the whole child

Health is a Creative Process

One of my staff members recently observed me going from room to room, seeing patients in my pediatric practice, without paper and without a laptop. This is my usual routine. I must have seen three or four kids in a row that afternoon when she asked me how I seemed to know who everyone was and how I remembered the details of their lives and of our encounters. It occurred to me that, after 20 years of practicing medicine, the "how" of each encounter had become as important as the "what."

Yes, I am keenly aware of what is happening in the room when I'm with patients. It wasn't always this way. As a medical student and resident, I was taught to focus on "taking a history" and "doing a physical exam." The very words that describe these basic tenets of practicing medicine convey a one-sidedness, something that doctors do to patients. At the same time, we are taught that the medical history -- literally, the patient's story -- holds the key to their diagnosis 90 percent of the time. I use the word "diagnosis" not simply as a label but as a guide to understanding what needs to change to create optimal health. I have come to understand that the interaction itself -- the sharing of stories -- is critical in this creative process. In order to be effective, the encounter needs to be a two-way engagement. Healing is not something I do to my patients, it's something that we create and facilitate, together.

Being aware of what's happening in the room -- paying attention to the process -- requires an intention, a willingness to be present, to show up and engage with our patients in a way that is mutually respectful and says, "I am here with you and what you have to say matters as much as what I have to say." Maybe it's my training as a musician, but I've come to see my time "in the room" with patients as an interactive creative process, closest in my mind to playing in a jazz ensemble. We each introduce themes, one playing off the other, improvising at times, taking the conversation where we need it to go to allow healing to happen. And when it does, it's magical. Amy Begel, a groundbreaking family therapist and jazz musician, introduced this idea to me years ago in very literal terms. Amazingly, she has pioneered the use of jazz musicians as consultants in family therapy. She asks them to listen to the family's dialogue from behind a one-way mirror, come in the room, and then "play" what they've seen and heard. The family members can in turn respond to the musicians' interpretations. The impact on the therapeutic process can be remarkable. Honoring the creative aspect of the clinical encounter in this way, to me, is genius. Why does it work when it works? Amy comments, "The creative process for both musician and therapist is dependent on the practitioner's ability and willingness to give up control of the outcome." This openness to sharing the process requires what Dr. Brene Brown has described as "the courage to be vulnerable" in order to enhance our connection, which in turn leads ultimately to healing. And that, I believe, is the point.

(originally posted for the Huffington Post)

Social Media and Medicine: Challenges and Opportunities

When it comes to adopting new practices, physicians as a group are typically “late majority” adopters. According to sociologist Everett Rogers, “These individuals approach an innovation with a high degree of skepticism and after the majority of society has adopted the innovation.” On one level, I understand the reluctance to integrate new clinical methods when people’s lives are at stake; of course, we want to minimize the risk of harm while assessing potential benefits. Yet if it weren’t for René Laennec, taking a chance 200 years ago and inventing something as crazy as, well, the stethoscope, we’d still be sticking our ear right up to every patient’s chest and hoping for the best.

The advent of social media in medicine has been met with the same skepticism. While a 2011 QuantiaMD survey found that 87% of physicians use social media personally and 67% use it professionally, most journal articles published on the topic read as four-alarm warnings to tread ever so carefully.

A prime example is the recent policy statement, “Online Medical Professionalism: Patient and Public Relationships,” published in the Annals of Internal Medicine by the American College of Physicians and the Federation of State Medical Boards. Though authors acknowledge that social media platforms present opportunities for professionals, their policy recommendations focus squarely on the challenges, cautioning us to maintain strict professional boundaries and guard our reputations.

While I agree that it’s important to understand the power and reach of what we post, I also agree wholeheartedly with Dr. David Shaywitz, who notes in his Forbes blog:

“I reject the view that the internet and social media are somehow degrading the culture of medicine, or causing it to change for the worse. Instead, I see emerging modalities as offering the profession an urgently needed chance to radically update its approach, and interact with patients, data, and each other in important new ways.”

I believe those who mindfully embrace new digital strategies will find incredible opportunities to engage patients and create what I call a “scalable community.”

With the spread of social media, digital health care initiatives are no longer simply about a one-way, top-down flow of information. Honestly, whether you offer health advice on your blog or publish it in the New England Journal of Medicine, you have to be cognizant about how your words are perceived. The idea of “Web 2.0,” though, is about interactivity, a back-and-forth conversation. It’s about connection and community, not simply information dumping and diagnosing.

