Spirituality in Medicine- An examination of religious service attendance and overall mortality among a cohort of female nurses

Whether by pure coincidence or divine action, within minutes of posting my last article regarding the imagery of an interconnected world existing amidst a “vibrational bowl” of love and the implications for those, like myself, wishing to practice medicine focusing on the spiritual being, I was “sent” a notification email from JAMA Internal Medicine informing me of a newly accessible, online first study entitled: Association of Religious Service Attendance With Mortality Among Women.

Already intrigued by the title I began reading through the abstract, and within minutes was already immersed in the body of the paper, piecing apart the intricacies of the statistical results and reflecting upon the ideas described in the thoughtful discussion. In an attempt to make the statistics a little more user-friendly I have presented the results of the study below as well as my own personal interpretation of the author’s conclusions.

Cohort Studied: “Attendance at religious services was assessed from the first questionnaire in 1992 through June 2012, be a self-reported question asked of 74,534 women in the Nurses’ Health Study who were free of cardiovascular disease and cancer at baseline. Data Analysis was conducted from return of the 1996 questionnaire through June 2012.”

1. A 33% decrease in all cause mortality for those individuals who attended one or more religious services a week versus those who did not attend any religious functions.

2. Decreased likelihood of dying from cardiovascular disease as determined by a hazard ratio (HR 0.79). A hazard ratio is basically the ratio of the likelihood of an event occurring for two different groups as defined by a single variable (in this case dying from cardiovascular disease for those who attended one or more religious services per week vs. those who did not attend any religious functions). A HR of less than 1 (such as the HR of 0.79 in this study) when combined with a predetermined p-value to show a “significant” likelihood of a true effect essentially means that the group of regular religious attendees were less likely to die from cardiovascular disease (CVD) than those who did not attend a religious service. Generally speaking, the smaller the hazard ratio (for example 0.35) the less likely the specified group with the defined variable (religious attendance) would suffer the measured effect (death related to CVD). It is important to note, however, that the researchers only found a significant decreased likelihood of death related to CVD as it pertained specifically to cerebrovascular disease (stroke) and other cardiovascular diseases (such as congestive heart failure) – but no such association with ischemic heart disease [heart attacks or in more medical jargon- dysregulated coronary vasculature (blood flow to the heart)]. 

Summary

The weekly religious attendees had a 0.79X less chance of dying from stroke and cardiovascular disease- but not ischemic heart disease, when compared to those who did not attend religious services.

3. Decreased likelihood of dying from cancer as determined by a hazard ratio (HR of 0.73). Sparing you a further “rabbit hole” description of a hazard ratio, I will simply share that the researchers also found a site specific cancer mortality effect for breast cancer (as this cohort was of female nurses) and colorectal cancer but not for any other forms of cancer.

What the researchers DID NOT find

1. Spirituality as a whole, if describable, had an effect on any other domain of health besides total mortality, mortality from cancer, and mortality from cardiovascular disease (excluding ischemic heart disease).

2. Populations outside of female health care workers- predominantly, white, middle class Christians did or would receive a benefit in regards to mortality as related to regular religious attendance.

3. Associations (as they were not directly measured) for quality of life across mental, emotional and physical domains for the regular religious service attendees compared to those who did not attend religious functions.

4. Specific mechanisms or pathways (outside of the associated mediators described below) for how religious attendance could cause the observed affects for decreased mortality. 

5. Spiritual practice, outside of regular attendance to a specific religious function, could not also give potential benefits as they relate to decreased total mortality and mortality from cardiovascular disease and cancer.

Addressing the practical question: How was the observed effect of decreased mortality mediated? 

One of the strengths of this study was the numerous confounding variables controlled for with regards to the primary variable analyzed (religious attendance) These variables included diet and exercise patterns, smoking, depressive symptoms, multivitamin use, medical diagnosis- comorbid disease and numerous demographic variables. Through all of this covariate analysis the researchers were able to isolate four primary mediators that likely contributed to the observed primary endpoints of decreased mortality.

1. Optimism 

2. Smoking Status

3. Depressive Symptoms

4. Social Support/Social Integration

Smoking was found to “explain” 22% of the observed effect, Social Support 23%, Depressive Symptoms 11%, and Optimism 9%. Additional mediators examined that did not show a significant mediating effect included: alcohol use, diet quality, and phobia related anxiety. The researchers calculated the “Social Support” score from multiple longitudinal surveys in the specified cohort and attempted to create a final score independent of social support associated with religious service attendance.

