.
BMJ 2004;329:1447-1450 (18 December), doi:10.1136/bmj.329.7480.1447
The limits of medicine
The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%
Oscar H Franco, scientific researcher1, Luc Bonneux, senior researcher2, Chris de Laet, senior researcher1, Anna Peeters, senior researcher3, Ewout W Steyerberg, associate professor1, Johan P Mackenbach, professor1
1 Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands, 2 Belgian Health Care Knowledge Centre (KCE), Wetstraat 155, B-1040, Brussels, Belgium, 3 Department of Epidemiology and Preventive Medicine, Monash University Central and Eastern Clinical School, Melbourne, Australia
Correspondence to: O H Franco o.francoduran@erasmusmc.nl
Abstract
Objective Although the Polypill concept (proposed in 2003) is promising in terms of benefits for cardiovascular risk management, the potential costs and adverse effects are its main pitfalls. The objective of this study was to identify a tastier and safer alternative to the Polypill: the Polymeal.
Methods Data on the ingredients of the Polymeal were taken from the literature. The evidence based recipe included wine, fish, dark chocolate, fruits, vegetables, garlic, and almonds. Data from the Framingham heart study and the Framingham offspring study were used to build life tables to model the benefits of the Polymeal in the general population from age 50, assuming multiplicative correlations.
Results Combining the ingredients of the Polymeal would reduce cardiovascular disease events by 76%. For men, taking the Polymeal daily represented an increase in total life expectancy of 6.6 years, an increase in life expectancy free from cardiovascular disease of 9.0 years, and a decrease in life expectancy with cardiovascular disease of 2.4 years. The corresponding differences for women were 4.8, 8.1, and 3.3 years.
Conclusion The Polymeal promises to be an effective, non-pharmacological, safe, cheap, and tasty alternative to reduce cardiovascular morbidity and increase life expectancy in the general population.
Introduction
Cardiovascular disease continues to be the leading cause of mortality and morbidity in Western populations.1 Although several risk factors for cardiovascular disease have been identified, its prevention is still suboptimal owing to high costs, low compliance, and side effects of treatment. In 2003 Wald and Law introduced the concept of the Polypill.2 The advocates of the Polypill selected six pharmacological components that by modifying different risk factors of cardiovascular disease multiplicatively might reduce the levels of cardiovascular disease in the population by more than 80%.2 In general, the medical community has welcomed the concept but questioned the potential adverse effects and costs of such an intervention.
Our objective was to define a safer, nonpharmacological, and tastier alternative to the Polypill in the general population: the Polymeal. We also wanted to calculate the potential effects of the Polymeal in terms of total life expectancy and life expectancy with and without cardiovascular disease.
Methods
The recipe
To optimise the Polymeal ingredients we used an evidence based diet conceptual framework, which follows similar principles to evidence based medicine.4 The constituting elements of a meal or recipe are selected on the basis of the best available evidence; the evidence available for each ingredient is graded according to the level of evidence. We searched PubMed, informed by expert advice, for nonpharmacological ingredients with evidence levels 1 or 2: randomised controlled trials, meta-analyses of randomised controlled trials, and meta-analyses of observational studies.5 To be included in the Polymeal, the ingredient had to have individually reported effects (not as an element of a diet) on reduction in cardiovascular disease events or modification of risk factors for cardiovascular disease. We checked papers retrieved for further possible ingredients. The following dietary elements met the inclusion criteria to be ingredients of the Polymeal: wine, fish, dark chocolate, fruits and vegetables, almonds, and garlic (Allium sativum).
Efficacy of the Polymeal
We obtained information from the literature on the benefits of the interventions (table 1). Daily consumption of 150 ml of wine reduces cardiovascular disease by 32% (95% confidence interval 33% to 41%).6 Fish (114 g) consumed four times a week reduces cardiovascular disease by 14% (8% to 19%).7 For chocolate, fruits and vegetables, almonds, and garlic, we found data on modification of risk factors for cardiovascular disease. One hundred grams of dark chocolate consumed daily reduces systolic blood pressure by 5.1 mm Hg and diastolic blood pressure by 1.8 mm Hg8; similar reductions in blood pressure correspond to a reduction in cardiovascular disease events of 21% (14% to 27%).9 A total of 400 g of fruit and vegetables consumed daily produced a reduction in blood pressure similar to that observed with chocolate (4.0 mm Hg systolic blood pressure and 1.5 mm Hg diastolic blood pressure), so we decided to assume the same reduction in cardiovascular disease effect as assigned for chocolate (21%).10
View this table:
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[in a new window]
Table 1 Effect of ingredients of Polymeal in reducing risk of cardiovascular disease
Daily consumption of garlic reduced total cholesterol concentrations by 0.44 mmol/l (17.1 mg/dl),11 12 corresponding to 66% of the reduction (0.66 mmol/l) that was found to be associated with a 38% reduction in cardiovascular disease at age 50.13 Therefore, we considered 66% of the effect previously reported and assumed a reduction of 25% (21.7% to 27.7%) in cardiovascular disease events for garlic. Most of the randomised controlled trials included in the meta-analysis used 600-900 mg/day of dried garlic powder preparations, equivalent to 1.8-2.7 g/day of fresh garlic.14 We selected 2.7 g/day of fresh garlic for the Polymeal. Consuming 68 g/day of almonds produced half the reduction in total cholesterol (10 mg/dl) observed with garlic,15 16 so we assumed a reduction in cardiovascular disease half the one assigned to garlic.
