What's Ahead in 2011

• The “sick tax” is still with us and not likely to go away in light of a gigantic state deficit.
• The federal government has yet to fix the flawed Medicare physician payment formula, causing insecurity for our colleagues and our patients.  Will it be fixed in 2011?  I am not holding my breath. . .
• Federal and state health reform legislation has passed, and I have a mixture of hope and concern about how this will affect our ability to care for our patients.
• Greater consolidation is occurring among hospitals and clinics in order to survive economically.
• The Baby Boom generation is nearing retirement age.
• Some of us are beginning to wonder if we will ever retire, and if so, who will take care of our patients?

Well, this is starting to put me in a sour mood, so I think I’ll turn to my New Year’s Resolutions, which this year focus on me living my beliefs about physician wellness - the theme of my presidency.

• I resolve to do better to establish and maintain a personal wellness regimen including sensible diet, exercise, work, play, meditation, prayer and cooperation with my colleagues.
• I resolve to support, affirm or hug a physician daily.
• I resolve to be part of solutions instead of problems.
• I will remember why I entered a serving profession and love those whom I have the privilege to serve.
• I will continue to work with others in the MMA to address the overall wellbeing of my colleagues. 
• I will be a positive role model for young people considering medicine, for students and residents.
• I will attend the MMA Day at the Capitol and respectfully educate my legislators who impact our daily lives.
• I resolve to stop making my resolutions public, really, it’s just too much pressure.

But that’s next year. For this year, please hold me accountable. I will be able to succeed with your encouragement. Please feel free to share here your own concerns and resolutions.  Happy New Year!

Patricia Lindholm, MD,
2010-2011 MMA President

Recently a reporter interviewed me for a story to be published at year’s end about a certain politician’s legacy regarding Minnesota health care. As is often the case, there were positives and negatives to report. I had to carefully consider which statements I was making on behalf of the Minnesota Medical Association, and which opinions were my own.  I hope that I represented MMA’s positions clearly and accurately. Anyway, the end of the year talk got me thinking about my own concerns and hopes for 2011. First, here are some of my top concerns:

Learning to say no

Patricia Lindholm, MD,
2010-2011 MMA President

We all have multiple roles in life, and I recently found myself filling several of them during my father’s terminal illness and death in early November. 

Several weeks ago it was apparent that my father was very ill and needed to be hospitalized.  The working diagnosis was pneumonia, but it soon became obvious that something more serious was afoot when a thoracentesis uncovered a significant lung mass.  He allowed the physicians to order scans, cytology, etc.  Later he confessed that he already knew about the cancer as it had been diagnosed in another medical facility; he confessed this to his sister, not to the physicians. (Imagine trying to diagnose and treat a patient who decided not to share such information with you!) My father liked to keep secrets.

I was the health care proxy and executor of my father’s estate.  He lived in Florida, so before getting there, I was doing long-distance work with him and the doctors/relatives/social worker, etc regarding pain management and hospice placement.  It seemed relatively easy initially to be on the “family” end of a health care crisis.  My siblings and I arrived in Florida barely in time to say farewell.  Then it was a blur of arranging cremation, cleaning up his apartment, and selling and giving away household items.   During the two weeks I was away, I carried out some media interviews for the MMA and answered e-mails and even participated in a conference call.  As physicians, we are able to go into “crisis management mode” and defer our own emotional reactions to a later time.  This state of numbness (brain-dead is what I felt at the time) continued for a little while.  Thankfully, the long drive home from Florida was a buffer between the intensity of the family loss and the return to work and life as usual.

Since returning, I have taken more time to grieve and process what has happened, and I’ve  surprised myself by saying “no” to a couple of things. Saying no is something I have spent years trying to learn, and with practice I get better at it.  As physicians, we have been trained to rise to any occasion, to get up and work in the middle of the night, to work with little sleep, and to function in spite of whatever personal issues we are facing.  We were not trained to nurture ourselves when needed.  Saying “no” was somehow shameful. I encourage us all to practice the art of saying “no.”  Obviously this must be done judiciously.  Sometimes saying “no” to more work and responsibility is actually saying “yes” to life and health.  One test that I use to decide whether to say “yes” or “no” is to ask this question: “Will this activity suck the life out of me or give me life?”  It is simplistic, but it works for me. 

Are you doing what works for you?

