Doctor/Patient Relationships: Who is Responsible

By Karin Krisher

This blog post around, a strong opinion is just what the doctor ordered. The idea of the doctor ordering anything is the topic behind my not-so-subtle opinion. General perceptions/interpretations of a well-written article about doctor/patient relationships– and the conversation surrounding it– have me steamed. And here’s why:

It’s easy to point out the obvious, which is that doctors can act in an authoritarian rather than an authoritative manner that doesn’t allow their patients to feel comfortable having an honest conversation. Of course, this statement is general—and neither the fact of this possibility nor the ease of pointing it out is my criticism of the article.  In fact, the article itself does a lot in the way of exploration.

Here’s my real problem. The article lends itself to a misinterpretation that renders the resulting conversation moot. Most commenters make some sort of sweeping statement about how they agree that the whole system of doctorhood should change. Some make suggestions about what current practitioners can do to ease their patients into conversation.

Teaching the Doctor/Patient Relationship

But few comments, if any, suggest what they as patients can do—and even fewer make statements about how our educational system can make this change before seeking out medical advice on one’s own is even a concern.

My mind immediately flashed to my high school health class, which sufficiently outlined the dangers of drug use and unprotected sex. Completely absent, though, was any mention of general healthcare and the overwhelming responsibility of taking it into one’s own hands.

How? Isn’t learning to communicate with healthcare professionals and solidifying the doctor/patient relationship part of continuing health? Isn’t that facet of health as, if not more, important than an oft-repeated and wildly authoritarian summary of normal teenage risks?

What if the discussion of health as a continuing process became a standard of public education?  Similarly, what if communication classes and a basis in psychology became a standard for medical education programs? Judging from the comments of an educated population on such a well-researched article, this concept really has been so long ignored that we now have only one option: give authority to those that we are saying have too much of authoritarian attitude to fix something broken.

The sheer scope of suggestions about how to fix the system clearly tells us that creating something functional in the first place isn’t on the public’s radar. But it’s in my nature to trace something to its roots, and mine run deep in a public education system that grossly ignores the power of learning how to communicate effectively.

Educating students about communication strategies in public school health classes should not simply be relegated to a one hour session about how important it is to say no to peer pressure. Educating medical students about communication strategies shouldn’t be relegated to a few weak examples of how one will feel the first time they must give an unfortunate diagnosis. We need to dig deeper.

What about teaching the value of general openness and how to achieve it? What about placing that responsibility on both ends, giving both the question asker and the responder the power to effect an open relationship? Currently, we’re stuck asking for less authority and at the same time demanding more. And I use the word stuck for a reason.

Let’s move forward, together. If you are someone who has the power to discuss health education in any sort of forum, do so. And tell us about your efforts in a comment.

Talk to Your Patients About Virtual Care

By Karin Krisher

virtual care











Maybe virtual care isn’t a topic you approach often.

Maybe that’s because of your own thoughts on the doctor/patient relationship, or maybe it’s because you feel your patients won’t be receptive. Whatever the reason, virtual diagnoses and treatments are an up-and-coming phenomena of which you, and your patients, should be aware.

Many insurance companies, including Aetna and Cigna, have made the leap to cover telemedicine. Many patients are searching for an economically sound solution for their health care issues. Many doctors are responding by taking their practices to the web. What can you do?

Simply discussing the possibility of virtual care with your patients will give you a better gauge for telemedicine’s potential.

It may seem counterintuitive at first—after all, isn’t the point of working in a practice that it allows you to develop a relationship with your patients that gives you better, personal knowledge to respond to their medical needs?

But in a changing global communication environment, that relationship can be developed over a vast space. Proximity shouldn’t dictate our ability to give and receive information. Further, doctors enjoy the ability to open up their schedules for appointments that require face-to-face examinations, and patients get the same freedom. The cost is also less for both parties.

Writes Phil Galewitz of Kaiser Health News, “One major obstacle has remained, however: Many state medical boards make it difficult for doctors to practice telemedicine, especially interstate care, by requiring a prior doctor-patient relationship, sometimes involving a prior medical exam.”

