Tag: wellness

Does your neurologist walk the talk?

Thanks to Daniel Kahneman and Amos Tversky behavioural psychology and behavioural economics have become very sexy. Kahneman & Tversky have spawned an industry of nudge theorists; people who devise ways of getting populations of people to do things that are good for them.

People with MS are no different from the general population when it comes to doing what they are told to do. We have major issues getting MSers to adhere to lifestyle interventions.

In this long-term follow-up study below MSers who report higher levels of health promotion activities and greater functional ability tend to experience lower levels of fatigue, pain and sleep disturbance and higher levels of cognitive abilities in subsequent years.

Is this the chicken or the egg; i.e. did MSers who were simply doing better more likely to engage in healthy activities compared to those doing less well? The only way to sort this out is to do a randomised controlled trial, which is virtually impossible for lifestyle interventions. What we need are ways of getting MSers to adopt a Brain Healthy lifestyle as part of their routine management plan. The following is the list of things to do:

  1. Smoking – if you are a smoker stop smoking.
  2. Exercise – try and do 5x 30 min aerobic sessions per week. If this is too hard and you are not too disabled you can try HIIT (high-intensity interval training) instead.
  3. Diet – eat a healthy diet. My philosophy is to eat ‘real-food’ that is culturally compatible with your family and friends. Avoid ‘fad diets’ and processed foods, particularly processed carbohydrates.
  4. Alcohol – don’t consume too much alcohol, it is neurotoxic even in relatively small amounts.
  5. Sleep – please make sure you don’t have a sleep disorder and make sure you get good quality sleep.
  6. Comorbidities – make sure you are screened for co-morbidities (hypertension, diabetes, impaired glucose tolerance, high cholesterol levels and dyslipidaemia) and get them treated.
  7. Infections – try and make sure you don’t get recurrent avoidable infections. The big one in MSers is UTIs.
  8. Concomitant medications – review your medications and try and reduce your anti-cholinergic burden as much as possible.
  9. Stress, depression and anxiety –  if you suffer from these get them treated and managed actively. If you haven’t tried mindfulness therapy it is worth giving it a go.
  10. Social capital – work on your social networks. Make sure you have time for friends and family.
  11. Menopause – if you are menopausal you may want to consider hormone replacement therapy. The evidence on whether HRT makes a difference to MS outcomes is weak but interesting enough to consider it if you are a woman.
  12. Wellness – this not only refers to your lifestyle but how it relates to the environment and your spirituality. Many argue you need to live in harmony with the environment to be truly well. I tend to agree. For example, my problem is my carbon footprint, which is impacting on my wellness.

If you have any suggestions to help other MSers with adhering to these principles, or you have any other to add to the list, please feel free to comment. Don’t be shy.

I also think you need to find yourself a neurologist and/or HCP who walks the talk. It is difficult to take a neurologist who is obese, smokes and clearly does not look after himself or herself, seriously when they tell you to improve your lifestyle. Or maybe I am wrong?

Becker et al.  Functional and health promotion predictors of PROMIS® scores in people with multiple sclerosis. Health Psychol. 2019 May;38(5):431-434.

OBJECTIVE: The purpose of this study was to examine the impact of perceived functional abilities and health promotion activities on subsequent symptom experience among those who have lived with multiple sclerosis (MS) for many years.

METHODS: This longitudinal mailed survey study examined Health Promoting Lifestyle Profile II (HPLP) scores and MOS SF 36 scores as predictors of PROMIS® Pain Interference, Pain Intensity, Fatigue, Sleep Disturbance, and Applied Cognition Abilities Scoresamong 260 adults with MS. The community-dwelling sample was initially recruited from the mailing list of the MS Society in a large southwestern state. Respondents were predominantly female, with an average age of 67 years. They had been diagnosed an average of 30 years. Forty per cent reported relapsing-remitting MS, and 41% have the more severe progressive form of the disease.

RESULTS: HPLP and SF 36 Role Physical, Role Emotional, and Social Function scores assessed in 2013 were moderately correlated (r > .30) with PROMIS® Fatigue and PROMIS® Cognitive Abilities scores measured in 2014 and were somewhat predictive of PROMIS® Pain and Sleep Disturbance scores (r > .20). These results were replicated in an analysis using data from Years 2016 and 2017.

CONCLUSIONS: Findings suggest that those who report higher levels of health promotion activities and greater functional ability may experience lower levels of fatigue, pain, and sleep disturbance and higher levels of cognitive abilities in the subsequent year.

AAN 2019 Living Well

I arrived in Philadelphia on Thursday to attend the 2019 AAN annual meeting. The programme of this year continues much of what was started in 2017 and 2018 around burnout and its opposite wellness.

The AAN states: “Neurology is the only medical speciality that has both one of the highest rates of burnout and the lowest rates of work-life balance. AAN leadership is well aware of your daily challenges and how emotional exhaustion can lead to the loss of interest and enthusiasm for practising medicine. It’s important to remember that it is possible to prevent burnout as well as restore well-being. Your health matters to the AAN and we’re here to help. Each day AAN staff and member volunteers are working on your behalf to decrease regulatory hassles to make it easier to be a successful neurologist. Additionally, we’ve compiled the following resources to provide you with tips, tools, and strategies for cultivating well-being and resiliency in your life.”