Chairing a physician well-being task force

Patricia Lindholm, MD,
2010-2011 MMA President

Over the course of the last six months or so, I have been chairing the MMA Physician Well-Being Task Force.   While I was President-Elect I knew that this would be the emphasis of my presidential year and wanted to get an early start on the project.  We have a multidisciplinary group including physicians, chaplains, an attorney and a physician’s spouse.  We are in the process of generating a report and recommendations to the MMA board on how to address physician well-being. 

If you follow the MMA web site you will soon see a section on physician well being.  We have generated an extensive bibliography of articles and resources as well as web links.  We will identify opportunities such as retreats, workshops and educational sessions.  I also hope to provide information to you about how to start a physician peer support group in your local medical community.  We hope to produce some video material that can be accessed on-line. 

A great resource in Minnesota is the University of Minnesota’s Center for Spirituality and Healing.  We will soon have a link to this site.  The Center has many offerings that are valuable regarding self-care including Mindfulness Based Stress Reduction (MBSR) courses.  These are based on the pioneering work of Jon Kabat-Zinn at the University of Massachusetts.  I can enthusiastically recommend this program.  In my personal journey I have practiced MBSR for about two years.  When anxious or stressed the mindfulness meditation exercises have a wonderful calming effect on the mind and bIody. 

Another mindfulness exercise that many of us are practicing is yoga.  When we are practicing yoga asanas or another form of exercise we get out of the brain chatter that is constantly happening in our minds.  We are able to attend to what is real.  We realize where we are and are able to live in the moment.  I have not yet arrived at a continuous state of mindfulness (and likely never will) but even brief mindfulness of my breathing, emotions or bodily sensations during a stressful day can be very healing.

There are several books by Jon Kabat-Zinn that I would recommend if you would like to learn more about mindfulness.  Full Catastrophe Living, Coming to Our Senses and The Mindful Way through Depression have been very valuable resources for me.  Do you have other recommendations to share with your MMA Colleagues?  We would love to hear from you.

Take your own advice and stay home

Patricia Lindholm, MD,
2010-2011 MMA President

A topic of interest to me is “presenteeism” among medical students, residents and physicians.  Yes, this is the opposite of “absenteeism.”  Both conditions may be problematic.  Have you ever presented for work when you were ill?  I confess that I have committed the act of presenteeism on more than a few occasions over the course of my training and career.

Most of us have received the subtle message that illness is a sign of weakness.  Doctors cannot afford to be ill, and especially cannot afford to be absent from work.  When we are absent, our colleagues usually have to pick up our workload and may let us know that they resent it.  Some patients even try to “guilt trip” us after an absence.  Most of us realize that returning to work after any type of absence means facing a mountain of charts, mail and messages that need addressing. 

Is it good practice to work when we have an infectious illness?  Of course not.  Would we advise our patients to stay home when ill?  Of course.  However, the misguided “macho” ethic of our profession has bullied us into doing the wrong thing for ourselves, our coworkers, and especially our patients. 

Is it good practice to work when we are sleep deprived, suicidal, manic, intoxicated?  Is it heroic to work immediately postoperatively or postpartum contrary to the advice of our physicians? 

Friends, let us permit ourselves to heal when sick, recover from surgery and tend to our mental health—if not for ourselves, then for our patients.   Let us also have mercy on our students and colleagues and give them the space to care for themselves.  It is odd that we even need this type of advice, isn’t it?

“Physician heal thyself” indeed!

Wellsprings of resilience

Patricia Lindholm, MD,
2010-2011 MMA President

As physicians, we confront a host of stressful conditions and adversities, related to patient care, practice management, and just life. The challenge of a long-career in medicine is to learn how to bounce-back from these ups and downs, while still maintaining our equilibrium, openness, and wholeness. This is called resiliency by  physician-wellness experts.

I recently listened to a podcast about physician resiliency by pediatric radiologist Richard Gunderman, M.D., of Indiana University. It was part of series of podcasts I highly recommend called “Healthy Practices,” which are moderated by Dr. Mamta Gautam, who is known as “The Doctor’s Doctor.”

One of Dr. Gunderman’s thoughts is that aspiring to significance in our practices and our lives - leading lives that matter - can serve as a wellspring of resilience in ways that striving for success and prestige cannot do. In my view, medicine is a calling, not just a career or a job. I believe that burnout is more likely if we feel like cogs in a big machine, cranking out patient encounters, and racking up RVUs. If we realize that we are actually servants touching the lives of people when they are vulnerable, our work has great significance indeed.  