This stipulation could be reassuring to your patients, though, and isn’t necessarily a negative concept to hold onto for a moment as we ease our way into this new era of medicine. After we become comfortable with the idea, and telemedicine is a more widespread practice, this stipulation will likely fall to the wayside, giving way to a world in which your patients can choose their care from a wider range of practitioners, and you can expand your clientele to include more patients concerned with your specialty.

Whatever your feeling on the changing medical communication landscape, your patients should know that the option exists. Ask them for their opinion and their concerns to further your understanding of patient desires, and share your opinion and concerns with us– in a comment!

Understanding Depression: Talk to Your Patients About New Information

By Karin Krisher

understanding depression

We know—the conversation about understanding depression is overdone—now.

But 20 years ago, depression was still relatively under the radar, and it took humble admissions from several prominent figures (most notably, Tipper Gore) for American society to recognize and generally accept that depression concerns a chemical imbalance, rather than a lifestyle choice.

Today, there persists a strong dichotomy in the treatment process: depressed people can either A) attempt to correct their chemical imbalance with prescription drugs, or B) change their lifestyle via therapy and personal effort, and wait for mood changes to come about naturally, depending on chosen environment.

But what if neither of these proposed solutions are actually solutions at all? What if depression is a fact about someone’s physical makeup, like blue eyes or big hands, and an attempt to “correct” it is doomed from the start? A newly published study suggested that might be the case.

depression pills

Understanding Depression in Chemical Terms

The study showed that those with higher releases of dopamine in the striatum and ventromedial prefrontal cortex are more willing to work hard for rewards. In other words, a dopamine flood to the areas of the brain that play roles in motivation and reward will motivate those people, regardless of the reward.

“On the other hand, those who were less willing to work hard for a reward had high dopamine levels in another area of the brain that plays a role in emotion and risk perception, the anterior insula.” (Janice Wood, PsychCentral) That lack of motivation persisted even when the participants had knowledge that the resulting reward would be less.

Though the study explicitly refers to motivation as it relates to effort, its implications for mental health are staggering. For so many years, we’ve been “treating” depression, anxiety, schizophrenia and ADD/ADHD as if dopamine was a transmitter whose powers could be harnessed and regulated. Now, the truth is becoming clear: Location, location, location.

If one’s brain were hardwired to release dopamine to certain areas, redirecting it would be a massive task that employed the powers of geneticists, neurologists and psychologists alike—perhaps so massive that we should reconsider the very fact of any effort to “correct” chemical imbalances, and change the way we talk about depression.

depression brain

Motivation is a huge factor in depression. If a person truly desires a reward, they’ll take the necessary initiative. In a world chock full of over-achievers, if a person isn’t willing to work hard because he or she doesn’t actually want the reward that badly, s/he is often faulted in a way, and relegated to a diagnosis of depression.

Or, taking it one step further, the reward the person wants might be different, as the release is in the area of the brain associated with emotion and risk. Perhaps (and this is speculative, but seems intuitive) s/he would be more motivated to take a large emotional risk for an emotional, rather than monetary, reward. But does that make that person, who the rest of society might label “unmotivated,” clinically depressed?

Talk About It

Talking to your patients about depression can be tough. Certainly, you don’t want to negate the reality of its existence. Certainly, what they feel is very real, and in this fast paced, whole-lot-of-work-for-little-reward world, stifling. Certainly, support is needed for that person to function happily amongst those who are in the striatum camp.

But what kind of support is the issue. Maybe we should focus on making the things we can’t change work for us, instead of trying, often without result, to change them. With that thought in mind, talk to your patients about depression and anxiety. It’s a reality that negatively impacts one in ten American adults—and now, we are learning, one that might never change.

That doesn’t mean there is no hope for overall happiness—only that hope needs a new direction.

Tell us about your experiences with understanding depression. Will this new information change how you view that conversation? In what ways?

Vermont Debating Inoculation Legislation

By Karin Krisher

The hot topics among parents today include Autism, diet, technology dependence and of course, inoculation. Most states require vaccinations for children entering public school; currently, Vermont does not.

The debate is, as should be expected, based on the balance between utilitarian arguments and personal freedoms. When so many people do take the steps to proper vaccination, and those individuals’ choices are affected by those that do not take the steps, we have a difficult legislative battle on our hands.