Summary

 No one mediator was found to strongly correlate with the observed effect of decreased mortality, however, it appears that non-smoking individuals with a self-reported positive outlook, minimal depressive symptoms and supportive social structures were the least likely to die during the time period of this study. Whether or not regular religious service attendance added a significant “value” for an individual outside of the mediators discussed is open for debate and certainly would be an area worthy of further study.

Implications and Ideas

Author’s Conclusion: “Religion and spirituality may be an under appreciated resource that physicians could explore with their patients, as appropriate.”

Personal Conclusion: Spirituality is a complex description of one’s personal beliefs, faith in a greater energy, being, or creator, as well as a motivating sense of purpose, connectedness with others/ the natural world and cannot simply be “quantified” by regular religious service attendance. This specific study provides some evidence that cultivating a positive social support network through regular attendance to religious functions (a “surrogate” for spirituality) can be a means to maintain health and avoid premature death. In the end, quantifying one’s own sense of spirituality is not likely possible with a single measure or combined variable, and the scientific method/ study through traditional clinical research designs does not provide a realistic means to determine the relative importance of spiritual practice to any one individual.

References

Li S, Stampfer MJ, Williams DR, VanderWeele TJ. Association of Religious Service Attendance With Mortality Among Women. JAMA Intern Med. 2016 May 16. 

Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012 Dec 16;2012:278730. 

Vibrations: How Do You Share Your Love?

             So just yesterday, while reflecting upon a podcast from The Evolution of Medicine's Functional Forum entitled: Anatomy of a Calling- an interview with holistic physician Dr. Lissa Rankin MD, I realized (among many other things) why writing, studying medicine, and blessing others with my thoughts brings me so much joy: I have precisely no clue who or how any of my words or ideas will touch others. I have mentioned this concept before in some previous posts, specifically on the impact of the written word and my interest in writing, but as I wandered in the Pennsylvania woods, hearing Dr. Rankin speak of compassion and “wholism,” all within the context of her passion for psycho-spiritual healing, I couldn’t help but consider the reality that, yes, her “whole health” practice of nourishing the spiritual body was exactly the type of medicine, or dare I say, the type of “healer” that had been born in me, before I would ever consciously decide to attend medical school. Since discovering my desire to pursue functional, “root-cause resolution” medicine as a way to understand the complex nature of the human web of physiologic systems, I have only slowly begun to realize that this functional, evolutionary framework of understanding is only a piece of the puzzle, only one page of the story, merely a starting point for seeing the true capacity for healing made possible by acknowledging a relative unknown spiritual energy- our essence- the human soul. For a profession so profoundly defined by science and what can be experimentally determined, psycho-spiritual healing relies on nearly polar opposite values: intuition, belief, the acceptance and embracing of uncertainty, and the genuine desire to, perhaps, never know the answer to the question: Why? So while I share all of this perspective, knowing it is personal and focused primarily on my beliefs in the medical profession, there is, however, a powerful, imaginative thread that can be woven from these concepts into the larger stories of all humans alike. 

           During her intimate conversation (podcast) with James Maskell, Dr. Rankin describes an incredible image of an interconnected universe whereby there exists “a vibrational bowl” where love and light are intertwined, and we, as humans, have the capacity to instill a more positive, harmonious vibration, capable of travelling, in a state of dynamic continuity, to some other distant part of the “vibrational bowl.” Taking this imagery to a more practical level, and thinking within the scope of our Earth, we can imagine each small act of love, every moment of “paying it forward,” each gift of altruism as actually impacting or influencing the actions of another on the other side of the globe. Share some parenting wisdom with your child, give a hug to your ailing grandmother, or mow the grass for your currently disabled father- all of these acts of light and love can travel through this vibrational network and bless the spirit of someone in Australia, Slovakia or Mozambique, and make it all the more possible (or more likely) that he or she can share his or her love through a reciprocal act of kindness, or at the very least, make it all the more unlikely and impossible to create more suffering for another human being. No longer can we confine ourselves to only see the positive or negative effects of our actions through the lenses of our eyes, for these “vibrations of love” can disperse farther than we will ever be capable of seeing. Wouldn’t the world be a better place, if we all added vibrations of love, of light, of hope into this great bowl? While I may never be able to prove that my small vibrations ever influence the lives of those a thousand miles away, I can most assuredly tell you that I have felt the ripples of light wash over my soul from the acts of love and kindness shared by people I will likely never meet. For somehow this belief, stemming from the simple choice of being a source of light and warmth, for a person living in a world “obsessed” with rationality in science, is all the evidence I will ever need.