I would love to hear your stories of resiliency.  How have you recovered from adversity in your professional or personal life?  Can your life lessons inspire one of your colleagues? Leave a comment here or email me. 

Patients may ask about “Dollars for Docs”

Patricia Lindholm, MD,
2010-2011 MMA President

This week I was interviewed for a story by KARE 11 TV about a recent public listing of physicians who have received payments from pharmaceutical companies. We commonly get reporter requests requiring a quick turnaround, and this was one of them. In the middle of a clinic day, I had less than two hours to respond – fortunately, I was able to do the interview on the telephone.

As part of the federal health care reform legislation there will be a requirement for all pharmaceutical companies to report payments to physicians (speaker’s fees or consultant fees) by 2013. This year a few companies published their information and it was noted that over $3 million has been paid to Minnesota physicians from these companies. ProPublica.org, NPR, and other media have made the information searchable by physician and call the project "Dollars for Docs."

KARE11 Reporter Kyle Porter was concerned about how patients should react to the issue of physicians being paid by pharmaceutical companies to promote their drugs. He was concerned that doctors may have a conflict of interest in prescribing drugs they have promoted rather than prescribing alternatives that would be more appropriate for the patient based on cost or other factors.

Earlier this year the MMA issued a policy statement regarding the relationship of physicians and industry that essentially says we disapprove of physicians accepting gifts from pharmaceutical and medical supply companies. Furthermore, the MMA supports making industry payments to doctors for services such as speaking, consulting, or doing research public and transparent. 

You may get questions from patients who have seen this story in various media outlets. If they ask about whether you are prescribing a drug due to relationships with industry, do not be surprised. If your name is on the list of physicians who have received payment from industry I encourage you to be transparent about that arrangement with the patients who ask. 

Personally, I am glad the days are in the past when we were offered free ski vacations, luxury accommodations, expensive meals, etc in the guise of “consulting.” Such offers were tempting, but ethically compromising. Yes, I suppose a pen or pad of paper is a minor trinket, but apparently research has shown that even small tokens subliminally affect prescribing habits.  I guess we are as human as “the next guy.”

Useful Canadian Physician Wellness Websites

Patricia Lindholm, MD,
2010-2011 MMA President

As I mentioned in my last post, the Canadians are doing something special when it comes to physician well-being.  I would like to share some of their resources with you since they are freely available to all of us, and it is not necessary to reinvent the wheel.

One resource that I have been following for over a year is the CMA web site ePhysicianHealth.com.  The content is excellent and includes wellness topics such as nutrition and fitness and resiliency.  There are also modules on anxiety, depression, burnout, substance abuse, disruptive behavior and so forth.  The content is updated periodically.  I was told by some Canadian physicians in Chicago that the site has drawn visitors from numerous countries around the world, with the most frequent use by Russian physicians.  Check it out!

Connected to the ePhysicianHealth.com site is a related site called eWorkplaceHealth.com.  This has good information on how to make our teams and workplaces healthier for ourselves and our coworkers.

Stay tuned for another gem from Canada!

Physician Wellness is an International Concern

Patricia Lindholm, MD,
2010-2011 MMA President

Originally Posted: October 4, 2010

This week I am attending the International Conference on Physician Health in Chicago.  It is jointly sponsored by the AMA, British Medical Association and Canadian Medical Association.  There are physicians here from other countries such as Spain, Australia and Saudi Arabia.  It is clear that we in Minnesota are not alone in our concern for the well-being of physicians.  

It is interesting to see research data that shows that a physician’s self care practices are directly related to the advice that they give patients about self care.  For example, a physician who has had colorectal cancer screening is more likely to advise it for their patients.  If we have adequate exercise and a healthy diet we are more comfortable advising our patients in these areas.

There is an entire “track” at this meeting studying the correlation of physician well being and quality of patient care.  People are also starting to ask how to make the lives of medical students, residents and practicing physicians better.  This is foreign territory for a profession that feels its members should care for others at the expense of ourselves.  There was also a very powerful talk by Dr. Michael F. Meyers on the subject of physician suicide and resilience.  The abstracts for most of the presentations are available on the AMA web site. 

I also notice that the British and the Canadians are way ahead of us in the study of the prevention and treatment of distress in physicians.  However, this month the AMA has released its new toolkit:  AMA Healthier Life Steps-A Physician’s Guide to Personal Health.  It is a good start, but there is much more that we must do for our colleagues.  I am looking forward to advancing this work in Minnesota together with the MMA.