Think of these interactive tools as complements to your patient portal. You and your patients can rely on the portal for secure, patient communication about specific health care issues while using social media to engage the community as a whole. Better yet, the most widely used social media are free and portable marketing tools. You just have to learn how to use them.

Medical practices have often been local sources of education and support, and now we’re able to take it to a new, global level. With mindful use of social media, we are able to leverage our positions as trusted community leaders to create and nurture a much larger community. Aamer Hayat, CEO of awc management and my co-presenter at this week’s athenahealth User Conference 2013 session, “Growing Your Business in the Digital Age,” agrees:

“Think of social media as an extension of your neighborhood bar, salon, or even the backyard. It’s a place where you connect with your neighbor, friend, confident and source of all the things you want to know. As physicians, caregivers, and healthcare advocates, that’s what we are supposed to do, connect with people. Social media is a B12 shot to that connection. Embrace it, own it, and you can manage that connection to achieve amazing results.”

(originally posted for athenahealth's blog)

We are the Earth, and the Earth is Us

There is a road in the hearts of all of us, hidden and seldom traveled,
which leads to an unknown, secret place.
The old people came literally to love the soil,
and they sat or reclined on the ground with a feeling of
being close to a mothering power.
Their teepees were built upon the earth
and their altars were made of earth.
The soul was soothing, strengthening, cleansing and healing.
That is why the old Indian still sits upon the earth instead of
propping himself up and away from its life giving forces.
For him, to sit or lie upon the ground is to be able to think more deeply
and to feel more keenly. He can see more clearly into the mysteries of
life and come closer in kinship to other lives about him.
- Chief Luther Standing Bear

The first “official” Earth Day in the U.S. was held on April 22, 1970. The event was one of the signposts of a new environmentalist movement, and we now mark it every April as a reminder to take good care of our Earth. Yes, we should remember this each and every day, but it’s good to have a special time to be mindful of this mission.

The idea of celebrating the Earth is ancient. Native Americans have always considered the care of nature a basic element of their worldview. “We are the Earth and the Earth is us,” they say. We are not separate from nature, from the land and water, from the birds and beasts. How we live our lives impacts our planet and thus affects our lives.

This circular concept is so important to my health philosophy that the first object you will see entering The Whole Child Center is a framed Native American medicine wheel, a mirror of the cyclic nature of life and our relationship to the Earth.

Our interconnectedness to nature is something I teach children in schools when I give Earth Day presentations. I demonstrate for kids the healing power of nature, describing how the Native Americans’ first medicines were the plants that grew around them. Their lives literally depended on cultivating the flowers and trees with which they co-inhabited the Earth. I bring an assortment of herbs like chamomile, lavender, and peppermint, and we talk about how people have relied on these magical cures for as long as we can remember. The kids love to smell and touch the herbs and many, for the first time, viscerally realize how important nature is to our well-being. They are so happy to discover this truth that they laugh out loud while exploring the herbs and spices! My hope is that this experience motivates them to take better care of the Earth.

Is it possible that something as simple as happiness could be the motivating factor to stimulate sustained ecological behavioral change? Professor Paul Bloom at Yale believes so, as he discusses in one of my favorite essays about how to best engage people in environmental stewardship. Are the rising rates of environmentally-linked illnesses like asthma and autism not direct enough for us? Are the scientific predictions of the wide-ranging health impacts of climate change too removed? Bloom offers a compelling and deceptively simple argument for perhaps the most immediate reason why we should want to preserve our habitat: Being in nature makes us happy.

“Put aside for the moment practical considerations like the need for clean air and water, and ignore as well spiritual worries about the sanctity of Mother Earth or religious claims that we are the stewards of creation. Look at it from the coldblooded standpoint of the enhancement of the happiness of our everyday lives. Real natural habitats provide significant sources of pleasure for modern humans. We intuitively grasp this, and this knowledge underlies the anxiety that we feel about nature’s loss. It might be that one day we will be able to replace the experience of nature with “Star Trek” holodecks and robotic animals. But until then, this basic fact about human pleasure is an excellent argument for keeping the real thing.”
- Professor Paul Bloom 

Whatever your motivation, please take a moment today to appreciate the Earth, have a conversation with your children about the wonders of nature, and take the KIWI pledge:

“We pledge to keep the earth clean and protect this planet for future generations. It is our job to promote an eco-friendly lifestyle and maintain a natural, sustainable standard. This is a responsibility we feel will empower humanity and improve our quality of life. We also believe that the protection of the environment is of the utmost importance, and, therefore, will remain in the forefront of our minds.”