Unconscious Bias: Not Just a Medical Student Problem

            The other day, during my cursory reading of Medscape News articles (like any responsible medical student looking to stay up to date on the latest research/news in medicine and also willing to give at little a little time to topics outside of the functional and integrative medicine sphere), I came across an interesting and rather pertinent title: Medical Students: False Beliefs About Black's Biology Common. Delving into the first paragraph, I was quickly made aware that from the specific research cohort studied in the original article, "Half of (the) white medical students held at least one false belief about biological differences between black and white patients, a trend that affected both their perception of the patient's pain." The article went on further to say "The more false beliefs the students held, the more likely they were to rate a black patient as experiencing less pain than a white patient in the same scenario, and the less likely they were to make an appropriate medical recommendation." While slightly disturbed by the conclusions of the research study: it was not entirely "new news" to my ears as I have often appreciated the scope of both implicit and explicit bias in medical practice. From gender and sexual orientation to weight (obesity) and race, there is often significant implicit (or what I consider subconscious bias) as well as overt explicit bias seen in taking care of patients. 

            Stepping back from the article as judgment was already seeping from my skin, the natural defense mechanisms started to flood forth: "Well I'm pretty sure I'm not racist, and sure I'm a medical student, but this study doesn't really pertain to me." Just as we can be easily mislead by medical abstracts and headlines when it comes to the actual population studied (yes, not everyone falls under the demographic parameters of the Nurses' Health Study [I or II]), we need to remain vigilant when making recommendations to patients from clinical “evidence,” avoiding the recommendation, for instance, that a specific drug may be helpful for them, when in actuality, the study population from which your recommendation was made, was completely different than that of the person sitting in your office. 

            Staying vigilant, I continued to read on, only to see from the first commentary by the researchers of the cited study that the origins of the medical students studied was none other than the University of Virginia in Charlottesville. Just as quickly as I was already defending a position that perhaps this studied was not relevant to me, I was finding out that, indeed, I was actually one of the study participants! It is not everyday you read about a medical study and find that the recommendations or conclusions made actually involved your input, and couldn’t exactly be tossed aside like the leftover meatloaf. Having already made a joke/passing comment to my mother, before realizing I could have very likely been one of those “half of white medical students,” it became quite clear that this was indeed, a time to get back to my mindfulness roots.  Sticking to the idea “I’m special” and “this research study is not really pertinent to me,” was just not going to work. 

            Honestly speaking, judgment and pattern recognition can be incredibly helpful for clinicians in the fast-paced setting of diagnostic medicine, however, they can also be potentially detrimental and subversively harmful when carried through in a long term, continuous care setting. When we look at how a scenario involving implicit bias (not simply subconscious racial prejudice) might play out in the everyday medical world, I’d like to present a plausible and practical (constructed) example from a hard working family medicine clinic.

            After following a patient for nearly 10 years, family doctor Dr. A begins to glance over a chart prior to his next 20 minute follow-up visit, giving a look at the patient’s most recent set of labs and confirming, oh yea this is Mrs. B, a postmenopausal female, some hypothyroid issues, working on the hot flashes, has never taken any hormone replacement, doesn’t seem to be interested in cancer screening by the review here, lipids looking a little off since last visit-wonder if she’s changed her diet or gained some weight?  Before Dr. A even has a chance to drop a pen from his white-coat, he is already formulating questions to ask regarding her symptoms, a potential plan to rectify the perceived disturbed blood work, and further inquire into why Mrs. B is reluctant about cancer screening tests (who doesn’t want a colonoscopy on their 50^th birthday?). 

            While objectively speaking, there is almost nothing wrong with what Dr. A is thinking and hoping to achieve during this follow-up clinic visit, we can see that there would be at least few differences if we were to replace Dr. A with a third year medical student, just starting on his family medicine rotation and newly minted with coffee stains on a half-heartedly ironed white coat. While Dr. A is entering the encounter carrying a “weight” of past perceptions, past conversations, and judgments as to what Mrs. B may be thinking, the third year medical student is just seeing Mrs. B’s chart for the first time in his or her life (30 seconds maybe 60 tops), and is likely only carrying with him or her a stethoscope and shreds of paper meant for scribbling something illegible with regards to Mrs. B’s primary complaints. Following the brief “glancing over” of her chart, the third year medical student is aware that Mrs. B is a 64 y/o female here for a 6-month follow-up; her vital signs including blood pressure and oxygen saturations are within normal limits and the primary comment from the triage nurse states “happy to see the birth of her first grandchild last December.”  Stepping into our third year medical student’s mind, we might find some thoughts that include: “I have to make sure I remember to listen to her heart with my stethoscope on bare skin,” and “I wonder what the drug reps are bringing for lunch today,” –so yes, we can all agree there are appreciable and explicit differences between the medical student and the doctor when it comes to this clinical encounter. And while one might say, given the depth of clinical experience of the family physician, that of course, the doctor is better equipped to help and treat Mrs. B, but perhaps, we shouldn’t be so quick to jump to such conclusions. 

