Monday, September 1, 2014

High Tech, High Touch: Technology to Recharge Patients and Family Physicians

I wrote this for the Ohio Family Physician about four years ago.  It's still a message about one of my favorite mechanical health strategies.  I use it a few times each month to get more wholehearted (attempting to balance the autonomic nervous system.)

By A. Patrick Jonas, MD from my article in The Ohio Family Physician

Cardiovascular disease is still the leading cause of death in America. Strategies to decrease the incidence of premature heart deaths are improving. Stents, medications, exercise, diet, etc. are well known interventions.  Biofeedback strategies for controlling blood pressure and stress were popular in the 1970-1990’s, but lost out in the reimbursement wars and disappeared from common use.  With enhanced understanding, those methods are making a comeback, even with some support from the Professional Golfers Association (PGA).
Golfer Nick Doherty had a habit of “choking” on the last day of pro golf events when he was in contention.  A few years ago, he forgot how to choke and became a very effective golfer late in competition.  When other golfers pressed him for his secret, he let them know he was using a biofeedback technology from Heartmath.com, called emWave Personal Stress Reliever and emWave Desktop.  These tools, now used by golfers around the globe, enabled him to be calm and focused under pressure.

Family Physicians are professionals under mounting pressures from outside forces in the health care system as they notice extra pressures in and from their patients.  The focused office visit to manage the high blood pressure is often stretched by the patient into a four or five problem encounter, sometimes trivializing the importance of the blood pressure and its complexity.  The sudden addition of the need to “refill” prescriptions for allergic rhinitis, asthma, gastroesophageal reflux disease (GERD), and the shampoo originally prescribed by their dermatologist add to the stress of the family physician and increase the risk of burnout.  While there are many reasons for these daily events in family medicine practices nationwide, there is no denial of the increased stress in the lives of family physicians and their patients.  With the addition of healthcare transformation and the shift to the Patient Centered Medical Home (PCMH), the stresses havel increased.

Could family physicians and their patients benefit from technology that helps golfers? Could the same technology enable both patient and physician to lower their blood pressure?  Studies support the use of the emWave biofeedback technology to lower blood pressure, improve sleep quality and even help many with poor eating habits when under stress.  In fact, family physicians are all trained to have insights about, and have strategies to help patients with, stress induced symptoms and diseases.  The EM Wave builds on that knowledge with information from neurocardiology about the impact of stress on the heart and subsequent effects on the limbic system, especially the amygdala.
 
One measure of heart-brain connection is heart rate variability (HRV), commonly used to monitor the wellbeing of unborn babies during labor, but also used as a measure of autonomic nervous system function.  Heart rate variability changes from second to second as our thoughts change.  The amygdala is continuously scanning our emotional memory to compare our current situation to past situations.  If a current pattern matches a past stress inducer- boom- a stress response is turned on to protect us.  This immediately decreases the quality of our cognition (test anxiety, anyone?) and increases heart rate, blood pressure and respiratory rate, among other elements of the response.  If our patient is having increased stress reactions and we’re trying to help them with the resulting blood pressure and get to the bottom of a stress reduction strategy, we get our own stress response when they deflect our efforts with the request for the four unrelated prescriptions.  We both need help!

The HRV synchronizes with the amygdala, sending messages from heart to brain and brain to heart.  If the HRV is “coherent” indicating a balance between sympathetic and parasympathetic nervous system elements of the autonomic nervous system, the amygdala is content to allow contentment.  If the HRV is chaotic, the amygdale finds an emotional state in memory that matches that HRV, generating a negative emotional state with a stress reaction, affecting the entire brain and body.
The HeartMath people have a “quick coherence technique” to teach people how to decrease the stress and re-balance the autonomic nervous system.  It has three simple steps that also are used with their software for skill training:
“1.  Heart Focus:  Shift your attention to the area of the heart and breathe slowly and deeply
2.  Heart Breathing:  Keep your focus in the heart by gently breathing- five seconds in and five seconds out- through your heart. Do this two or three times.
3.  Heart Feeling:  Activate and sustain a genuine feeling of appreciation or care for someone or something in your life.  Focus on the good heart feeling as you continue to breathe through the area of your heart.” (Wilson and Childre, 2006)

The beauty of the quick coherence technique and having the ability to become coherent in even the most stressful situations is that the patient or physician employing the skill need not be in a trance-like state.  This is not relaxation therapy.  They can be totally present and contributing with their best brain and heart function in full support.
 