We calculated the combined effect of the ingredients of the evidence based diet Polymeal by multiplying their correspondent relative risk estimates. This is the same method that was used for the Polypill.
Saturday, March 27, 2010
Friday, March 26, 2010
FOTEO- reading list (Dr J Moch)
FOTEO Reading list. (*** Essential for the FOTEO program)
1. ***Dan Buettner – The Blue Zones
2. ***Wayne W. Dyer DVD: Explores the spiritual journey from ambition to meaning.
3. *** Jonny Bowden – The 150 healthiest foods on earth.
4. Andrew Weil – Healthy Aging (a lifelong guide to your physical and spiritual well-being.
5. Andrew Newberg - How God changes your brain.
6. Daniel Goleman – Emotional intelligence.
7. Joseph Le Doux – The emotional brain.
8. Eric Kandel – In search of memory.
9. Norman Doidge – The brain that changes itself.
10. Michael Gazzazinga – The ethical brain.
11. Don Campbell – The Mozart Effect
12. Howard Gardner – Multiple intelligences.
13. Daniel Siegel - The mindful brain.
14. Daniel Levitin – This is your brain on music.
1. ***Dan Buettner – The Blue Zones
2. ***Wayne W. Dyer DVD: Explores the spiritual journey from ambition to meaning.
3. *** Jonny Bowden – The 150 healthiest foods on earth.
4. Andrew Weil – Healthy Aging (a lifelong guide to your physical and spiritual well-being.
5. Andrew Newberg - How God changes your brain.
6. Daniel Goleman – Emotional intelligence.
7. Joseph Le Doux – The emotional brain.
8. Eric Kandel – In search of memory.
9. Norman Doidge – The brain that changes itself.
10. Michael Gazzazinga – The ethical brain.
11. Don Campbell – The Mozart Effect
12. Howard Gardner – Multiple intelligences.
13. Daniel Siegel - The mindful brain.
14. Daniel Levitin – This is your brain on music.
FOTEO: Nine brain circuits - muliple intelligences (H Gardner)
FOTEO Part three:
The Nine Types of Intelligence
By Howard Gardner
1. Logical-Mathematical Intelligence (“Number/Reasoning” Smart)
Logical-mathematical intelligence is the ability to calculate, quantify, consider propositions and hypotheses, and carry out complete mathematical operations. It enables us to perceive relationships and connections and to use abstract, symbolic thought; sequential reasoning skills; and inductive and deductive thinking patterns. Logical intelligence is usually well developed in mathematicians, scientists, and detectives. Young adults with lots of logical intelligence are interested in patterns, categories, and relationships. They are drawn to arithmetic problems, strategy games and experiments.
2. Linguistic Intelligence (“Word Smart”)
Linguistic intelligence is the ability to think in words and to use language to express and appreciate complex meanings. Linguistic intelligence allows us to understand the order and meaning of words and to apply meta-linguistic skills to reflect on our use of language. Linguistic intelligence is the most widely shared human competence and is evident in poets, novelists, journalists, and effective public speakers. Young adults with this kind of intelligence enjoy writing, reading, telling stories or doing crossword puzzles.
3. Musical Intelligence (“Musical Smart”)
Musical intelligence is the capacity to discern pitch, rhythm, timbre, and tone. This intelligence enables us to recognize, create, reproduce, and reflect on music, as demonstrated by composers, conductors, musicians, vocalist, and sensitive listeners. Interestingly, there is often an affective connection between music and the emotions; and mathematical and musical intelligences may share common thinking processes. Young adults with this kind of intelligence are usually singing or drumming to themselves. They are usually quite aware of sounds others may miss.
4. Spatial Intelligence (“Picture Smart”)
Spatial intelligence is the ability to think in three dimensions. Core capacities include mental imagery, spatial reasoning, image manipulation, graphic and artistic skills, and an active imagination. Sailors, pilots, sculptors, painters, and architects all exhibit spatial intelligence. Young adults with this kind of intelligence may be fascinated with mazes or jigsaw puzzles, or spend free time drawing or daydreaming.
5. Bodily-Kinesthetic Intelligence (“Body Smart”)
Bodily kinesthetic intelligence is the capacity to manipulate objects and use a variety of physical skills. This intelligence also involves a sense of timing and the perfection of skills through mind–body union. Athletes, dancers, surgeons, and craftspeople exhibit well-developed bodily kinesthetic intelligence.