             Research has shown that given proper education and tutorials on cardiac auscultation, medical students fair just the same and sometimes better (and at least no worse) when it comes to properly diagnosing heart murmurs as compared to attending/practicing physicians. While one might say, “Yeah, but you are talking about a measurable skill, and I don’t really see how this applies to the scenario with Mrs. B or even to unconscious bias for that matter” My simple response to this, reasonable statement is this, “Yes, you are right, literally speaking, there is really nothing about listening for heart murmurs that seems related to unconscious bias, and likely isn’t relevant for Mrs. B but what if we ask ourselves a slightly different question: “Who do you or did you think would be better at diagnosing heart murmurs- the third year student or the family doctor? While I cannot tell you or predict your answer, I have my suspicions that it was likely the family doctor, or at the very least, most of us would hope that to be true. I can tell you that when I was asked this very same question as a third year medical student just a few short months ago, I quickly realized my answer, discovered a previously unconscious belief/bias, and for the first time really recognized what it was exactly that I was carrying into Mrs. B’s room besides my stained white coat: “I am just a medical student, what do I really know and what can I really do when compared to an experienced  practicing doctor?

            Bringing this post to a close, I would encourage everyone to see the bigger implications of the research study I have just described, seeing beyond medical students’ bias and beyond medicine in general. As human beings we are blessed with the capacity to perceive and cursed by the capacity to know and seek truth. As much as we would like to believe our conscious perceptions are not truth, even when it comes to something we think is so clear: 2+2=4, we “truthfully” only have a personal perception of our present reality, just as the person next to us has his or her own perception of the present situation. Scary as this sounds, it only gets scarier when we realize how much our subconscious and unconscious minds are actually “controlling” our behavior (see Stephan Guyenet’s post on his blog: Whole Health Source: “How Much do You Know About Your Brain?” if you dare to “know” more. 

            So what are we left with when it appears that our subconscious/unconscious mind is really running the show, allowing all of these deep-seated unconscious biases and prejudices to affect our actions and behaviors? Sounds like a terrifying proposition, but I choose to see hope and an opportunity for everyone to grow beyond this supposed “cage” of thinking--and guess what: it all starts with just a little mindfulness.  Realize the nature of the unconscious mind, realize your patterns of automatic thoughts and pattern recognition, realize you have unconscious bias that will likely not disappear, but that’s okay- we are not here to defeat the unconscious into unconsciousness because yep, you guessed it, it is already there. We can simply notice these patterns, biases and reactive thinking, all the while cultivating greater self-awareness, realizing that we all are carrying judgments and preconceptions (good or bad) into the inter-personal experiences of our daily lives.  In the end, we must all accept a truth, perceived or not, that we can be certain there is uncertaintyin our beliefs, and perhaps, it is best to mindfully step through the murkiness of this uncertainty knowing that maybe it isn’t uncertainty that we should be fearing, but certainty itself.

So what exactly are we doing when it comes to Psychiatry?

             Being a month removed from my last medical school clinical rotation (Psychiatry), I can safely say for as much as I enjoyed my time exploring mental illness, I was more than a little dismayed at Western medicine’s approach to healing when it comes to the disturbed mind.  As this post could easily explode into a rant, I want to start off by providing a solid foundation for a health discussion and acknowledge the inspiration behind this post: the pioneering work of one of my idols in functional medicine (specifically functional neuropsychiatry): Dr. Kelly Brogan. Dr. Brogan has just released her widely acclaimed book A Mind of Your Own that seeks to question much of we are doing with modern psychopharmacology- SSRI’s for pediatric obsessive-compulsive disorder, anti-psychotics for sleep deprived, stress outs Type A’s, and benzodiazepines (BZD’s) for anything else causing you a little anxiety. We’ve reached a scary point where drugs have taken over our treatment plans, yet interestingly enough, data continues to emerge showing the research for SSRI’s for mild/moderate depression, stimulants for ADHD and BZD’s for anxiety is rather weak and biased- some evidence actually shows potential harm for these drugs over the long term! But as I mentioned before, this is not about bashing drugs, but about promoting holistic and functional approaches to disease. So no better place to start than with a whole foods diet, a mindfulness practice, a little sun exposure, some energizing exercise, and time spent with loved ones.  Taken together, regardless of one’s current symptoms or physiologic disturbance, these five things will get you towards your goals of obtaining and sustaining optimal health; it also just so happens that the data behind these specific lifestyle practices for the treatment and prevention of mental illness is quite encouraging.