For more information, check out KIWI’s terrific Earth Day badges.

(originally posted for Kiwi Magazine Online)

The Rx Life Solution

Posted to the Huffington Post: 04/01/2013 

"Insanity is doing the same thing over and over again and expecting different results."
-- attributed to Albert Einstein

The Problem: Americans are sicker than ever before, and despite throwing tons of money at the problem, we continue to be sicker than citizens of most other affluent countries. According to the Institute of Medicine:

The United States is among the wealthiest nations in the world, but it is far from the healthiest. For many years, Americans have been dying at younger ages than people in almost all other high-income countries. This health disadvantage prevails even though the U.S. spends far more per person on health care than any other nation.

The Solution: Americans are being prescribed, taking and spending more money on medications than ever before. Staggering fact for the day: More than 10 percent of Americans (and more than one-third of those 60 and older) used five or more prescription medications in the past month, according to this 2008 CDC/NHCS survey.

Note to self: It's not working.

Our "one ill-one pill" solution is expensive, ineffective and (in an increasing number of cases) unsafe. We need a new approach. I'm proposing a new solution, one that is more affordable, accessible, effective and safe for the chronic health conditions I see in practice every day -- conditions that in most cases are caused or exacerbated by stress. It's a solution that is truly preventive rather than reactive, one that creates health and wellness. It's participatory and collaborative. I'm calling it "Rx Life."

The Rx Life Solution:

1. Rx Food: Eat real food, not a long list of processed ingredients mashed together masquerading as food. Teach your children that food comes from the earth, not from a can. Grow and prepare your own food. Cultivate a garden or a farm. Buy and eat locally-grown, chemical-free food. Learn why Dr. Mark Hyman believes in the "power of the fork" and spread the word. Teach your kids that eating is a mindful process, not only about ingesting calories but also about nourishing your body, mind and soul. Eating is and ought to be a community activity.

2. Rx Activity: Move your body. Start with something -- any amount, as much as you are able, and build on that foundation. Get your heart rate moving and see what it feels like to be so active that even your hair sweats. Get outside. Experience what author Richard Louv calls the "transformative power of the natural world" and refuse to let your children suffer from nature deficit disorder. Support school recess and encourage free play in natural settings. Inspire creativity -- dance and sing, draw and paint, make things with your own hands, and cultivate your children's imagination.

3. Rx Rest: Make sleep a priority. Create opportunities for rest, especially for teens; they always need far more sleep than they get. Instill good sleep habits from the beginning. Create a quiet, calm place for restful activities. Take time to simply be. Unplug and recharge. Value downtime. Remind your kids -- and yourself -- that it's OK to stop. Listen to Dr. Aviva Romm when she tells you to stop pushing, pushing, pushing... and just breathe.

4. Rx Mindfulness: Be here now. Pay attention to the process. Realize that the most important time is now, the most important person is the one you're with and the most important thing to do is what are doing right here, right now (thank you, Jon Muth -- oh yeah, take time to read stories to your kids like The Three Questions). Practice yoga and meditation -- anything to cultivate what Elena Brower calls the "art of attention." Accept that you will never make all the stress in the world disappear and help your children build their stress-coping toolboxes. Take time to look someone in the eyes, listen to her story, and let her know that you hear her. Be willing to sit in the mud until it settles and the water clears.

My promise to my patients and their families -- and to my family and to myself -- is to spend more time prescribing and living life, to honor the power of food, activity, rest and mindfulness to promote healing and prevent illness. I am fully and authentically committed to walking this walk. Will you join me?

A Pediatrician Recommends the Nature Prescription

For the Children and Nature Network:

It’s late afternoon in the late spring, school’s been out for an hour or so.  I can’t really say for sure ‘cause I’ve totally lost track of time.  I’m knee deep in the muddy creek, eyes scanning for crayfish.  There it is!  Caught one, put in the bucket. We’re also “building a dam,” as we liked to say.  Gathering the perfect shape and size sticks and stones to hold back the mighty river!  Success was when the water slowed at our a-beaver-would-be-proud construction and diverted around the edges.  We never could stop that flow completely despite elaborate architectural debates and plans. My buddies and I are doing what we do after school pretty much every day, all afternoon until the sun started to work its way down, and we knew it was time to head up the hill for dinner.I’m only a few hundred yards from home but I might as well be anywhere.