6. Naturalist Intelligence (“Nature Smart”)
Designates the human ability to discriminate among living things (plants, animals) as well as sensitivity to other features of the natural world (clouds, rock configurations). This ability was clearly of value in our evolutionary past as hunters, gatherers, and farmers; it continues to be central in such roles as botanist or chef. It is also speculated that much of our consumer society exploits the naturalist intelligences, which can be mobilized in the discrimination among cars, sneakers, kinds of makeup, and the like.
7. Interpersonal Intelligence (“People Smart”)
Interpersonal intelligence is the ability to understand and interact effectively with others. It involves effective verbal and nonverbal communication, the ability to note distinctions among others, sensitivity to the moods and temperaments of others, and the ability to entertain multiple perspectives. Teachers, social workers, actors, and politicians all exhibit interpersonal intelligence. Young adults with this kind of intelligence are leaders among their peers, are good at communicating, and seem to understand others’ feelings and motives.
8. Intra-personal Intelligence (“Self Smart”)
Intra-personal intelligence is the capacity to understand oneself and one’s thoughts and feelings, and to use such knowledge in planning and directing one’s life. Intra-personal intelligence involves not only an appreciation of the self, but also of the human condition. It is evident in psychologists, spiritual leaders, and philosophers. These young adults may be shy. They are very aware of their own feelings and are self-motivated.
9. Spiritual/Existential Intelligence
Sensitivity and capacity to tackle deep questions about human existence, such as the meaning of life, why do we die, and how did we get here.
{From: Overview of the Multiple Intelligences Theory. Association for Supervision and Curriculum Development and Thomas Armstrong.com}
The Nine Types of Intelligence
By Howard Gardner
1. Logical-Mathematical Intelligence (“Number/Reasoning” Smart)
Logical-mathematical intelligence is the ability to calculate, quantify, consider propositions and hypotheses, and carry out complete mathematical operations. It enables us to perceive relationships and connections and to use abstract, symbolic thought; sequential reasoning skills; and inductive and deductive thinking patterns. Logical intelligence is usually well developed in mathematicians, scientists, and detectives. Young adults with lots of logical intelligence are interested in patterns, categories, and relationships. They are drawn to arithmetic problems, strategy games and experiments.
2. Linguistic Intelligence (“Word Smart”)
Linguistic intelligence is the ability to think in words and to use language to express and appreciate complex meanings. Linguistic intelligence allows us to understand the order and meaning of words and to apply meta-linguistic skills to reflect on our use of language. Linguistic intelligence is the most widely shared human competence and is evident in poets, novelists, journalists, and effective public speakers. Young adults with this kind of intelligence enjoy writing, reading, telling stories or doing crossword puzzles.
3. Musical Intelligence (“Musical Smart”)
Musical intelligence is the capacity to discern pitch, rhythm, timbre, and tone. This intelligence enables us to recognize, create, reproduce, and reflect on music, as demonstrated by composers, conductors, musicians, vocalist, and sensitive listeners. Interestingly, there is often an affective connection between music and the emotions; and mathematical and musical intelligences may share common thinking processes. Young adults with this kind of intelligence are usually singing or drumming to themselves. They are usually quite aware of sounds others may miss.
4. Spatial Intelligence (“Picture Smart”)
Spatial intelligence is the ability to think in three dimensions. Core capacities include mental imagery, spatial reasoning, image manipulation, graphic and artistic skills, and an active imagination. Sailors, pilots, sculptors, painters, and architects all exhibit spatial intelligence. Young adults with this kind of intelligence may be fascinated with mazes or jigsaw puzzles, or spend free time drawing or daydreaming.
5. Bodily-Kinesthetic Intelligence (“Body Smart”)
Bodily kinesthetic intelligence is the capacity to manipulate objects and use a variety of physical skills. This intelligence also involves a sense of timing and the perfection of skills through mind–body union. Athletes, dancers, surgeons, and craftspeople exhibit well-developed bodily kinesthetic intelligence.
6. Naturalist Intelligence (“Nature Smart”)
Designates the human ability to discriminate among living things (plants, animals) as well as sensitivity to other features of the natural world (clouds, rock configurations). This ability was clearly of value in our evolutionary past as hunters, gatherers, and farmers; it continues to be central in such roles as botanist or chef. It is also speculated that much of our consumer society exploits the naturalist intelligences, which can be mobilized in the discrimination among cars, sneakers, kinds of makeup, and the like.
7. Interpersonal Intelligence (“People Smart”)
Interpersonal intelligence is the ability to understand and interact effectively with others. It involves effective verbal and nonverbal communication, the ability to note distinctions among others, sensitivity to the moods and temperaments of others, and the ability to entertain multiple perspectives. Teachers, social workers, actors, and politicians all exhibit interpersonal intelligence. Young adults with this kind of intelligence are leaders among their peers, are good at communicating, and seem to understand others’ feelings and motives.
