Shrinks In Sneakers

Author: Dr. G

  • Introduction to Mindfulness

    Introduction to Mindfulness

    Mindfulness never struck me as something I could see myself doing on a regular basis. For many years, I viewed the practice as something for “enlightened people” with no practical application for the average person. As the years went on and the research continued to pile up in the literature, I decided to try it out. 

    There are two basic ideas to keep in mind during meditation practice. We are not aware of how our body is feeling, and we are not aware of the constant stream of thoughts occurring all day long. By bringing attention to these two things we can begin to take control of our bodies and our minds.

    The process is very simple and can be performed from most locations. Ideally you want a quiet place where you will be undisturbed for 10-15 minutes. I personally like the 10-minute mediation session, and it works well if you have a busy schedule. 

    To begin the process, find a chair, preferably one you can sit upright in with your feet on the floor and back straight. I like to rest my hands on my legs.

    I begin the process with my eyes open, and a few deep breaths in through the nose and out through the mouth. On the 5th breath I close my eyes. I return to my normal rate and rhythm of breathing in through the nose and back out through the nose. 

    Next I begin the process of performing a body scan. I like to start at the head and work my way down to the toes, noting any discomfort or tension. I will also take note of areas on the body the fell relaxed and tension free. This should take 1-2 minutes. 

    If at any point thoughts pop into your head, it’s fine let them come but most importantly let them go. Do not dwell on any one particular thought, just allow them pass. 

    The next step is a series of breathing exercise I learned several years ago. Start with 10 breaths in through the nose and out through the mouth, counting each one. Then perform 10 breaths in through the nose and out through the nose, again counting each one as you go. Finally, take a breath in through the nose, hold it for 5 seconds, and release it slowly through the mouth to a count of 4. This sequence of breathing exercises should be performed two times for a total of 60 breaths. This will take approximately 5-7 minutes. 

    For the final 1-2 minutes do not count or breath in any particular manner just allow the mind the space to think about anything it wants to. After a minute or two bring the focus back to the body, feel the feet on the floor, and arms on you lap. Open your eyes slowly, and sit for a minute to think about what you are grateful for before starting your day. It’s an excellent way to practice some gratitude. 

    The more you practice this technique the easier it will be for you. As the days go on you will experience more control over both your body and your mind. 

  • Millennial Doctors Financial Woes Continue

    Millennial Doctors Financial Woes Continue

    Introduction

    All millennial physicians had a lot to process over the last several weeks. The coronavirus rapidly spread across the United States leading to the worst financial crisis since 2008. No generation in history has had to deal with two major events that ravished the economy in a relatively short period of time. It started with the financial crisis of 2008, and now a coronavirus pandemic that once again threatens the financial future of many people. At this point no one knows the full impact this pandemic will have on the economy.

    The current crisis presents a number of concerns for young physicians. The primary concern of many recent graduates, or early career physicians is taking care of patients and remaining safe. A big part of what happens to the economy over the next several months depends on the work of public health officials, hospital systems, and healthcare providers.

    Understandably, financial well-being is not the primary concern for many. Most physicians make a big financial sacrifice early in life, forgoing the earnings of our early 20’s in favor of education. Once you navigate medical school successfully, you enter another period of low earnings in residency. There is no doubt that our career choice and the multiple financial crises altered the lives of young physicians permanently.   

    Financial Tips for a Recession  

    It wasn’t too long ago when I received the first paycheck I ever made as a physician. It was a big moment for me, I received $763.26 for doing the work that I loved. I even have the paycheck framed on my wall. After eight years of not making a single dollar and taking out a six-figure loan to fund my education, I finally felt like this was my time. There were many things I neglected over those eight years that I needed to address. Most of my friends and family who chose different career paths were buying houses, saving for retirement, and not driving an old car. My initial goal was simple, I just wanted to stop worrying about how to pay my monthly bills. Below are several strategies I used over the last three years to save money, pay debt, and improve my financial health. 

    Living with Family to get a Jump Start  

    The first choice which helped me immensely was selecting a residency program close to home which allowed me to move back in with parents for the first year. A goal of mine was to practice in the community I grew up in, and when that opportunity presented itself, I could not pass it up. It also allowed me to live rent free for one year to help pay for transportation, build a small emergency fund, and pay off the one private loan I took out for residency applications and travel. I realize this is not possible for everyone and my situation is unique, but if an option like this is available to you, consider it.

    Secure Reliable Transportation 

    I started with selling my old Honda and looking for reliable transportation. I eventually settled on a Honda which I purchased used for $16,500. I know it seems pricy for a person with limited resources, but the investment felt worthwhile due to my expected commutes. I like Honda for their reliability, low cost maintenance, and fuel economy. The other car company that fits into this category is Toyota. 