            Just in the past 3 years, studies focused on sun exposure (and not just Vitamin D levels,) quality/quantity of social relationships, adherence to a Mediterranean style diet, aerobic exercise, mindfulness meditation, and combining mindfulness meditation and aerobic exercise have all shown to be helpful in multiple areas related to mental health including: 1)improving negative mood symptoms, 2)preventing depression, 3)decreasing anxiety/social anxiety and 4)decreasing the likelihood of relapse after one’s initial presentation with a mental illness. As we continue to explore the biologic and pathophysiology behind specific mental disorders, we are discovering that disturbances in the body that lead to a state of chronic, low level inflammation can actually affect the integrity the blood/brain barrier that essentially allows inflammatory cytokines free access into the intricate structures of the brain, leading to a cascade of microglial activation and disrupted neuronal cell function. Coupled to a disturbance in one’s gut microbiota (responsible for the production of many neurotransmitters- including nearly 80-90% of all the serotonin in our body), you can quickly see that a neurotransmitter deficiency in one region of the brain isn’t exactly the whole story when it comes to depression. The inflammatory cytokine model of depression as described above as well as the relatively unknown effect of chronic environmental toxin exposure, are together, providing more truth to the story of mental illness. I will be the first to admit that in regards our current pharmaceutical approach to depression, there is supporting evidence that in moderate to severe depression there is a short term and substantial benefit for SSRI’s, however, when it comes to mild-moderate depression, placebo and the wonders of time are just as good- or perhaps better when you consider the lack of side effects. That being said, just because we observe some benefit for the most severely depressed, does not mean we completely understand the mechanism by which this may occur (for example: start from a worse/ the worst place imaginable and go forward in time, can things really get that much worse?), or that we should see the same effect on those less impaired at baseline are both rationalizations that simply cannot be made and truthfully hold little validity. So why do we still see so much suffering when it comes to depression for thousands of Americans? Well guess what, it just so happens that most people diagnosed or treated for depression fall within the mild to moderate range based on verified depression severity scales and what to this point have we been primarily offering them for treatment?- exactly, something no better and possibly more harmful than a placebo.

             But the problem with prescribing SSRI’s is not simply one of “Big Pharma” perpetuating their products, but of the way we practice family medicine- prescribing drugs because you only have fifteen minutes to talk to a patient presenting with mental illness. As Dr. Brogan points out in her book, we are not here to attack “Western Medicine” and demand the cessation of inappropriate pharmaceutical use, we are here to have a voice and hold a space saying there is another way to address mental illness, and it’s actually it’s a space that may be much more “medical” than “psychological.” Through careful evaluation of one’s gut health including intestinal permeability, food allergies, gluten sensitivity, SIBO, the presence of parasites or other infections, and fungal overgrowth, to an overall assessment of one’s current state of inflammation, blood sugar regulation, sleep patterns, social and work environments, exercise and movement patterns, hormonal imbalances and autonomic (in)stability, we see that mental illness does not exist in a silo where medical intervention is reserved for extreme cases. Adding even more fuel to the fire there’s our burgeoning understanding of the effects of our genetics (SNP’s) and the epigenetic inheritance from our parents/grandparents on our risk for developing mental illness. Did you know that if your grandmother was in a relative state of stress/anxiety/famine when she gave birth to your mother, regardless of your mother’s living conditions and environment, you may be at a greater risk for developing obesity, metabolic syndrome or a mental illness as it relates to your personal experiences of stress and/or traumatic life events?