8. Intra-personal Intelligence (“Self Smart”)
Intra-personal intelligence is the capacity to understand oneself and one’s thoughts and feelings, and to use such knowledge in planning and directing one’s life. Intra-personal intelligence involves not only an appreciation of the self, but also of the human condition. It is evident in psychologists, spiritual leaders, and philosophers. These young adults may be shy. They are very aware of their own feelings and are self-motivated.
9. Spiritual/Existential Intelligence
Sensitivity and capacity to tackle deep questions about human existence, such as the meaning of life, why do we die, and how did we get here.
{From: Overview of the Multiple Intelligences Theory. Association for Supervision and Curriculum Development and Thomas Armstrong.com}
Monday, March 22, 2010
Laughter is the best medicine (1)
The winning joke
After much careful scrutiny, we finally found the joke that received higher ratings than any other gag. Here it is:
Two hunters are out in the woods when one of them collapses. He doesn't seem to be breathing and his eyes are glazed. The other guy whips out his phone and calls the emergency services. He gasps, "My friend is dead! What can I do?". The operator says "Calm down. I can help. First, let's make sure he's dead." There is a silence, then a shot is heard. Back on the phone, the guy says "OK, now what?"
After much careful scrutiny, we finally found the joke that received higher ratings than any other gag. Here it is:
Two hunters are out in the woods when one of them collapses. He doesn't seem to be breathing and his eyes are glazed. The other guy whips out his phone and calls the emergency services. He gasps, "My friend is dead! What can I do?". The operator says "Calm down. I can help. First, let's make sure he's dead." There is a silence, then a shot is heard. Back on the phone, the guy says "OK, now what?"
Laughter is the best medicine (2)
In second place
The joke that came second was submitted by Geoff Anandappa, from Blackpool in Britain:
Sherlock Holmes and Dr Watson were going camping. They pitched their tent under the stars and went to sleep. Sometime in the middle of the night Holmes woke Watson up and said: “Watson, look up at the stars, and tell me what you see.”
Watson replied: “I see millions and millions of stars.”
Holmes said: “and what do you deduce from that?”
Watson replied: “Well, if there are millions of stars, and if even a few of those have planets, it’s quite likely there are some planets like earth out there. And if there are a few planets like earth out there, there might also be life.”
And Holmes said: “Watson, you idiot, it means that somebody stole our tent.”
The joke that came second was submitted by Geoff Anandappa, from Blackpool in Britain:
Sherlock Holmes and Dr Watson were going camping. They pitched their tent under the stars and went to sleep. Sometime in the middle of the night Holmes woke Watson up and said: “Watson, look up at the stars, and tell me what you see.”
Watson replied: “I see millions and millions of stars.”
Holmes said: “and what do you deduce from that?”
Watson replied: “Well, if there are millions of stars, and if even a few of those have planets, it’s quite likely there are some planets like earth out there. And if there are a few planets like earth out there, there might also be life.”
And Holmes said: “Watson, you idiot, it means that somebody stole our tent.”
Saturday, March 20, 2010
The World in Search of A Sabbath!
Bay Area - 9 Counties, 8 Bridges, 7 Million People
March 19, 2010, 1:14 pm
A New Take on the Old Sabbath Ritual of Unplugging
By MICHELLE QUINN
I am typing fast because at sundown (7:20 p.m.), I plan to join in the first National Day of Unplugging and turn my electronic devices off until sundown Saturday. The effort, reported in The New York Times and elsewhere, is the brainchild of Reboot, a nonprofit organization of Jewish professionals who want to adapt the concept of Sabbath traditions to the digital age.
I thought at first, yadda yadda yadda. Go ahead and unplug, everyone. But then I saw “Yelp,” the YouTube video above by Ken Goldberg and Tiffany Shlain. It uses Allen Ginsberg’s “Howl” as the muse for a short video promoting the day of unplugging. Having just reread “Howl” for a post on the movie about Mr. Ginsberg’s life, I felt “Yelp” kept somehow true to the poem, even if the creators mixed Mr. Ginsberg’s visceral words with the less-visceral brand names of the soon-to-be-disconnected digisphere: Google, iPhone, Facebook.
Mr. Goldberg is a professor of robotics at the University of California, Berkeley, and Ms. Shlain is best known for putting on the Webby Awards, celebrating the best of the Internet. This Mill Valley couple, with their two children, left Friday morning for Hawaii, where they will try to stay unplugged for six days. Not that they are doctrinaire about their unplugged-ness. I interviewed them via cellphone as they sat on the tarmac ready to leave. But more on that in a second.
Reboot is not the first or the last group to address the jittery need among many to clean out e-mail in-boxes and glance at RSS feeds. Starting in February at the Actual Cafe in Oakland, laptop use has been forbidden on weekends — an attempt by the owner to get patrons to talk to one another, as The San Francisco Chronicle described. In “The Keep,” by Jennifer Egan, the main character loses his bearings and sense of self, like a character in an Edgar Allan Poe (or Franz Kafka) story, when he is cut off electronically from the outside world.
