What’s the Quick Fix for the Quick Fix?

Well, I just ran across some news items which remind me of our quick-fix nation. One is a Washington Post article about a project associated with President Obama’s Brain Research through Advancing Innovative Neurotechnologies (BRAIN Initiative) involving the development of computer chips to help treat neuropsychiatric syndromes such as post-traumatic stress disorder.

The program manager at the Defense Advanced Research Projects Agency (DARPA) envisions that the chip would be an alternative to medications–which, by the way, are viewed by many as just another quick fix. A physician blogger who does bariatric surgery also “weighs in” on the issue:

Another funny item seems connected to our drive to have things our way yesterday. There’s a new study which makes older people trip in order to prevent them from falling. You heard that right–to prevent falls, make them trip.

Note the woman who was the subject of this study frankly admits that “she still occasionally falls–even after the training.” Part of the impetus for the study was frustration over the length of time it takes for other proven methods to be effective for fall prevention, things like physical conditioning and avoiding medications that predispose to falls, the latter of which implicates many drugs prescribed by doctors for off-label purposes.

Explain to me again why we can’t teach patience to patients–and doctors?

So what would be the analogous trip-them-up method for preventing emotional distress or psychiatric syndromes? Intentional exposure to the wrong motivational speakers? The idea would be to desensitize you to shame and guilt, I guess.

Are there any other methods for developing resilience and homeostasis other than implantable computer chips and practicing judo on the elderly for their own good?

Well, in fact, mindfulness comes to mind. A recent study published in the American Journal of Psychiatry used mindfulness training to enhance physiologic recovery after inducing predeployment training stress (yes, deliberately) in Marines [1]. In the discussion section, the authors say that mindfulness “…demonstrated beneficial effects across multiple domains indicating enhanced recovery from stress. Moreover, these effects were observed in a nonclinical sample and suggest that responses to stress may be improved through training prior to stress exposure, even in individuals without a mental health condition. Given these results, it is reasonable to speculate that even stronger treatment effects may be observed in treatment-seeking clinical populations. Taken together, these findings constitute evidence for the prevention and treatment of stress-related pathology. In addition, using measures in multiple domains, this study is an important step toward the application of Research Domain Criteria and neuroscience-based diagnoses. The results also have important implications for stress-related mental health research and evidence-based foundations for nonpharmacological prevention and treatment options.”

Did you get that? “Research Domain Criteria” or (RoDC), the holy grail of modern psychiatric research. If we could just speed up that process!

Geddown from there already!

Geddown from there already!

Because here’s the deal about mindfulness–it takes a while to develop a consistent mindfulness practice which would provide the kind of longer term benefit typically seen in experienced meditators. It reminds me of what I learned in the Mindfulness-Based Stress Reduction (MBSR) class I recently “completed” (you never really finish MBSR; you embark on a lifelong learning path to integrate mindfulness into your daily life). When you meditate, one of the first things you notice is the tendency for the mind to wander away repeatedly from focusing on the breath. So you have to “teach the puppy to stay,” which can often feel like telling the puppy repeatedly to get down off the furniture.

It makes me wonder whether this quick-fix culture we have in the training of physicians could use a little early intervention. One way to introduce a sort of tolerance to the time we need to develop well-rounded, humanistic doctors (clinician-teachers as well as research scientists) would be to pay more attention early on in our college careers to the importance of patience. Some of the posts I read on the Humanizing Medicine Blog seem to have a subtext pointing to what seems to be both a symptom and a cause of what’s been called the “hidden curriculum” in medical education.

When I read between the lines of Nina Stoyan-Rozenzweig’s post, I get a sense of the pervasive dark shadow that may lead to much of the stress and burnout in residency and beyond. A couple of excerpts may help reveal what tends to be concealed in everyday life on the wards:

“The development of humanism in medicine requires that these lessons be firmly imprinted, since there are so many factors in medical training and medicine that can throw people off track.”

“Undergraduates tend to admire medical students for having successfully navigated the required medical school hoops, and feel that medical students can be trusted (since students may perceive that certain professors or other authority figures may not truly be on a student’s “side”). Medical students also lack the intimidating level of authority of some professors.”

Doorway to homeWhile mindfulness could be the way out of the morass of medical training, the ironic part of this solution is that we can’t use it like just another quick-fix goal. That’s because it’s a way of being instead of doing. We can open a door with it, which can let us out–and let other things in.

References and Resources:

1. Johnson, D. C., et al. (2014). “Modifying resilience mechanisms in at-risk individuals: a controlled study of mindfulness training in marines preparing for deployment.” Am J Psychiatry 171(8): 844-853.

OBJECTIVE: Military deployment can have profound effects on physical and mental health. Few studies have examined whether interventions prior to deployment can improve mechanisms underlying resilience. Mindfulness-based techniques have been shown to aid recovery from stress and may affect brain-behavior relationships prior to deployment. The authors examined the effect of mindfulness training on resilience mechanisms in active-duty Marines preparing for deployment. METHOD: Eight Marine infantry platoons (N=281) were randomly selected. Four platoons were assigned to receive mindfulness training (N=147) and four were assigned to a training-as-usual control condition (N=134). Platoons were assessed at baseline, 8 weeks after baseline, and during and after a stressful combat training session approximately 9 weeks after baseline. The mindfulness training condition was delivered in the form of 8 weeks of Mindfulness-Based Mind Fitness Training (MMFT), a program comprising 20 hours of classroom instruction plus daily homework exercises. MMFT emphasizes interoceptive awareness, attentional control, and tolerance of present-moment experiences. The main outcome measures were heart rate, breathing rate, plasma neuropeptide Y concentration, score on the Response to Stressful Experiences Scale, and brain activation as measured by functional MRI. RESULTS: Marines who received MMFT showed greater reactivity (heart rate [d=0.43]) and enhanced recovery (heart rate [d=0.67], breathing rate [d=0.93]) after stressful training; lower plasma neuropeptide Y concentration after stressful training (d=0.38); and attenuated blood-oxygen-level-dependent signal in the right insula and anterior cingulate. CONCLUSIONS: The results show that mechanisms related to stress recovery can be modified in healthy individuals prior to stress exposure, with important implications for evidence-based mental health research and treatment.

Link to book Staying Human in Residency

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