    Have a Small emergency Fund

    Next, I opened a high interest savings account with the goal of having $1,000 in it for emergencies. I wanted a small amount of cash available to cover any unforeseen expenses.

    Develop Good Financial Habits and Protect Your Family

    I focused on developing good financial habits, learning to save, and started thinking about how to invest a portion of my earnings in the next few years. Financial education became a big part of my study plan because it’s not taught in any medical school. I also secured own occupation disability insurance, and term life insurance. It’s important to protect yourself and your family in the event you are unable to do your job or pass away unexpectedly. This is even more important with the COVID-19 pandemic.

    Housing Is a Major Expense 

    One of the keys to my success was low cost of living. I made the decision to move out of my parents house 2nd year. This required some significant out of pocket expenses including a security deposit, some furniture, and costs associated with setting up a new place. The biggest impact was related to the monthly rent payment. Although it was reasonable for the location it was still a significant portion of my monthly income. Finding ways to reduce your housing costs may be the single biggest benefit to your financial future.

    Investment Options:

    From all my research, it was clear that index fund investing was the best method and produced reliable returns over time with minimal management on the investors part. The real decision was between opening a personal retirement account like a ROTH IRA or opening an employer sponsored account such as a 401k or 403b. Most advice you will find recommends the ROTH over the employer account given the eventual higher earnings and tax bracket most doctors will be in after completing residency. I have since found that it really depends on your individual situation. If you have a high student debt burden and want to reduce your adjusted gross income, or your employer matches contributions you may want to opt for the 401k or 403b. I settled on the employer-based retirement plan. I was able to select several low-fee index funds and was happy with the options provided. The automatic deductions made the process simple, and helped me reduce my adjusted gross income and thus my student loan payments.

    COVID-19  Optimism

    This is a work in progress as the year is ongoing. I’ve been looking at the entire COVID-19 situation in terms of the potential benefits that may arise. If you are still in training or an early career physician, the most important financial asset you have is time. Over the span of a 30-year career the economy will fluctuate, with some bad years and some really great years. Things were bad in 2008, but if you made saving a priority, invested your money wisely, and paid off debt by 2018 you were doing really well. Unlike those who are looking to retire, or are retired we have an opportunity to invest heavily in a down market. I believe it’s a prime opportunity to lay the foundation for your financial future.

    We also have the added benefit of some student loan relief which was not an area of focus in 2008. It looks like the economic stimulus will allow for no interest and no payments on direct or federally held loans for the next 6 months. If you are on REPAYE, PAYE, or PSLF you don’t need to do anything to qualify for the payment and interest freeze. It’s refreshing to see the federal government acknowledge the need to provide student loan relief after failing to consider the long term impact it would have in 2008. 

    We need to prepare ourselves for the next several months and continue to take the necessary steps to secure our financial future. We must believe in our own resiliency and capacity to grow during hardship. We’ve been through a recession before, and this is not likely to be the last. 

  • Chronic Inflammation And Depression

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    Introduction:

    Inflammation is the body’s natural response to infection or injury. It’s an important response in the acute setting but chronic inflammation can contribute to the development of diseases such as heart disease and even depression. Most psychiatrists now recognize that inflammation plays a role in depressive disorders, although it’s not an inflammatory disease. Much of the research on inflammation and depression is ongoing and will develop over time. 

    Risk Factors for Inflammation

    ·         Childhood trauma

    ·         High stress levels (work, school)

    ·         Depression that is resistant to treatment

    ·         Severe anxiety

    ·         Obesity BMI> 30

    ·         Medical illness

    ·         Recent injury or surgery

    What are some nonpharmacological things we can do to reduce inflammation and thus the risk of disease?

    Complementary and alternative therapies

    Lifestyle: Exercise, Healthy diet, Mindfulness practice, CBT all have anti-inflammatory effects.

    N-acetylcysteine studies with 2000 mg/day improved anxiety and depressive symptoms

    L-methyl folate: L-methyl folate 15 mg/day as augmentation to antidepressants

    Omega-3: 1000 mg/day of omega-3 fatty acids with DHA to EPA ratio > 60% improved depressive symptoms

  • When Should Hospitalization be Considered for Depression?

    Introduction 

    This post is significant to me because one area I really enjoy working is the inpatient psychiatric unit. This might seem strange, but it’s a place I just gravitate towards and fell like I’m having a meaningful impact. You can think of it as the equivalent to the medical intensive care unit (ICU). It’s a place to learn about the most severe psychiatric pathologies and medication management.

