilt, wrote an informative piece explaining and defending how he conducts the practice. I, as a non surgeon, found his description of the clinical aspects of the practice very informative, and I encourage you to read his article here.

I was especially happy with Dr. Langerman's discussion of informed consent:

If you’re a patient, in your first visit with a surgeon, ask about the plan for your case, the surgeon’s strategies for trainees, and the way the surgeon handles his or her surgical schedule. I encourage you to get to know any residents who may be involved in your operation; they are a highly valuable second set of eyes who have already completed college, medical school, and often years of training so their ideas, questions, and participation elevate care. I would argue you do not need to require the absence of trainees or the continuous presence of the surgeon but rather a well-thought-out plan that has your best interests in mind.

If you are a surgeon or part of a surgical team, discuss your plan with your patients. You should let them know whether a trainee will be participating in or handling a portion of the procedure, and you should let them know if you are going to be out of the room.

If Dr. Langerman's surgical colleagues had all followed his wise guidance, the practice of simultaneous surgery would not have had the shocking impact it had when the story broke.

New Massachusetts Regulations on Simultaneous Surgeries

Two weeks ago I posted about the practice of simultaneous surgeries. It had been the focus of a Boston Globe Spotlight series. Two days ago, the Massachusetts Board of Registration in Medicine - the body that regulates medicine on behalf of the state - ruled that surgeons must record when they leave and reenter the operating room. Nurses currently do this. At many hospitals, surgeons don't.

Simultaneous surgery raises two central questions: What is its impact on patient safety and surgical outcomes? And, what is the impact on patient and public trust of physicians and hospitals?

Dr. James Rickert, president of the Society for Patient Centered Orthopedics, correctly identified informed consent as the central ethical issue:

“I know that surgeons don’t think this is an important issue, so they assume that it’s not important to patients. However, this thinking is wrong. Patients want to know that their surgeon is the individual who actually operated on them, and I think they have a right to this information. We are talking about situations where patients are completely vulnerable and, by definition, there is a risk of death or severe bodily injury.”

I learned from an op ed piece in today's Boston Globe that the American College of Surgery has created a committee to develop policy about simultaneous surgery. The committee includes proponents and opponents of the practice.

There's an important lesson about health system ethics in all of this. Just as it takes a village to raise a child, it takes multiple components of civil society to promote an ethical health system. With regard to the practice of simultaneous surgery, the Boston Globe Spotlight Team brought the issue to a wider public. Individuals, like the author of the op ed I cited (Nancy Brinker, founder of the Susan Komen breast cancer charity) pitched in thoughtfully. A professional association - the American College of Surgery - is working on evidence-based guidelines for how the practice should be handled. Another professional organization - the Society for Patient Centered Orthopedics - nailed the fact that meaningful informed consent must be part of the process.

We tend to think about ethics in terms of individual conscience and behavior. But just as we have come to see quality of care as a system responsibility and errors as not simply the result of individual "bad apples," we must understand health system ethics as the responsibility of organizations as well as individuals. To improve the ethics of the health system we depend on ethical health organizations as well as vigilant individuals.

How to Deal with Controversy over Physician Assisted Death

We in the U.S. are not skilled at resolving controversy. We're vulnerable to demonizing those who hold different views on issues that matter a lot to us. Polarizations like "pro life" vs "pro choice" harden into rigid convictions. Physician assisted death (PAD - sometimes referred to as "physician assisted suicide") could fall into the same intractable trap. The American Association of Hospice and Palliative Medicine (AAHPM) teaches us how to approach the issue in a morally mature manner.

With regard to whether it is ethically acceptable for a physician in a state that allows physician assisted death (currently Oregon, Washington, Montana, Vermont and California) to prescribe a potentially lethal medication for a terminally ill patient that the patient can use if he chooses, the AAHPM believes, as I do, that "sincere, compassionate, morally conscientious individuals stand on either side of [the] debate." That's the opposite of demonization. This crucial recognition leads the Association to take what it calls "a position of 'studied neutrality' on the subject of whether PAD should be legally regulated or prohibited."