At home, my husband and I have talked about the messages we’re sending to our children by the constant checking of our cellphones and laptops. As we stood looking out to the Pacific Ocean at Point Lobos, a state park on the craggy coast, my son, 7, asked me, “Why do people go to beautiful places and look at their cellphones?”
But back to Mr. Goldberg and Ms. Shlain, who managed to post her thoughts about unplugging this morning on The Huffington Post as the two carted a 6-year-old and 10-month-old baby to the airport.
Ms. Shlain said they were approached by Reboot to do something for the day. Three weeks ago, they knocked out the poem “Yelp” during a four-hour drive back from Tahoe, then decided to create a short video, using imagery from a feature-length documentary film Ms. Shlain is working on called “Connected: A Declaration of Interdependence.”
Have a great trip, I said, adding that I would send an e-mail message with the link to this post, since they wouldn’t see it for six days.
Oh, Mr. Goldberg said, we’ll sneak a peek at the Internet. “I’m sure I won’t make it a week,” he said.
* Copyright 2010 The New York Times Company
* Privacy Policy
* NYTimes.com 620 Eighth Avenue New York, NY 10018
March 19, 2010, 1:14 pm
A New Take on the Old Sabbath Ritual of Unplugging
By MICHELLE QUINN
I am typing fast because at sundown (7:20 p.m.), I plan to join in the first National Day of Unplugging and turn my electronic devices off until sundown Saturday. The effort, reported in The New York Times and elsewhere, is the brainchild of Reboot, a nonprofit organization of Jewish professionals who want to adapt the concept of Sabbath traditions to the digital age.
I thought at first, yadda yadda yadda. Go ahead and unplug, everyone. But then I saw “Yelp,” the YouTube video above by Ken Goldberg and Tiffany Shlain. It uses Allen Ginsberg’s “Howl” as the muse for a short video promoting the day of unplugging. Having just reread “Howl” for a post on the movie about Mr. Ginsberg’s life, I felt “Yelp” kept somehow true to the poem, even if the creators mixed Mr. Ginsberg’s visceral words with the less-visceral brand names of the soon-to-be-disconnected digisphere: Google, iPhone, Facebook.
Mr. Goldberg is a professor of robotics at the University of California, Berkeley, and Ms. Shlain is best known for putting on the Webby Awards, celebrating the best of the Internet. This Mill Valley couple, with their two children, left Friday morning for Hawaii, where they will try to stay unplugged for six days. Not that they are doctrinaire about their unplugged-ness. I interviewed them via cellphone as they sat on the tarmac ready to leave. But more on that in a second.
Reboot is not the first or the last group to address the jittery need among many to clean out e-mail in-boxes and glance at RSS feeds. Starting in February at the Actual Cafe in Oakland, laptop use has been forbidden on weekends — an attempt by the owner to get patrons to talk to one another, as The San Francisco Chronicle described. In “The Keep,” by Jennifer Egan, the main character loses his bearings and sense of self, like a character in an Edgar Allan Poe (or Franz Kafka) story, when he is cut off electronically from the outside world.
At home, my husband and I have talked about the messages we’re sending to our children by the constant checking of our cellphones and laptops. As we stood looking out to the Pacific Ocean at Point Lobos, a state park on the craggy coast, my son, 7, asked me, “Why do people go to beautiful places and look at their cellphones?”
But back to Mr. Goldberg and Ms. Shlain, who managed to post her thoughts about unplugging this morning on The Huffington Post as the two carted a 6-year-old and 10-month-old baby to the airport.
Ms. Shlain said they were approached by Reboot to do something for the day. Three weeks ago, they knocked out the poem “Yelp” during a four-hour drive back from Tahoe, then decided to create a short video, using imagery from a feature-length documentary film Ms. Shlain is working on called “Connected: A Declaration of Interdependence.”
Have a great trip, I said, adding that I would send an e-mail message with the link to this post, since they wouldn’t see it for six days.
Oh, Mr. Goldberg said, we’ll sneak a peek at the Internet. “I’m sure I won’t make it a week,” he said.
* Copyright 2010 The New York Times Company
* Privacy Policy
* NYTimes.com 620 Eighth Avenue New York, NY 10018
Friday, March 19, 2010
Rest Well!
Opinionator - A Gathering of Opinion From Around the Web
March 18, 2010, 9:30 pm
At Midnight, All the Doctors…
By LISA SHIVES
All-Nighters is an exploration of insomnia, sleep and the nocturnal life.
Tags:
medical training, residency, sleep deprivation, sleep doctors
“I’m a sleep doctor.” Silence. There is a pause in the conversation, which is common.