            Brogan is opening “Pandora’s Box” so everyone can see the truth behind our current (flawed) approach to psychiatric care and I can only hope her message spreads like wildfire to family practice clinics and psychotherapy groups across the nation. Unfortunately, after seeing the relative lack of acknowledgement for underlying physiologic “medical” disturbance in an inpatient psychiatry unit (IV’s were not allowed on the unit- some would say for obvious reasons, and blood work was virtually limited to drug levels of anti-psychotics and mood stabilizers) I am not overly optimistic. Perhaps, most disturbing of all  with regards to the observed inpatient psychiatry care, was the approach to diet whereby all patients were given double portions, and there was no such thing as a diabetic or heart healthy diet. I can only speculate on the perceptions of other health care workers in charge of hospital care/policy, but perhaps it was seen that being on the psychiatry unit wasn’t exactly “pleasant” so why not just let the patients choose what they wanted to eat and give them double of everything (of course your loved ones could also bring in all the soda and candy you might want as well). As I saw it, by providing this substantial amount of processed food without a context for nutritional education and in complete disregard to the research behind a whole food or Mediterranean style diet for the treatment/prevention of depression, anxiety and psychosis, we were inadvertently sabotaging any realized gains from the treatments we could and did provide simply by adopting a “caring” approach to food for our patients.

            So I end with three final questions, (coming from someone who really does not like drugs) 1) Is there possibly, just maybe, a role or actual benefit for SSRI’s as a treatment for depression when we remove the overt antagonists- poor diet, substance abuse, minimal movement, no natural light exposure, and toxic relationships? Or (coming from someone who sees all those antagonists on the extreme end of poor choices) 2) If we actually choose to push beyond simply NOT doing something so BAD and choose, instead to shoot for DOING something relatively GOOD we would find a path to true healing for those suffering from mental illness? And finally (coming from someone with an open and gracious heart) 3) If you are to remember one thing from this post, can you remember to acknowledge those things that are directly harmful to the well-being of your patients, and choose to not to put your energy to attacking those things you may perceive as “bad” but choose instead with your complete consciousness to hold a space for the relief of suffering? For in the end, for those in the health care field, we may be (feel) obliged to “care” for all the patients we encounter, but do we actually believe in the choice to be compassionate, and perhaps, question if my belief and duty in the obligation to “care” is actually really caring at all?

Mindfulness: A Practice For All Americans?

            Mindfulness. The practice has made its way into popular media and is now being touted as the perfect “drug” to increase productivity in the workplace. While I will likely never tell someone he or she should not pursue a mindfulness practice, I get a little queasy when I see individuals believing that such practices will bring their business greater wealth/profits and in general, allow them to do MORE. Instead of criticizing people for their personal choices when it comes to starting meditation or yoga, I choose to take the higher road above any desires for personal gain and draw from the remarkable wisdom of congressman Tim Ryan, perhaps the only open meditator in politics, and ask what would America be like if it were full of mindful citizens passionately pursuing meaningful work for a greater good? I don’t think anyone would argue, that sounds like a country in which we would all love to live.  The only problem standing in the way?- the very foundations and infrastructure government and society have created leading us to our present state of relative dillusionment. From dysfunctional food and energy production to hierarchal big business controlling what we eat, read, and use to medicate, we might be literally and figuratively stuck climbing stairs towards goals and a future we don’t really want. As Ryan has postulated in numerous interviews and talks including CBS’s 60 Minutes: what if by promoting mindfulness in our daily pursuits, we can transform the way we produce, distribute and feed our nation, reinvent the way businesses promote healthy lifestyles and support wellness for their employees and reinvigorate a failing education system where grades and test scores are replacing physical activity, creative expression and social engagement? Without sounding too greedy, I ask why can’t we have our cake and eat it too? Why can’t mindful and compassionate living lead to greater happiness as well as a more productive and efficient workforce? You see, mindfulness can be the gateway drug to so many positive changes for an individual and for our nation as a whole. And lucky for us, the addiction has no side effects, only the potential for us to be and do all in the same breath.