One of the fuels for the battle is the misperception that vaccines and vaccines alone directly cause diseases, disorders or behavioral issues. Parents who choose not to vaccinate are, in their minds, choosing health, making it difficult for anyone to fault them.

But the problem arises when people making that decision would also like to be part of a massive public educational infrastructure, which is a product of the needs of the many. As a majority of people do have their children vaccinated, putting that decision in jeopardy due to the decisions of the few is likely unethical.

At the same time, choices about health are a personal freedom in many senses, and to take that away makes a statement. Our feeling is that representatives are elected to speak for a majority, and so will generally attempt to promote the needs of the majority. The majority of people do vaccinate, and health has become a public effort in many ways, meaning we think Vermont will be making some changes.

How do you feel about vaccinations? Do you recommend them to your patients?

Retractions of Scientific Papers: Talk to Your Colleagues About Truth

By Karin Krisher

retractions of scientific papersWhat does it mean when retractions of scientific papers are on a noticeably steep upward trajectory? Does it mean individuals are less credible overall? Does it mean that publications have abandoned their commitment to truth seeking?



Or does it simply reflect a changing scientific environment that facilitates competition between many little fish in an ocean, rather than encouraging collaboration between the big fish in a smaller pond?

We’re inclined to blame the environment, a negative result of a generally positive change —growth. We of course recognize that online publication of papers allows them to reach a wider audience, meaning errors are likely spotted more often. But the argument here is not really about statistical method—it’s about the attitude shift that seems to have occurred with a boom in numbers of college (more specifically PhD) students and subsequently, scientists.

Because government spending on medical research has increased over time, and because media publication is a business, money is often a factor in a researcher’s success. Writes Carl Zimmer of the New York Times:

“The National Institutes of Health accepts a much lower percentage of grant applications today than in earlier decades. At the same time, many universities expect scientists to draw an increasing part of their salaries from grants, and these pressures have influenced how scientists are promoted.”

These pressures can also lead science down a terrible path: A promotion (and more flawed research efforts) might depend on research that isn’t viable if the researcher/writer has published many articles in journals of high import, an ability also determined by grant allocation.

By definition, the scientific method recognizes ignorance and incorrectness on the part of the scientist. But it has always been about dispelling, rather than encouraging, those traits. Talk to your colleagues about the sharp increase in retractions and discuss what it means to your practice and your way of understanding information.

With the advent of online publication comes the civilian’s ability to rapidly discover and absorb. While access to information is a beautiful thing, access to misinformation can be harmful—and retractions don’t always make headlines.

That’s why it’s important to know your stuff and be capable of dispelling those beliefs that may have been generated from since-retracted studies, either for your patients’ sake or for the value of your own information-seeking lifestyle.

How have you dealt with misinformation in the past, either with your patients or yourself?

How do you feel science can get back to the basics in ensuring the publication of only verifiable material, cutting the number of retractions of scientific papers? Tell us in a comment!

The World’s Oldest Practicing Physician Dies

By Karin Krisher

Dr. Leila Denmark began her career as the first resident of Henrietta Egleston Hospital for Children in Atlanta, admitting the first patient. That was in 1928.

oldest practicing physicianShe retired at 103 as the world’s oldest practicing physician, and died Sunday in Athens, GA at 114, the world’s fourth oldest person.

Dr. Denmark began her personal pediatrics practice in her home in 1931 and saw patients all hours of the day for 70 years, including those children in desperate need of care during the Great Depression.

Family members cited Dr. Denmark’s love of her work and her diet as the reasons for her longevity. Her commitment to the craft of healing was unparalleled.

Talk to Your Patients About Aspirin Therapy

By Karin Krisher

Asprin therapyLet’s begin with a fair warning. This post has nothing to do with supplements or Complementary and Alternative Medicine, except that it relates to something with which 100 percent of your patients are familiar: aspirin therapy. 

We’re bringing it up now because it’s in the news, and so often, that’s where patient concerns are generated. Advocating for or against aspirin therapy might be a little touchy, so instead, let’s just examine the facts. Familiarizing yourself with these ideas, theories and data will equip you to better answer patients’ questions when they arise, or to start the conversation yourself.