The desktop version of the EM Wave Desktop includes a breathing trainer and games such as flying a balloon or painting a meadow with your coherence.  Several screens in the software enable the user to see a lead II of ECG, coherence scores, autonomic nervous system moment to moment balance between sympathetic and parasympathetic elements, and previous sessions for the same user.  Multiple users can use the same software which is totally self instructional down to the basics of HRV and stress.

Booklets about using the system to approach specific conditions are available on the web site where the EM Wave is sold.  These include, The HeartMath Approach to Managing Hypertension, Transforming Anxiety, Transforming Stress, Transforming Depression, Managing Emotions:  Golf’s Next frontier Booklet.


There are many ways to relate to stress reduction and blood pressure reduction.  The use of electrophysiology and biofeedback may help many family physicians and their patients to avoid or manage stress related diseases.

Friday, August 22, 2014

Patient Response to Appointment Issues and Priorities


Here's a really insightful comment in response to my post Family Medicine: The Generalist

I'm not sure there's a solution to this problem. As a patient I usually come to the doctor with an assortment of complaints. Often it's hard to summarize everything that's going on in a few short statements on a form or when making an appointment. Issues come and go. New things may have come up since the appointment was made. Also, being an old guy, I think I was trained by the doctor I saw several decades ago to simply talk about everything that is bothering me during an appointment. And I sometimes wonder if some minor problem may contain information that would be helpful to the doctor in understanding the more serious problem...and could actually be connected to it. I come to the doctor not as a symptom, but as a person with a number of reasons to seek medical attention. I greatly appreciate the fact that I can come to a family doctor that way and not have to visit a bunch of specialists who may have conflicting ideas about what's wrong and what to do about it. All that's good...from Dave Levingston

This statement is really helpful to remind physicians of how life really is for our patients.  The era of the Electronic Medical Record adds to the tension of misaligned expectations between patients and physicians.  We don't use ours, yet, but may soon dive in.

My response which didn't show was this:

Thanks, Dave for your comments. We have the continuing creative tension between patients and physicians, trying to figure out the big and little picture at the same time as enjoying a continuing relationship of humans. We might have "little picture" visits and "big picture" visits, to balance focus needs with long range needs. The patient's story remains central to every visit. Both persons stories remain central to the relationship of patient and physician- which we could find a better way to emphasize. Your comments are very insightful and right on.

As we work together on saving the good parts of health care, these considerations are important in designing the electronic connections away from the billing focus of the early EMR's to human focus.  I believe it can be done in Family Medicine as we work with patients and doctors to refocus on what's important.

Onward.

Sunday, August 10, 2014

The Family Doctor Song


Fellow Family Physicians,

I was humming the "Family Doctor Song" and feeling proud of what I do as a Family Doctor that is so well supported by this song.  The Family Physician author knows about the Myth and the Magic of Family Doctors.  They also understand the Brain and the Heart of Family doctors.  Likewise, the Myth and Magic, Brain and Heart of Family Medicine.

Such insight generating such poetry and translating into such a song is rare.  But, leave it to Family doctors to express the un-expressible in such a way that the imaginations of those who listen to and feel the message, understand it.

Have you heard it yet?  Have you hummed it yet?  Or sung it yet?

Listen.

Listen to your heart, where the records of thousands of past, present and future patients resonate with human vibrations of meaning.

There is the song.

You are the author.

It isn't finished, yet.

apj