            While I have limited knowledge into policy development, drafting and enacting legislation or anything remotely related to instituting change on nationwide let alone a statewide scale, I do have some knowledge when it comes the smallest functional unit of our society: the individual. Starting from a place of one, we cannot get any more simple or grassroots. One person choosing to recognize their thoughts for what they are at that very moment: just electrical activity coursing through the anatomical wonder that is the human brain, is exactly that, one person. True healing is about creating a relationship with one person: the patient. While I believe providing holistic treatment for a single individual requires a team of like minded healers and social support from other patients, family and friends, at the core of the healing process is the individual: mind, body and spirit. Unfortunately, even integrative practitioners can become lost in the numerous resources to provide healing, and can encourage their patients to make multiple lifestyle changes including improving diet, exercise and sleep as well as increasing sun exposure, social activity and incorporating a regular stress reduction practice. To be honest, I’m overwhelmed just from reading that list and can’t imagine the perspective of an individual being presented with these concepts for the first time.       As an antidote and alternative to this mountain of healthy lifestyle habits, I routinely tell patients, as well as myself, to start with just one simple thing: 5 minutes of a mindfulness practice. Whether you choose to sit on the sofa and breathe for 5 minutes, walk out to your mailbox and back while rhythmically breathing and pacing, or listen to music as you reflect on your day and fall fast asleep, a mindfulness practice can be anything. The key? Start small, start simple, and start without expectation. The most basic practice I recommend is simply this, no matter where you are just breathe in for 3 seconds and breath out for 6 seconds. Do this for at least 10 breaths, which if you do the math is 90 seconds. Add in a few pauses and variation between breaths and you are still looking at only 2 minutes. 2 minutes! I think we can all agree that we have the capacity to do something as basic as a breathing exercise for 5 or even 2 minutes each and every day. Taking his mindfulness practice one step further,  I suggest to you that from this place of self awareness, we have the potential to see clearly, live in the present moment and act with right intention towards our greater goals. Suddenly, just by starting with a 5 minute mindfulness practice, those other lifestyle changes may not seem so daunting after all.  There are no such things as absolutes in medicine, and I will not sit here and say mindfulness is the answer to all our ills, nor delve into the growing scientific literature showing the benefits of mindfulness to try and validate my proposition, I merely want to share my belief of empowerment and encourage self experimentation into something as simple as a 5 minute mindfulness practice

            Because I am a visual person, I will end this post with my final thoughts articulate through descriptive imagery. Imagine a country that collectively each and every morning at 7:00 AM took a 2-minute pause to just breath: no work, no school, no play, no doing, just being. And what if you are sleeping or engaged in an activity such as driving or flying a airplane at 7:00 AM, no worries, just don’t close your eyes. The cynics and realists of the world would say our nation of workers could never stop for 2 minutes, as we would all just crash and burn into some chaotic oblivion. And I would say to them, well, what a quiet and reflective end that would surely be.

Stress: Is there a positive side to all this caring?

            Key Points

1. Stress is your mind’s interpretation of either an internal or external stimuli

2. Stress does not function as a simple external force causing harm

3. You have the ability to modulate your perceptions and approach to adversity, ultimately deciding if “stress” will cause DISTRESS or EMPOWERMENT

4. By learning to control your internal thoughts and your reactions to external stimuli, you can create an effective and downright feel good physiologic “stress response.”

5. Stress is simply CARING, A LOT

6. Stress can be way to create meaning in our lives, to connect with others and to reach higher states of functioning rather than succumbing to anxiety and fear.

            If you haven’t been living under a rock for the past few years, you are probably more than aware that stress management is often a pivotal part of any functional approach to improving health and avoiding disease. Along with this message, you may have also heard of the idea that chronic stress in the form a perpetually hyperactive  sympathetic nervous system, or ‘fight or flight” response, can create a relative imbalance in our overall autonomic nervous system, leading to significant dysfunction, morbidity and just plain poor health. Taking this into consideration, nothing seems more worrisome to me than an “automatic” machine that evolved to perform functions such as regulating blood pressure, orchestrating proper digestion and maintaining metabolic energy balance working in a less than optimal manner.  I cannot stress this enough (no pun intended)- automatic DOES NOT mean optimally functioning- it simply means autonomously and continuously performing a given task that may or may not actually be helpful to the system in question. Lastly and perhaps most intriguingly, automatic DOES NOT mean out of OUR control. While we are blessed with an autonomic nervous system that can function independently of any conscious thought, the beauty of this system lies in the fact that we CAN control the inputs to this system such that we can alter our physiology simply by our thoughts!  Ever heard of psyching yourself up for the big game? Well guess what, you may have just willfully increased blood flood to your skeletal muscles, mobilized glycogen stores to provide precious glucose for your mitochondria to make ATP- and increased your cardiac output in order to supply your cells with the oxygen required to maximize this energy production- did someone just say Electronic Transport Chain?

            In order to help answer the main questions at hand: what exactly is stress and how does it affect our overall health, I have turned to the wisdom of Kelly McGonigal, a prominent health psychologist, who has become the leading researcher wiithn this field of stress psychology. If you have not seen her TED Talk, I would like to say you are not alone, but the truth is, she has over 9 million views! Just perhaps she has something interesting to say.