Sleep medicine, as a field, is new enough that people are often taken off guard: “You do what?” The disheveled older man, who seems to have Ritz crackers woven into the fabric of his tie, leans closer. He appears to have misheard or misunderstood. (I often wonder what goes through peoples’ minds in that split second; what do they think they heard me say: “I’m a peep doctor”?) I repeat and explain that I do sleep medicine, “you know, insomnia, sleep apnea, that sort of thing.” “Oh, yes. I see.” His eyes widen with interest; now he steps really close, and a trembling hand lightly lays itself on my forearm.
Doctors preach the importance of sleep, yet medical students and residents are trained to be sleep-deprived.
I know that if I am not extremely creative and diplomatic, I will be stuck in the corner all night doing what I do all day — listening to some sad soul pour out his story of tortured, restless sleep. At a party, I am right up there in popularity with the dermatologist and plastic surgeon. Everyone needs our help and no one is embarrassed to say so.
Don’t get me wrong; I feel for this sleep-deprived, soiled and seemingly desperate man, but not much can be solved in a few minutes over canapés and gin. I am happy to help out and give useful advice where I can; it’s just that most people want to talk to me about their insomnia, and insomnia is the “dreaded disease” of sleep medicine. Every medical specialty has the one patient complaint that makes the doctors groan. For neurologists, it is headache; for rheumatologists, chronic fatigue; and for gastrointestinal docs, it is irritable bowel. What these all have in common is that we doctors don’t know how to treat them very well. One reason is that they are disorders, which means they are sets of symptoms, rather than one clear-cut, pathologically definable disease, and in their complexities, they are often not well understood and consequently not well treated using Western medical paradigms.
If there were a medical solution to sleeplessness, there would not be this need for sharing stories of nocturnal misery and outlining strategies for persevering. There have, however, been advances in our understanding of the disorder. The latest biomedical explanation for insomnia is much like the one for depression: There is an imbalance in the neurotransmitters in the brain, in this case, the ones that control the sleep/wake cycle. However, mapping out exactly what the problem is in which part of the brain remains the challenge for medical scientists.
One piece of advice I have to give to all insomnia suffers is to beware of the word “insomnia.” The problem is that the word is used by patients and doctors to describe the symptom of not being able to initiate sleep or maintain sleep or having persistent early morning awakenings. But it is also the word used for the final diagnosis. Patients walk into their primary care doctor and say: “Hey doc, I can’t sleep. I have insomnia.” And they are getting into their car before the ink has dried on the prescription for Ambien. People don’t walk into their internist’s office and say, “I’m having appendicitis.” They tell the doctor about the horrible pain in their “stomach,” and it is the doctor’s job to think of all the problems this might represent and to narrow the possibilities by asking further questions, doing a physical exam and running tests. Insomnia is not that easy to work up, and it takes the one thing that doctors have so little of: time for questions and discussion with the patient.
So be a proactive patient and do not easily accept chronic insomnia as your final diagnosis. There are, after all, so many medical problems that can masquerade as insomnia. Sleep disorders like sleep apnea and delayed sleep phase disorder can mislead patients and non-sleep doctors. Psychiatric disorders, cardiovascular disease, lung disease and rheumatologic and endocrine disorders (as well as the medications used to treat them) can all disrupt sleep and lead people to think that they suffer from insomnia.
The gentleman with the crumb problem (which is likely secondary to being sleep deprived and living without a wife as most phenomena are multifactorial) wanted to know what got me interested in the area of sleep medicine. I answered: “Because it is an oxymoron — sleep and medicine do not go together at all.” Doctors preach to patients how important sleep is to lower their risk of all sorts of diseases: high blood pressure, heart disease, stroke, diabetes, weight gain and obesity, depression and dementia. Yet the institution of medical training in this country practices systematized sleep deprivation of medical students and residents. By the way, we use the term “resident” because junior doctors used to live in the hospitals.
Driving while sleep deprived can be just as dangerous as driving drunk.
For the majority of the three years I trained in internal medicine (and during the two years before that when I did clinical rotations as a medical student), I would work 30 to 36 hour shifts every fourth night with no guarantee of sleep. Why, you might wonder, are students and residents pushed so hard, for so long? One reason is that medicine is a very tradition-bound profession and this is just the way “things have always been done.” But there are myriad other reasons: a culture of hard work that tests the mental stability and physical stamina of these brave young men and women; a belief held by many doctors that residency training is simply too short to teach doctors all they need to know unless they are pretty much working non-stop during that period seeing all the “interesting cases” that come through; and the simple economic fact that residents are a cheap way to man the hospital around the clock.
After 24 hours on duty, I would crave sleep like other people desire food or sex. And like an addict, I would plot and plan and structure my activity around getting the balm I so desperately needed. I would try to squeeze some sleep in, no matter how short the time allotted, no matter the location. I have slept in wheel chairs and on a patient gurney; I have dozed in stairwells and while riding on elevators. I, like almost every resident physician I know, would routinely fall asleep during the morning and noontime lectures that were meant to teach me how to be a decent doctor. Every woman doctor I know, and quite a few men, have wept from sheer exhaustion. The question is not only how did I live through this, but how did my patients?