    In this post I will cover some of the signs and symptoms that may indicate inpatient hospitalization could help and possibly be lifesaving. 

    Signs and Symptoms

    Suicidal Ideation:

    If your depression has become so profound that you have thoughts about “killing yourself,” then it might be time for inpatient treatment. Many clinicians, especially those not working in mental health, feel uncomfortable asking direct questions about suicide. Contrary to a common belief, asking about suicide does not increase the risk of suicide. I like to use the term “kill yourself” when doing a suicide assesment. It’s very definitive and clear to the patient what I’m talking about. The concern increases if there is a plan in place for the person to kill themselves, the plan is logical, feasible, and the person intends to carry out the plan. All of these are warnings that the person is at high risk. If these thoughts are persistent that’s another indicator that the problem is more serious. 

    There is a significant difference between the above situation and the person who has “passive suicidal thoughts.” Passive suicidal thoughts are statements like “If I didn’t wake up tomorrow, I would be okay with it.” It’s not that the person is actively trying to prematurely end their life, rather they would not mind if something happened that hastened the path towards death. 

    Hopelessness:

    Another validated risk factor for suicide is severe, unremitting hopelessness. Hopelessness consists of feeling that nothing is getting better, nothing will ever get better, and there’s nothing I can do about it. This, independent of other risk factors, puts the person at high risk for suicide.

    Loss of Interest:

    Severe anhedonia (loss of interest) in previously pleasurable activities is part of the diagnostic criteria for depression, it’s also something that can increase suicide risk. If a person previously went to the gym five days a week or watched every new episode of The Bachelor and suddenly no longer cares about these things, it may be cause for concern.

    Poor Response to Outpatient Treatment:

    If you have been in traditional outpatient therapy and medication management for many years with minimal or no improvement, and you have never been hospitalized for psychiatric purposes before, then inpatient hospitalization may help. Sometimes the break from the daily life stressors for 3-5 days allows the mind and body to rest. If you tried everything else, then who knows? This could be the intervention that changes your life.

    Seeking inpatient psychiatric care is nothing to be ashamed of, and many mental health professionals are working hard to destigmatize psychiatric care. I like to think about inpatient psychiatric care as a mental wellness camp, and not as a punishment for mental illness.

    If this information is useful please like, share, and subscribe to the blog and other social media sites. Drop us a comment about what topics you are interested in, and we will try to cover them. 

    If you or someone you love is at risk for suicide, the following resources are available. 

    National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org

    National Suicide Prevention Hotline: 1-800-273-8255

    SAMHSA: https://www.samhsa.gov/grants/grant-announcements/sm-20-011

  • How to Tell if You Have Depression

    Images that show what it feels like to suffer from mental illness. Bringing the inside to the outside.

    Depression is not always easy to spot, and in a world filled with social media it always seems like everyone is living their best life. 

    In the most severe states people can have suicidal thoughts and profound hopelessness. The symptoms can be mild, moderate, or severe. Depression can affect anyone. 

    Depression is an illness like any other disease (diabetes, hypertension, heart disease) that affects thoughts, feelings, physical health, and behaviors. 

    People with major depressive disorder have several of these symptoms every day or nearly every day for 2 weeks or more. 

    Here are some signs that you may have depression 

    At least one of the following, loss of interest in things you previously enjoyed or depressed mood  

    At least 3 of the following 

    • Feeling slow or restless 
    • Feeling guilty or worthless
    • Increased or decreased appetite
    • Suicidal thoughts 
    • Problems concentrating, making choices, or remembering things 
    • Difficulty sleeping or sleeping too much 
    • Having low energy 

    Potential physical signs of depression include 

    • Headaches
    • Muscle tension 
    • Digestive symptoms 
    • Sexual problems 
    • Feeling “keyed up”

    This can be summed up in the mnemonic SIGECAPS taught to medical students everywhere. The mnemonic comes from the prescription a doctor might write for a depressed patient

     SIG:  1 energy capsules per day 

    Please like, comment, and share the post if it was helpful. Let us know what else you would like to see. 

  • Steps For Young Physicians New to Managing Money

    Steps For Young Physicians New to Managing Money

    A quick Disclaimer before continuing: Obviously as physicians we do not enter into the field of medicine with the sole purpose of making money and buying stuff. If this were the case, I would have gone into investment banking, sales, or marketing where I would not have spent the last 8 years of my life taking out huge student loans to pay for the torture of getting through undergraduate and medical school. 