TED Talk Link

https://www.ted.com/talks/kelly_mcgonigal_how_to_make_stress_your_friend?language=en

 Additionally she recently did two wonderful podcasts with Brian Johnson, one of the most practical and productive mental health geniuses I know, which provide further fuel to this discussion.

Podcast Link:

 The Upside of Stress: https://brianjohnson.me/philosophers-notes/the-upside-of-stress/

One of Brian’s most important “Big Ideas” from his discussions with McGonigal is that “stress” can actually be a motivating and helpful component of our daily lives. As he point outs, rather than seeing stress as the all or nothing “fight or flight” response or stress as chronic, runaway anxiety with actually minimal amounts of “fighting or flighting,” we should simply see stress as the acknowledgment that we CARE, A LOT. Taking our positive approach to stress and applying it to a real world situation, let’s examine the scenario of an impending thunderstorm barreling down overtop some hikers completely exposed to the elements. If you feel like this would be a good time to begin some quiet mindful reflection, trying to avoid overt sympathetic arousal, maybe you should apply our new positive stress paradigm and think instead, "I do not have to necessarily fight or flee, but maybe I should start CARING, A LOT.”

            While we commonly associate enthusiasm and passion as “positive” traits and stress and anxiety as “negative”, McGonigal argues and I agree, why can’t stress be positive? Why can’t we channel this physiologic energy into passionate work? Ever been buzzing as you churned through a book, or hummed along writing a deadline paper- you may have been in what some people call a “Flow State.” With creativity seeming to ooze from your eyeballs, in this perceived “Flow State” there often times is very little thinking, just doing, feeling, and moving with the moment. Just as you can’t tickle or scare yourself by jumping around a corner, you cannot seek to obtain or reach a “Flow State” through purposeful action; it just simply happens. Now if I were to ask you how you were feeling during one of these moments of clear action, of precise expression, of being “in the zone” I can almost guarantee you would not describe it as the sympathetic response- running away from a saber tooth tiger, but you surely would also not describe it as a calm, collected and peaceful parasympathetic state; so what exactly then is this “Flow State?” To answer this last question, I turn to the work of Andrew Bernstein.

            Bernstein’s most recent book: “The Myth of Stress” seeks to completely shatter the idea that stress is some external force leading to the systematic activation of our sympathetic nervous system. Rather, Bernstein postulates that stress is pretty much all a mental construct, an interpretation, internally created through our thoughts regarding our present environmental circumstances. Bernstein discusses this idea and others further in a thought-provoking podcast with Robb Wolf.

Podcast Link

http://robbwolf.com/2015/11/10/episode-295-andrew-bernstein-the-myth-of-stress/

        Taking even what seems to be the most obvious rebuttal to his theory regarding stress: a massive grizzly bear standing 20 yards ahead of your path, he argues that  while we all just assume the presence of the bear will initiate our "fight or flight" response, we actually have to mentally decide “hmmm, interacting with this bear might not be the best idea, maybe I should start caring about staying alive.” So we see that the ensuing physiologic response involving fleeing or possibly fighting, depending on the person in question, stems not from some switch the bear triggered, but from our internal ruminations, a conscious decision that this situation requires a different level of attention. Going back to our previously described “Flow State,” I suggest to you that perhaps, the reason we do not perceive these moments of action as stressors or stressful or conversely, describe them as soothing or calming- operating at our normal homeostatic baseline, is because, just maybe, we aren’t thinking much at all. Thus we return to the question: Without thinking, without an internal dialogue, without conscious awareness of our thoughts, is stress even possible? Whether operating in a “Flow State” or choosing to mindfully direct our energy during situations of perceived stress, it seems that we truly have the power to control stress, and more importantly, use stress to live more productive, happy and fulfilled lives.

              The possibilities of a positive approach to stress are endless, but I want to end this discussion with one last key question and idea: what if we saw stress as a positive way to create meaning? McGonigal sites an amazing study that looked people personal interpretations of stress and meaning in there lives and sure enough, the people who said they were the most stressed also identified more meaningful pursuits and relationships in their lives. So if we approach stress as the opportunity to acknowledge our values and subsequently create meaning in our lives, instead of just another moment to let anxiety, worry and disappointment reign supreme, would we see stress differently? And lastly, I ask you curiously, do we really need stress management, when we can have stress empowerment instead? Just an idea or maybe some misdirected stressful thinking, who knows, it’s all just in our heads anyway.