More in This Series
* “Night Lights, Blankets and Lullabies” By Siri Hustvedt
* “In the Night Kitchen” by Leanne Shapton
* “Seeing in the Dark” by Lisa Russ Spaar
* “The A-to-Z Cure” by Roz Chast
* The entire series »
I have a friend who wrecked her car three times in the first two months of her surgery internship. The same surgeon fell asleep with a needle-driver in her hand. Luckily, a senior attending caught her before she fell into the open wound. I was so tired driving home one afternoon after a call, that I had to roll down the window in the middle of Chicago winter, blast the radio and light a cigarette. I was shifting in my seat and flailing my arms so erratically that I thought other drivers on the road would think that I was having an epileptic fit. I didn’t worry about being mistaken for a drunk driver because even a drunk wouldn’t have acted as crazy as that. (Years later, in my training as a sleep medicine doctor, I learned that driving while sleep deprived can be just as dangerous as driving drunk.) It may assuage the reader’s fears to know that there are new regulations prohibiting resident physicians from working more than 80 hours per week, not to relieve the residents so much as to protect the patients because there was mounting evidence that many medical errors are attributable to physician fatigue.
Now I get my 7 to 8 hours without fail. Although I have not suffered much from insomnia, that inner, unwanted drive to wakefulness, I do know sleeplessness driven by external exigencies. I have a lot of sympathy and not a small amount of empathy for those sleepless souls who bleary-eyed and sallow-skinned must go forth into “the desolation of reality,” in Yeats’s memorable phrase. Day after day, they drag themselves into my office. Their minds are muddled; their hearts are heavy; and many are just plain angry. So I tell them: “I have no quick fix, no miracle pill, but I will listen long and hard to your story of chasing the elusive elixir of sleep. Although I might not cure you, I’ll go through this with you, as your witness, your night watchman, as someone who knows how long one night can seem.”
Lisa Shives, a doctor and the medical director of Northshore Sleep Medicine in Evanston, Ill., is an official spokesperson for the American Academy of Sleep Medicine. She is working on her first book which will focus on pediatric sleep disorders.
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March 18, 2010, 9:30 pm
At Midnight, All the Doctors…
By LISA SHIVES
All-Nighters is an exploration of insomnia, sleep and the nocturnal life.
Tags:
medical training, residency, sleep deprivation, sleep doctors
“I’m a sleep doctor.” Silence. There is a pause in the conversation, which is common.
Sleep medicine, as a field, is new enough that people are often taken off guard: “You do what?” The disheveled older man, who seems to have Ritz crackers woven into the fabric of his tie, leans closer. He appears to have misheard or misunderstood. (I often wonder what goes through peoples’ minds in that split second; what do they think they heard me say: “I’m a peep doctor”?) I repeat and explain that I do sleep medicine, “you know, insomnia, sleep apnea, that sort of thing.” “Oh, yes. I see.” His eyes widen with interest; now he steps really close, and a trembling hand lightly lays itself on my forearm.
Doctors preach the importance of sleep, yet medical students and residents are trained to be sleep-deprived.
I know that if I am not extremely creative and diplomatic, I will be stuck in the corner all night doing what I do all day — listening to some sad soul pour out his story of tortured, restless sleep. At a party, I am right up there in popularity with the dermatologist and plastic surgeon. Everyone needs our help and no one is embarrassed to say so.
Don’t get me wrong; I feel for this sleep-deprived, soiled and seemingly desperate man, but not much can be solved in a few minutes over canapés and gin. I am happy to help out and give useful advice where I can; it’s just that most people want to talk to me about their insomnia, and insomnia is the “dreaded disease” of sleep medicine. Every medical specialty has the one patient complaint that makes the doctors groan. For neurologists, it is headache; for rheumatologists, chronic fatigue; and for gastrointestinal docs, it is irritable bowel. What these all have in common is that we doctors don’t know how to treat them very well. One reason is that they are disorders, which means they are sets of symptoms, rather than one clear-cut, pathologically definable disease, and in their complexities, they are often not well understood and consequently not well treated using Western medical paradigms.
If there were a medical solution to sleeplessness, there would not be this need for sharing stories of nocturnal misery and outlining strategies for persevering. There have, however, been advances in our understanding of the disorder. The latest biomedical explanation for insomnia is much like the one for depression: There is an imbalance in the neurotransmitters in the brain, in this case, the ones that control the sleep/wake cycle. However, mapping out exactly what the problem is in which part of the brain remains the challenge for medical scientists.