When I first read “Last Child in the Woods,” this memory came flooding back in full color and sound.  This was my childhood, as I’ve heard from so many people my age and older.

As I reminisced, I also grew increasingly worried for my children and their generation, because I’m seeing every day the price they are paying for living in a world that doesn’t recognize the true value of nature and free play.

I am a father, but I’m also a pediatrician with a busy primary care practice.  And I am witnessing the slow and steady destruction of our children’s emotional and physical wellbeing.

Kids are being diagnosed with anxiety, depression, ADHD, irritable bowel syndrome and migraine headaches at all time high rates.  Whatever labels we want to use, the message is clear – our children are suffering from stress.

While I’ve written previously about our medical systems’ ineffective and (at times) dangerous “one ill-one pill” approach, my point here is about prevention.

Getting kids back into nature is a key part of the solution to keeping kids healthy and truly creating wellness. A mounting number of research studies highlight the positive impact of free outdoor play on children’s emotional and physical health.

I like that and it makes us feel good. It also helps to fund projects when people demand proof. But do we really need randomized controlled trials (RCTs) to prove that spending time in nature is good for us and for our children?

In medical school, doctors are taught that RCTs are the gold standard to prove the worth of medical interventions. But what if the intervention is not a drug dosed exactly the same for every person for the same condition? What if the “treatment” — or better yet, the “prevention” — is something so multifaceted as nature? The more complex our challenges, the more complex the solutions.

This whole person philosophy, embedded in holistic health practice, is critical to solving the chronic health woes of our time, both in research and in practice.

And it is why doctors alone will never solve any of our current major health issues. If we continue to ignore common sense and place our children in increasingly stressful environments without teaching them the crucial coping skills and providing them with the opportunities for safe, unstructured free time in natural settings, we will continue to watch painfully as they deteriorate in mind and body.

We must be willing, as a health care profession, to leave our silos and work together with those colleagues in education, government, and environmental planning who value nature as a key to optimal health. It will only be through this commitment and investment that we will save our children and our future.

 

 

Honey: Nature’s Magical Medical Cure

From Kiwi Magazine:

Winnie-the-Pooh had it figured out—it’s all about the honey. People over many centuries have gathered this tasty, sticky delight to treat everything from coughs to sore throats to skin infections. Honey may, in fact, be nature’s safest over-the-counter cough and cold treatment and its most potent antibiotic—all without the potentially dangerous side effects of conventional medications. Here are some of my favorite medical uses for honey:

1. Cough: Coughing is the body’s way of clearing irritated airways to help your child breathe more comfortably. However, persistent coughing may only irritate the airways and throat further. All that hacking prevents a restful night’s sleep, something parents everywhere want for their little ones. With continuous coughing, it’s no wonder parents reach for whatever can ease the symptoms. However, the AAP and CDC have warned that codeine and dextromethorphan, two common cough medicine ingredients, offer little help and potential for great harm for young children. Complications such as drowsiness or hyperactivity are possible, and more serious adverse effects, like respiratory depression, can happen with overdosing. Many parents ask me about natural alternatives for persistent coughs that interfere with sleep or activities. I turn to honey, demonstrated to be safe and effective for pediatric coughs. You can mix one teaspoon in some water/herbal tea or give it straight up every 2-4 hours. You can also use a blend of honey and homeopathic medicines like Boiron’s Chestal cough syrup.  Do not use honey in babies under a year, as they are at risk for botulism. 

2. Sore throat: I’ve always found honey to be particularly soothing and appealing for kids (and adults) with sore throats. It can be given the same way as noted above for coughs. One study showed how effective Malaysian Tualang honey was for pain and healing after tonsillectomy. If you’ve ever had your tonsils out, you’ll agree that if honey worked for this condition, it will likely do the job for any run-of-the-mill viral pharyngitis. While some evidence suggests certain types of honey may have anti-strep activity, I don’t recommend honey alone as a treatment for streptococcal sore throats. I do, however, recommend it as a complement to antibiotics.