First, the most recent news: Two studies published last Thursday indicate that taking daily doses of aspirin can lead to reduced risk of cancer. The results of the studies are no less than staggering.

Writes Rony Carin Rabin for The New York Times, “One of the new studies examined patient data from dozens of large, long-term randomized controlled trials involving tens of thousands of men and women. Researchers at the University of Oxford found that after three years of daily aspirin use, the risk of developing cancer was reduced by almost 25 percent when compared with a control group not taking aspirin. After five years, the risk of dying of cancer was reduced by 37 percent among those taking aspirin.”

The second study found that over an average of 6.5 years, daily use of aspirin reduced the risk of adenocarcinomas by 46 percent. As the findings are hailed as promising and doctors the world over make points of recommending daily aspirin intake in preventative regimens, some are still taking pause. It is widely known that aspirin increases the risk of hemorrhagic strokes and gastrointestinal bleeding, so recommending it, as we mentioned, can be touchy.

Writes Rabin, “An analysis in Archives of Internal Medicine in January found that for every 162 people who took aspirin, the drug prevented one nonfatal heart attack but caused about two serious bleeding episodes.” It’s a matter, then, of weighing the risks and benefits for each patient. If a patient has a long history of colonic cancers in his or her family, perhaps aspirin would be overall beneficial rather than harmful.

If a patient is otherwise healthy with no family history of cancers, recommending daily doses of aspirin could be more detrimental than preventative. Generally, those that take daily aspirin now do so because their perceived cardio risk is greater than the risks of popping that daily pill.

When studies like this come around, many consumers get popping right away, without understanding the study itself or the risks associated with making those types of quick decisions. The Oxford studies, for example, were designed to determine aspirin’s effects on vascular disease, not cancer, though the summarized results don’t generally reveal that information.

Talking to your patients to assess the risks and potential benefits of an individualized aspirin regimen will allow them to make informed decisions. We still don’t know what the “right” amount of aspirin is, or how frequently that amount should be ingested to hit the Goldilocks zone of prevention—studies use anywhere from 75 mgs to 1200 mgs daily as control levels.

While some consumers might take negative comments on aspirin to heart and stop their daily doses suddenly, some might take the positive comments as fact and begin an unnecessary regimen on their own. Neither of these acts will be beneficial—guidance should be individualized.

Keep that in mind with every patient, and approach the conversation about aspirin therapy from an educational, but still exploratory, standpoint.

The Eyes Have it: How Eye Health Affects Total Health

By Karin Krisher

eye health

In humans, eye health can be a great indicator of one’s overall health, especially during the aging process. That’s not to say that people with poor eyesight are unhealthy—only that we can generally glean information from the eyes that tells us about other bodily processes and issues. Researchers at the University of Kansas Medical School have long had their sights set on this concept, and now they have more proof than ever that not only do the eyes indicate health, but the effects of light on the eye might actually contribute to health issues.

It seems intuitive that the amount of light we receive affects our bodies, but it wasn’t until 2002 that the eye’s role in circadian rhythms came to light. Dr. David Berson of Brown University discovered that our eyes actually have more photoreceptors than previously believed, and that the newly discovered properties of the retinal ganglion cells included the cells’ ability to communicate more directly with the brain.

eye healthThese cells are very receptive to blue in the light spectrum, also the part of the spectrum that’s filtered by the eye’s lens, which, as it ages, changes. The pupil gradually narrows and the lens tinges yellow with the passing years. The result is a lack of light (or a change in the wavelength of the light), and a disturbed circadian rhythm.

In a study published in The British Journal of Ophthalmology, Dr. Mainster and Dr. Turner (the aforementioned University of Kansas researchers) “estimated that by age 45, the photoreceptors of the average adult receive just 50 percent of the light needed to fully stimulate the circadian system. By age 55, it dips to 37 percent, and by age 75, to a mere 17 percent.” (Laurie Tarkan for The New York Times)

Eye Health and the Bodily Clock

What do these declining light reception rates mean for overall eye health? And how do we see the effects?