One piece of advice I have to give to all insomnia suffers is to beware of the word “insomnia.” The problem is that the word is used by patients and doctors to describe the symptom of not being able to initiate sleep or maintain sleep or having persistent early morning awakenings. But it is also the word used for the final diagnosis. Patients walk into their primary care doctor and say: “Hey doc, I can’t sleep. I have insomnia.” And they are getting into their car before the ink has dried on the prescription for Ambien. People don’t walk into their internist’s office and say, “I’m having appendicitis.” They tell the doctor about the horrible pain in their “stomach,” and it is the doctor’s job to think of all the problems this might represent and to narrow the possibilities by asking further questions, doing a physical exam and running tests. Insomnia is not that easy to work up, and it takes the one thing that doctors have so little of: time for questions and discussion with the patient.
So be a proactive patient and do not easily accept chronic insomnia as your final diagnosis. There are, after all, so many medical problems that can masquerade as insomnia. Sleep disorders like sleep apnea and delayed sleep phase disorder can mislead patients and non-sleep doctors. Psychiatric disorders, cardiovascular disease, lung disease and rheumatologic and endocrine disorders (as well as the medications used to treat them) can all disrupt sleep and lead people to think that they suffer from insomnia.
The gentleman with the crumb problem (which is likely secondary to being sleep deprived and living without a wife as most phenomena are multifactorial) wanted to know what got me interested in the area of sleep medicine. I answered: “Because it is an oxymoron — sleep and medicine do not go together at all.” Doctors preach to patients how important sleep is to lower their risk of all sorts of diseases: high blood pressure, heart disease, stroke, diabetes, weight gain and obesity, depression and dementia. Yet the institution of medical training in this country practices systematized sleep deprivation of medical students and residents. By the way, we use the term “resident” because junior doctors used to live in the hospitals.
Driving while sleep deprived can be just as dangerous as driving drunk.
For the majority of the three years I trained in internal medicine (and during the two years before that when I did clinical rotations as a medical student), I would work 30 to 36 hour shifts every fourth night with no guarantee of sleep. Why, you might wonder, are students and residents pushed so hard, for so long? One reason is that medicine is a very tradition-bound profession and this is just the way “things have always been done.” But there are myriad other reasons: a culture of hard work that tests the mental stability and physical stamina of these brave young men and women; a belief held by many doctors that residency training is simply too short to teach doctors all they need to know unless they are pretty much working non-stop during that period seeing all the “interesting cases” that come through; and the simple economic fact that residents are a cheap way to man the hospital around the clock.
After 24 hours on duty, I would crave sleep like other people desire food or sex. And like an addict, I would plot and plan and structure my activity around getting the balm I so desperately needed. I would try to squeeze some sleep in, no matter how short the time allotted, no matter the location. I have slept in wheel chairs and on a patient gurney; I have dozed in stairwells and while riding on elevators. I, like almost every resident physician I know, would routinely fall asleep during the morning and noontime lectures that were meant to teach me how to be a decent doctor. Every woman doctor I know, and quite a few men, have wept from sheer exhaustion. The question is not only how did I live through this, but how did my patients?
More in This Series
* “Night Lights, Blankets and Lullabies” By Siri Hustvedt
* “In the Night Kitchen” by Leanne Shapton
* “Seeing in the Dark” by Lisa Russ Spaar
* “The A-to-Z Cure” by Roz Chast
* The entire series »
I have a friend who wrecked her car three times in the first two months of her surgery internship. The same surgeon fell asleep with a needle-driver in her hand. Luckily, a senior attending caught her before she fell into the open wound. I was so tired driving home one afternoon after a call, that I had to roll down the window in the middle of Chicago winter, blast the radio and light a cigarette. I was shifting in my seat and flailing my arms so erratically that I thought other drivers on the road would think that I was having an epileptic fit. I didn’t worry about being mistaken for a drunk driver because even a drunk wouldn’t have acted as crazy as that. (Years later, in my training as a sleep medicine doctor, I learned that driving while sleep deprived can be just as dangerous as driving drunk.) It may assuage the reader’s fears to know that there are new regulations prohibiting resident physicians from working more than 80 hours per week, not to relieve the residents so much as to protect the patients because there was mounting evidence that many medical errors are attributable to physician fatigue.
Now I get my 7 to 8 hours without fail. Although I have not suffered much from insomnia, that inner, unwanted drive to wakefulness, I do know sleeplessness driven by external exigencies. I have a lot of sympathy and not a small amount of empathy for those sleepless souls who bleary-eyed and sallow-skinned must go forth into “the desolation of reality,” in Yeats’s memorable phrase. Day after day, they drag themselves into my office. Their minds are muddled; their hearts are heavy; and many are just plain angry. So I tell them: “I have no quick fix, no miracle pill, but I will listen long and hard to your story of chasing the elusive elixir of sleep. Although I might not cure you, I’ll go through this with you, as your witness, your night watchman, as someone who knows how long one night can seem.”
Lisa Shives, a doctor and the medical director of Northshore Sleep Medicine in Evanston, Ill., is an official spokesperson for the American Academy of Sleep Medicine. She is working on her first book which will focus on pediatric sleep disorders.
* Copyright 2010 The New York Times Company
* Privacy Policy
* NYTimes.com 620 Eighth Avenue New York, NY 10018
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