How to prevent suicide amongst our youth?

I think opioid crisis is a symptom of the great prevalence of people with mental health conditions.  I’d add that this great prevalence is really a reflection of the preponderance of fallacies in the contemporary mindset. For example:
1. I can think, consume, do what my mind wants without regard for the needs of my body, my community, rest of humanity or the planet.
2. All pain, suffering and illness must, should or can be avoided at all cost.
3. Having a “tool” (in the case of opioids or anything else for that matter) implies I know how and when to use it.
4. A set of rules that works yesterday will apply today; rules that works today should also work tomorrow; rules that work for one person, people, time or place should work for another.
5. I know how to manage the most important “tool” of all - my mind.
6. It is up to someone or something or some other government to rescue me.

Many fallacies that are ingrained in the contemporary culture.  Children are imprinted with these irreconcilable ironies and suffer the consequences of ignorance.  Premature mortalities and morbidities such as that of opioid crisis, suicides, type 2 diabetic crisis may all just be manifestations of the contraction of awareness.  These affects everyone and everyone we care about.

According to University and College Health Association:
http://oucha.ca/pdf/2016_NCHA-II_WEB_SPRING_2016_ONTARIO_CANADA_REFERENCE_GROUP_EXECUTIVE_SUMMARY.pdf
65 percent of students reported experiencing overwhelming anxiety in the previous year (up from 57 per cent in 2013).
46 per cent reported feeling so depressed in the previous year it was difficult to function (up from 40 per cent in 2013).
13 per cent had seriously considered suicide in the previous year (up from 10 per cent in 2013).
2.2 per cent reported attempting suicide in the last year (up from 1.5 per cent in 2013).
Nine per cent reported attempting suicide sometime in the past (not restricted to last year).
Mental health challenges seem to be the norm rather than the exception; and does not seem to go away with time.
According to CAMH:
By age 40, about 50% of the population will have or have had a mental illness.
The Canadian health care spendings is already in excess of $250 Billions; while the tax revenues is only a little more than $300 Billions.  It would seem that some wellness perspectives are fundamentally lacking in the contemporary mindset.
There also seem to be an imprecise sense that it’s I vs the world; I or we vs you; mine vs yours; us vs them; constituents vs politicians; patients vs doctors; parents vs teachers; one team, preference, choice, gender, race, nation, religion, believe vs another; etc.
These erroneous premises appears to be the source of all sufferings.  Such imagined divides can not be bridged by formalities, apologies, rules, policies or laws; they exist in varying forms and degrees within the individuals.  
Knowledge of these imprecision within myself is only a start; eliminating them is entirely another matter.  It is a lifelong process that requires authenticity, listening and sharing.

How can I change anything external, when I can’t even change what’s within?
It would then seem that the only solutions relevant to me would start with me.

1. Wide adoption of Mindfulness training programs (such as Mindfulness without Border Ambassador Program) and robust nutrition education at every level of the education system: schools, colleges and universities.
(I facilitate resilience groups for medical students and will speak at a local school parent teacher meeting on “addictions and mindfulness training”)
2. Wellness role modeling and promotion by our political leaders, community leaders, celebrities and other opinion makers.
( I spoke at a community garden club on “pain, suffering and illness”; it was well received, I will do the same at the community recreation center)
3. Wellness programs in government and private organizations.
(I now have some potential opportunities to help start “employee wellness programs” at the hospital and at a large corporation)
4. Expanded availability of GROUP psychotherapy in primary care, psychiatry care and beyond can greatly expand capacity. (I now run five weekly groups for patients in my practice and the community.  These groups complements my family and emergency practices. If anyone like to learn to run these groups or want to know more; I’d be happy to help!)

Sciatica management in ER

The other day In ER, I met a 51 year old overweight transport driver presenting with severe sciatica.  His last episode was several years ago; they seem to come on without apparent injuries. This one seems much worse.