    Protect the things that you have already worked hard for. You just graduated medical school and matched to the residency of your choice. Like many medical students you have received little if any training on managing your money or protecting your assets. At this point you may not feel like you have much to protect, but if you are like many medical students you just spent several hundred thousand dollars on your education and that is certainly something to protect. If you have a family, or children and a great deal of educational debt it’s equally important to protect them in the event of your death. The first two steps in this process will likely not bring you any wealth at all. They are simply there to protect you from misfortune which could potentially strike anyone at any time. The first recommendation is to obtain own occupation disability insurance from a quality provider such as Guardian. Basically, if there is any reason you become disabled and cannot do the job you were trained to do this policy is here to protect you. Most of the policies allow to increase the payout as you advance in your career. If you lock into a policy at a younger age you may be able to avoid the medical evaluation that often is required for these policies. The other insurance policy you want to have at the start of residency is term life insurance. In the unfortunate situation where you pass away before you make your fortune you will protect the people you love the most from financial hardship. I would suggest somewhere in the range of $500,000 to $1,000,000 depending on your debt burden. I will provide one additional tip here because I believe it’s important. If you have car insurance at the state minimum it’s a good idea to increase the rates. Again, this protects you from any potential issues in the event of a serious car accident. If people know you are a doctor they may assume you have a lot of money increasing the chances of a law suit. Bottom line make sure you are protected. 

    My next point which may or may not be popular with some people is do not do a fellowship in psychiatry. A fellowship is not required to work in most areas of psychiatry, and residents often wish they did not do one after having the experience. Unless the fellowship provides you with skills no one else possess, it provides very little value. Maybe doing a child/adolescent fellowship is valuable but doing a consultation-liaison fellowship is not. It’s hard to see how doing one year of additional consult psychiatry would make you any better since most residency programs have multiple rotations on consult service, and additional time can be spent in consult 4th year. Consult work, emergency psychiatry, addiction, and forensic work can all be done without a fellowship and board certification. The financial aspect is equally important, another year making approximately $60,000-$70,000 is difficult to justify. As a fellow you are still a student, and you do not have full ownership and responsibility for your patients. You are still not learning what it is like to be an attending.  

    There will be more to come in the next several posts.

  • Ketamine: What You Need to Know

    Ketamine: What You Need to Know

    Anyone following psychiatry in the media will have heard about ketamine. Ketamine as a medicine was primarily used for starting and maintaining anesthesia. It’s also a well-known recreational drug (special K) for its hallucinogenic and dissociative effects. Ketamine nasal spray was approved by the Food and Drug Administration (FDA) in March of 2019 for treatment resistant depression (TRD). Ketamine intravenous infusions were being offered for several years prior to FDA approval as an off-label treatment for TRD. esketamine is the S-isomer of ketamine (usually a mixture of both s-ketamine and r-ketamine). The nasal spray device contains 28 mg of esketamine and is administered as a single spray in each nostril.

    The guidelines for dosing the medication include an induction phase (weeks 1-4) of 56 mg on day one followed by 56 mg or 84 mg twice per week. From week five on 56 mg or 84 mg will be given every 1-2 weeks depending on patient response. Patients are required to remain in the office to be observed by a healthcare provider for at least two hours after receiving the medication. The device cannot be taken home, and the patient must come to the office for each dose. The clinic must be a certified Spravato treatment center to use the medication. Patients should be remined to avoid food 2 hours prior to treatment, and liquids 30 minutes prior to treatment. Blood pressure should be monitored 40 minutes after the dose. 

    Some of the limitations associated with this medication include high cost to the patient. Insurance will cover some of the cost and Johnson & Johnson set a list price of $590 to $885 per treatment. The major side effects include sedation, dissociation, increased blood pressure which is transient, cognitive impairment and inability to drive. One of the major arguments against the use of ketamine products is the potential for abuse/misuse. Some of this is mitigated by only allowing the medication to be administered at certified centers, and not allowing take home doses. Still patients with a history of substance use disorder may be at risk, and each case should be evaluated carefully. 

    What makes esketamine so exciting is this is the first medication that works through a different mechanism of action (MOA) to treat depression. The focus of depression treatment to this point has been on monoamines such as serotonin. Esketamine acts as N-methyl-D-aspartate receptor antagonist (NMDAR). The other exciting finding is the rapid relief of depressive symptoms this medication provides. Efficacy can be seen as early as 24 hours after the first dose. There is no other antidepressant medication on the market that can produce improvements in depressive symptoms so rapidly.  

    Esketamine’s use remains limitted to patients with treatment resistant depression. Research indicates it’s moderately effective and should be offered as an alternative for those who prefer medication over electroconvulsive therapy (ECT). The barriers to use include high cost, frequent clinic visits, and lots or regulation and monitoring requirements on the part of clinics offering the treatment.