3. Seasonal allergies: The theory is fascinating. Eating a small amount of honey made by bees pollinating local flowers may prevent seasonal allergies due those same pollens.  The idea has to do with immune system tolerance, or the concept that exposure to a small amount of an offending substance can lead to tolerance of large amounts of the same substance. But does it work? In some cases, yes. A recent study looked at response of those with birch pollen allergies to preventive birch pollen honey (BPH). During the allergy season, patients who ingested incremental amounts of BPH preventively reported significantly fewer symptoms and used 50% less antihistamines. You first have to find a farm or market that sells locally pollinated honey (or become a beekeeper) and then give your child a small amount—even a ½ tsp daily should suffice—daily for at least a month before the allergy season begins.  Watch for signs of allergies (runny or stuffy nose, itchy eyes, cough) when you start and stop the honey if those symptoms worsen with ingestion.

4. Impetigo: One of the most common skin infections in children, impetigo usually presents as crusty, weepy yellowish-brown lesions in and around the nose and mouth. Bacteria typically present include staphylococcal and streptococcal species. While these bacteria can peacefully coexist on healthy skin, any time there’s a scrape or cut leading to skin breakdown, these pesky germs can wreak havoc. Conventionally, topical or systemic antibiotics are prescribed, but more and more studies are proving that honey, nature’s antibiotic, may be a safer and equally effective choice. Certain types, like New Zealand’s Manuka honey, have been shown to be very effective when applied topically to infected wounds. Turns out that the most common bacterial infections are quite sensitive to antibacterial compounds in the Manuka honey. Look for brands like Manuka Health New Zealand Ltd’s “Active MGO 400+” and apply three or four times a day to the infected skin area.

This material is adapted from Dr. Rosen’s book, “Treatment Alternatives for Children.”

 

 

Yoga and Children: A Path to Mindfulness

“What day is it?”
It’s today,” squeaked Piglet.
My favorite day,” said Pooh.”
― A.A. Milne

One can always count on Pooh to remind us of what’s truly important. Those of us that work with children (pediatricians, teachers, therapists, and of course, parents) – if we are paying attention – are constantly reminded that children naturally tend to be “in the moment.” We lose that presence as we age and start to worry more about what came before and what will be. One of the costs of growing older may be a decline in mindfulness, the ability to “be here now,” as Yogi Ram Dass famously urged over 40 years ago.

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Buzzed: Energy Drinks + Stimulants = PEDs of Choice?

Teens and young adults are increasingly self-medicating with a combination of caffeine, stimulant medications and alcohol, and it seems that energy drinks -- at times mixed with other substances -- have become the performance-enhancing drugs (PEDs) of choice. Two recent Drug Abuse Warning Network (DAWN) reports from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) are deeply disturbing.

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Originally published in the Huffington Post

High Tech, High Touch: Why Technology Enhances Patient-Centered Care

We live and practice in an increasingly technology-driven society. Email and texting are default methods of communication, and our patients request that we friend them on Facebook and follow health advice delivered in brief 140-character bursts on Twitter. In a 2008 survey conducted by the Commonwealth Fund, nearly 90 percent of respondents indicated they wanted their physicians to communicate electronically. Patients want high-tech doctors. But they also want more face-to-face time, more personal connections; let's call it "high-touch" care. The 21st century buzzword is patient-centered care (PCC), defined by the Institute of Medicine as "care that is respectful of and responsive to individual patient preferences, needs and values." PCC reaffirms the doctor-patient relationship as a key to improving both clinical outcomes and cost-efficiency. There exists a common perception, dating back at least as far back as the Industrial Revolution, that the increasing reliance of society on technology necessarily furthers human disconnection. In the evermore complex world we inhabit, how do we reconcile our high-touch values with our high-tech realities?

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Originally published in the Huffington Post

'Let Them Read Books': Stories as Stress-Busters

Stress is everywhere. Most recent estimates are that 1 in 4 teens are diagnosed with an anxiety disorder. We've seen these numbers explode in recent years following traumatic weather disasters like Hurricanes Katrina and Sandy. Along with poverty, food insecurity and pollution, stress is a major environmental factor negatively impacting other health conditions like asthma. What has been the medical system's response? Predictably, medication prescriptions for conditions like anxiety, depression and ADHD have risen dramatically in recent years. At times, these drugs can be lifesaving, but they are widely over-prescribed and have significant potential adverse effects. The good news is that we have safer, equally effective and less expensive alternatives readily available.

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- Originally published in the Huffington Post