Physicians who support PAD will be disappointed that the Association does not endorse it. Physicians who oppose PAD will be disappointed that the Association does not oppose it. What the Association chose to do was to tell its members and society itself how patients can best be cared for if and when PAD is legal. Here's the essence of their view, quoted - with slight modification - from the AAHPM policy statement:

• The permissibility of PAD is dependent upon access to excellent palliative care. No patient should be indirectly coerced to hasten his death because he lacks the best possible medical and palliative care.
• Requests for PAD emanate from a patient with full decision-making capacity.
• All reasonable alternatives to PAD have been considered and implemented if acceptable to the patient.
• The request is voluntary. Safeguards should focus in particular on protection of vulnerable groups including the elderly, frail, poor, or physically and/or mentally handicapped. Coercive influences from family or financial pressure from payors cannot be allowed to play any role.
• The practitioner is willing to participate in  PAD, never being pressured to act against his own conscience if asked to assist a patient in dying.
• The most essential response to the request for PAD...is to attempt to clearly understand the request, to intensify palliative care treatments with the intent to relieve suffering, and to search with the patient for mutually acceptable approaches without violating any party's fundamental values.

The AAHPM has provided admirable ethical and clinical guidance. "Studied neutrality" reflects moral wisdom, not wishy-washy waffling. AAHPM is doing what a professional association does at its best - offering clear guidance to members, the medical profession as a whole, and to wider society.

Informed Consent for Simultaneous Surgeries

Two months ago (here) and again today the Boston Globe Spotlight team wrote about the practice of having one surgeon doing two operations at the same time, moving between two operating rooms and leaving fellows or residents "in charge." Dr. Dennis Burke, a prominent orthopedic surgeon at the Massachusetts General Hospital, brought his concerns about simultaneous surgery to the Spotlight team. Dr. Burke has been dismissed from the hospital for showing redacted records from his own patients to the Globe team. 

Physician leaders at the Massachusetts General Hospital and elsewhere insist that there is no evidence that simultaneous surgery has led to worse outcomes for patients. And advocates defend the practice - which is common at leading hospitals, as (a) efficient use of skilled surgical time and (b) a way to reduce waiting time for patients. 

If simultaneous surgery were recognized as having even a small effect on patient safety, for reasons of prudence (malpractice liability and terrible publicity) as well as ethics, hospitals would not allow it. But let's assume that definitive studies showed there was no increased risk. What then?

Think about it personally. If you were going under the knife, would you want to know that your surgeon would be going in and out of the operating room to do surgery on another patient at the same time? I would. 

If there's no difference in outcomes, physicians might say - "why do I need to tell patients - there's no difference in outcomes?" The answer is that we have an ethical duty to give patients information that's important to them. I've done an informal survey among friends as to whether they regard the question of whether their surgeon would be doing two operations at once as something they would want to know about as part of their decision-making process. 100% said it is.

Revealing the possibility of another surgeon taking charge in the small print of an informed consent "contract" does not do the job. Good ethics requires open discussion. This may well be uncomfortable for surgeons, just as candor about how often they have done a procedure when they are early in the learning curve is. But it's what we owe our patients, and to the reputation of our profession as trustworthy, not devious and evasive.

The Four "As" of Ethics

Here's a mnemonic I've found useful for thinking about the actions health organizations need to take to walk the talk of their values:

1. Analysis ("what is the right thing to do?") This is the activity most familiar to ethics committees and classes in ethics. When is it right to pull the plug? At what age should children make their own health care decisions? When the term "ethicist" is used it's generally associated with the analytic activity.
2. Advocacy ("let's do the right thing!") This is the charismatic leadership function. When  leaders are seen as admirable exemplars of the organization's values, bureaucratic position and natural authority coincide. This is a uniquely powerful configuration. But every group has members who others respect and want to emulate. Wise leaders look to these widely admired member of the group as strong influences on the organization's ethical culture.
3. Administration ("we need to create structures that make it easier to do the right thing.") Ethical behavior is strongly influenced by internal ego ideals, but it's also shaped by external factors like prompts in an electronic record that help us conduct and record advance care planning and nudge us when it hasn't been done.
4. Accountability ("how well are we living our ideals? how can we improve?") Many years ago, a primary care colleague had his assistant ask every patient after their appointment - "did Dr. X do what you needed him to do today?" If the answer was "no," the assistant was trained to intervene, either directly or by calling in to the office. Now we have well developed systems like Press Ganey to assist with accountability at the population level, but the basic function is the one Dr. X implemented on his own.

Ethically admirable health organizations need to cultivate all four of the "As".