He had no “red flags” for more sinister etiologies; so I explained to him that pain is like the warning lights on the dash of a vehicle.  A mechanic can either cover up the warning light with something like duct tape or get curious about what has caused the warning light and make necessary corrections.  In the case of sciatica, the pain is due to compression of the lumbar nerves by the gradual loss in integrity of adjacent structures. While, these structure may deteriorate irreversibly from injuries and advancing age; they can also reversibly decompensate from poor nutrition, poor posture and lack of exercise.  I suggested he increase his non-starchy vegetable intake to 400 grams daily; begin the ongoing practice of the lumbar decompression / core strengthening exercise we discussed. I also share with him my personal experiences with chronic sciatica. By being curious rather than fearful of the pain, I am able to respond appropriately rather than reacting inappropriately.  By being grateful rather than resentful of the pain, I am able to experience life fully.
He and his wife were grateful that he did not receive the “duct tape” solution; that the sciatica has served as a “warning light” to prevent many other worse possibilities;  that by eating each meal and living each moment mindfully, they can expect wonderful possibilities.

They smiled and thanked me as they walked out slowly.

Why youth cut themselves?

I worked ER this past Easter weekend.  I was asked to see a 12 year old boy who had cut himself for the first time.  He did not know why he did what he did; so I explained it to him while I repaired his laceration.  He left smiling and satisfied. His mom sent me an email today thanking me for taking care of her son.

I recall another earlier incidence.  It was the weekend just before last Christmas.  I had been asked to see another 12 year old boy who had cut himself.  The story was that “he began cutting only after having met a female friend who cuts”.  This was his third ER visit for cutting. Mom is a social worker. He has been seeing a therapist for sometime but was recently referred onto another therapist.  I asked mom why? She was first quiet; and later said it’s because the therapist felt that the new therapy team can provide the needed family therapy.

I asked him why he cuts?  He looked up briefly and said it’s because “everyone hates me”.  I asked him why if other hate him, they aren’t doing the cutting.  He looked puzzled. I then asked him if it is possible that he is struggling with difficult thoughts which he can’t stop; and that he is using  the pain of cutting to interrupt the thoughts. He then looked up and held my gaze and nodded his head. I then asked him what else he does to stop his thoughts.  He looked at his mom briefly but said nothing. I asked if he plays video games. He quickly denied it. His mom was also quick to point out that he is in rep hockey and has no time to waste.  I then asked him again what else he does to stop his thoughts. His mom looked surprised when he finally said he punched walls. I asked him again if the pain helps him stop his thoughts. He said yes.  I then asked him what else? He said he banged his head against walls. His mom looked shocked.
I asked him if I may share with him a painless technique called “Take Five” that may help him deal with difficult thoughts.  He looked at me earnestly and agreed. I instructed him as follows: 1. hold up one spread hand and hold out the index finger in the other.  2. Slowly trace the outline of the spread hand with the index finger of the opposite hand in the following way. 3. wait for the next (preferably involuntary) breath. 4. and trace up the digit with each inspiration.  5. and trace down the digit with each expiration. 6. repeat the same until the entire spread hand is traced.

I explained to him that by intentionally paying attention to the sensation of his breath and the tracing of his hand, he can redirect his attention away from his difficult thoughts without the the pain and trouble of his current methods.  I encouraged him to practice this new technique at every chance he gets. I suggested that his ability to direct his attention and manage difficult thoughts will improve with these regular practices - no different than how hockey drills improves his play.

I then asked him who else suffered difficulty with thoughts.  He said “my twin”. I said, “who else?” He pointed to his mom.  I asked, “how about your dad?” He said, “no.” I said, “what about when he loses his temper and yells at you about hockey?”  He thought and began smiling and nodding. So I suggested that he might find an appropriate moment to share his new learned knowledge and “Take Five” with his father.

He held my gaze continuously; and in my peripheral vision, I then noticed he had continued to practice “Take Five” by tracing his hand!

I then suggested that difficulty with thoughts is a problem most people suffer from; and that he is not alone with his challenging experiences.  I told him by developing his ability to choose the object of his moment to moment attention, he shall open many exciting possibilities.