After last years meeting, I penned the following which I posted on Medium. Little has changed but is clear that neurologists and clinicians, in general, are facing an existential crisis.

Is the art of medicine, and by inference neurology, in terminal decline? Reflections on attending the 2018 American Academy of Neurology meeting in Los Angeles.

The most important part of attending large International conferences is the time for thought, reflection and importantly introspection. The AAN 2018 was no exception. The programme was informative, in a disturbing sort of way, in that a lot of the teaching sessions were dedicated to survival in the workplace; i.e. dealing with burnout, mentorship, work-life balance, mindfulness and meditation, giving and receiving feedback and many issues related to private practice.

When I was a trainee I was expected to be resilient; I simply had to get on with the job at hand. I was too busy to think about or identify these sorts of issues. I am not even sure if ‘burnout’ was an identified problem back in the late ’80s when I started my clinical training. For me, and most of my colleagues, internal medicine and neurology was a calling; ‘our vocation’. Being a doctor was more than simply doing a job. What has changed? My wife tells me the millennials have changed things; they are not as accepting as we were of the status quo and want something different out of life. Play and leisure define the millennials and not their work. Is this true? If yes, maybe I need to play more and work less hard?

The millennials demanding something different from life doesn’t explain it all. Something more seismic is happening to society and medicine. In the current era, often referred to as the post-industrial era, technology has democratised knowledge and the medical profession’s power base of asymmetric knowledge has been eroded. This is leading to an existential crisis for the profession. Unless you have a technical skill that you have honed over years with practice, for example, a surgical skill, our knowledge-based skills are being challenged by the crowd and algorithms. This is leaving the average neurologist frightened and bewildered; like a rabbit caught in the headlights. In the past, my colleagues used to get excited about major advances in medicine. Now what seems to excite them most are reminiscences from the past, from the era when our seniors seemed to be the masters of the universe.

Gone are the days of the clinical anecdote. Big data is now king. I heard a talk at the AAN2018 on pathogen discovery using deep nucleic acid sequencing of clinical samples (blood, spinal fluid, biopsies, etc.) and clever bioinformatics; unsurprisingly, it outperformed the clinicians. Gone are the days when an astute well-trained clinician would have the edge over their colleagues. In the current era technology and big data trump clinical skills and human knowledge.

Another example of a threat to neurology is the revolution that is happening in relation to gene therapy and RNA interference. Both are creating an unprecedented need for presymptomatic genetic diagnosis. Why waste time screening for single genes? Why not simply do whole genome sequencing on everyone at birth so that we can identify treatable genetic diseases, risk profile everyone for common diseases and then let algorithms analyse and reanalyse the genomes of the world’s populations as new information becomes available? It won’t be doctors that will be making diagnoses or treatment decisions it will be algorithms.

Neurologists still cling to the neurological examination claiming it is too complex for a machine to do and interpret. This is clearly not true. Data is emerging that the way we use our smartphones and how we interact with the web tells tech giants, such as Google and Facebook if we are depressed or have signs of early Parkinsonism. Image analysis using artificial intelligence of pictures taken of suspicious skin lesions and the retinae of diabetics are outperforming dermatologists and ophthalmologists at diagnosing skin malignancies and diabetic retinopathy. The same goes for image analysis in radiology and pathology. Why wouldn’t machines get better than us at interpreting physical function?

As we enter a world of smart wearables and other smart technologies it is only a matter of time before a robot will be able to perform and interpret a neurological examination better than we can. I have little doubt that the neurological examination will be deconstructed, improved on and ultimately performed by machines.

So how are we physicians and neurologists going to ensure our survival? Dare I suggest we redefine our role? Clearly, the part we play as diagnosticians will become less important as the algorithms take over this role. Treatment of disease will increasingly be delivered by assistants using care pathways and standardised protocols. IT systems linked to the electronic record will analyse variance. Any variance from the protocol will trigger an investigation into our practices. I am already aware of this happening in multiple sclerosis in relation to possible over- and under-prescribing of highly-effective disease-modifying therapies or DMTs.

To survive in the brave new world neurologists will need new skills, particularly in relation to sifting, curating and communicating information. We will increasingly be called upon to fight fake news and anti-science movements so as to protect our patients from harm. To be effective in this role will need to actively engage with the new media and acquire new digital skills. Neurologists will need to become better listeners and better communicators. We will need to shift the focus from a disease-centric worldview to a preventative and holistic worldview. Treating disease will become a smaller part of our work. We will need to train and support teams of assistants and nurse practitioners who will do the majority of the hands-on work. We will need to become knowledgeable and skilled in lifestyle and wellness counselling. More importantly, we are going to have to walk the talk; we are going to have to live our lives the way we want our patients to live theirs. Neurologists who lead by example will become the pioneers of a new type of neurological practice. Based on my experience at the AAN2018 I would call this Wellness Neurology.

Are you prepared to retrain as a wellness neurologist?

I am still haunted by the concluding lines from The Great Gatsby that are as relevant to me today as they were when I read them as a 16-year old: “So we beat on, boats against the current, borne back ceaselessly into the past.”

Exit mobile version
%%footer%%