First, it’s important to recognize that our amazing bodily clock does need a bit of assistance from external influences, hence the plight of the night shift worker, who, interestingly enough, is at greater risk for health issues like insomnia, heart disease and cancer than the nine to five-ers. Because the part of the brain that receives messages from the photoreceptive cells is the same part that initiates the release of the hormones melatonin and cortisol, the amount of light absorbed can have far-reaching effects.

eye health

Studies have shown that people with low melatonin secretion have a higher incidence of issues like diabetes and heart disease, and melatonin is thought to have many beneficial actions, including the support of immune system health, memory, mood balance and sleep quality.* Darkness stimulates the release of melatonin and light suppresses its activity—consequently, normal melatonin cycles are disrupted when we are exposed to excessive light in the evening or too little light during the daytime. It’s not difficult to see, then, where eye health problems arise.

The aging process of the eye significantly affects the process that gives melatonin its meaning, according to several studies that prove Dr. Mainster and Dr. Turners’ theories have some clout. One such study, published in The Journal of Biological Rhythms, found that younger subjects had increased alertness, improvements in mood and decreases in sleepiness after having been exposed to blue light, but older subjects had none of the same effects.

Eye Health: Final Thoughts

Because the eye changes so much as we age, it’s important to pay attention to the light that surrounds us. It makes more sense that as we age, we want to spend more time indoors, but doing so further disrupts our circadian rhythms. Lacking support from melatonin, we will then want to spend even more time indoors, moving less and potentially developing associated health complications.

The cycle doesn’t have to continue. We can choose different lighting structures and types, as well as attempt to spend more time outdoors to keep our peepers—and our dispositions—fresh.


* These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.

Old Hat: Exercise and the Aging Process

By Karin Krisher

The aging process is a topic of worn-out discussion. We talk about aging joints, hearts, lungs, livers. We talk about aging parents, pets, friends, and minds. We talk about how to improve the aging process, and wishfully discuss how to slow it down. But what if our conversation changed direction? Instead of aging process generating ways to merely hold onto the youth we once had, what if we took it a step further, and offered patients some hope of actually improving themselves as the aging process carries onward?

That conversation might go something like this:


Even better than the simplicity of this conversation? You don’t have to be the first one to have it. Nearly 33 percent of patients who saw a doctor last year said that doctor told them to exercise—in 2000 this figure was only 23 percent, according to the CDC.

Surprisingly, significant increases in instances of this advice were reported in patients 85 and older. The changing tides of conversation could be the result of mounting evidence that exercise can work wonders for not only the bodies, but also the brains of the elderly. In a review of over 100 cognition-related studies, researchers at the University of Iowa confirmed that MRIs of people in their 60s showed gray and white matter increases after just six short months of exercise.

Exercise and the Aging Process: A Deeper Look

Further, “the hippocampus area of the brain, key for memory formation, shrinks 1 to 2 percent per year in those older than 60, but when people in this age group begin fitness regimens, it grows by 1 to 2 percent instead.” (LATimes)

And that’s not all. Exercise also improves the brain’s ability to work with itself—in other words, it improves the communication channels between different parts. These results showed up in patients that merely walked for 45 minutes, three days a week, suggesting that even moderate exercise has a large effect on cognition.

As if these improvements weren’t enough, the preventative merits of exercise should convince you of the value of this conversation. A study published in Neurology last year reported that of 1,238 elderly people studied, the 25 percent who were the most physically active were nearly half as likely to suffer silent brain infarcts.

Perhaps the most important fact to glean from the Iowa researchers’ analysis of the studies is that those at greater risk for cognitive decline (due to genetic predetermination) certainly have the most to gain from physical activity. Through reducing the chance of developing other conditions that can lead to Alzheimer’s disease, increasing blood flow to the brain, and releasing endorphins to improve stress responses, regular moderate exercise can truly improve patients’ brain function and the aging process.

Next time a patient comes to you concerned with his genetic predisposition to Alzheimer’s or dementia, ask if he has a treadmill.  If the answer is no, encourage him to get to the gym and show him how exercise affects the aging process. You may also want to discuss supplements for energy support and tips for staying active and healthy. His heart, lungs, neurons, synapses and family members will be glad you did.