I also pointed out to him that even the olympic silver medalist may cry for being only the second best; that the “worst” player exhibits great courage for simply being part of the game; and that everyone has the right to be happy.

He then reached out and shook my hand firmly for helping him.

His mom, sensing the interview is coming to an end,  voices her concerns of the repetitive nature of his past cutting behavior.  I explained to his mom that events in the past can not be changed. While they are informative; holding onto these thoughts may be depressingly harmful; and it’s best to let go of these thoughts by redirecting attention to the present.  She then asked what she should do if the his cutting behavior recurs. I explained to her that fear is a thought of a future possibility that may or may not happen; and preoccupation with them are not helpful and may lead to unnecessary anxiety.  I also pointed out that her son is no longer the same person as he now possesses new perspectives and an alternative method for dealing with difficult thoughts. I suggested that she might want to support her son by practicing the “Take Five” technique as well. I also shared a free 8 week online mindfulness training course with them.
As I was leaving, he shook my hand with both of his hands and thanked me again.

I wonder how much cannabis manufacturers pay patient advocacy groups and professional societies

I also wonder how much cannabis manufacturers pay patient advocacy groups and professional societies that have great influences on policies, guidelines, medical education and our culture.
The education on the medicinal use of cannabis is mostly funded directly or indirectly by the producers.
I read in Wikipedia, “..in vitro studies indicate CBD may interact with different biological targets, including cannabinoid receptors and other neurotransmitter receptors, as of 2018 the mechanism of action for its biological effects has not been determined...It is an allosteric modulator of the μ- and δ-opioid receptors as well.”   
While I have no clue how CBD actually works, it  being both a potent psychotropic and analgesic suggests to me of it’s potentially a dangerous substitute or quick fix solution for dealing with pain and suffering.
While I suspect there must be research on CBD safety and benefits eagerly and earnestly shared by producers and promoters; I am hesitant to abandon all caution.  I read not all that long ago Valium was promoted as safe and a way to safeguard the virtues of college girls who might otherwise succumb to crumbling moral standards.  More recently oxycodone was prophetically promoted as the “one to start with and the one to stay with”.

Three challenges of “quick fixes” or addictions are: 1. Suffering caused by a real need unmet. 2. Side effects of the substitutes.  3. Vulnerability to other harmful substitutes.
I believe much more conversations at an individual and system level about the true nature of addiction are needed.

I think in general, pain, suffering and illness are consequences of being alive, of having the freedom to choose between what’s good for me and what is bad.  They are teachers constantly reminding me of what my body needs and what my mind don’t. A “health care system” that narcotizes me and leaves me benighted of the consequences of my poor choices would only leave me insatiably dependent on it.
Hippocrates said “Before you heal someone, ask him if he's willing to give up the things that make him sick.”

I think, voicing problems without making any personal efforts towards potential solutions makes little sense.  Someone also said “you are either the solution or the precipitate”.

So my personal solution to this challenge, at least for now, is to continue to learn from my pains, sufferings and illnesses to let go of what my mind wants and make tough moment by moment choices that are good for the body, the community and the planet; and to share my perspectives at every opportunity and clinical encounters.







My patient asked me if I was high!

  1. I think having a conversation about non-pharmacological solutions generally take more time and care; in my experience, these conversations are needed, more often than not. I also have chronic pain. Rather than blocking these pains with analgesics, I have chosen to use these experiences as opportunity to discover sustainable solutions for myself and my patients. I try to share these perspectives with my patients in a compassionate way and I find that they are well received.

  2. I just saw a long term opioid reliant patient who I have on daily dispensing. Our non-pharma interventional contract is 20 minutes of meditation daily which she does on her own in my office. At her own request, she gets routine urine drug screen. She show them to her father so that he does not call her names. I encourage her to see her father as someone in need of help rather than one who victimized her. Just now, she pushed her face close to mine and stared into my eyes and waited for me to evaluate her pupil size (opioid state). She told me she is now eating her spinach; she has gained some much needed weight; she even ate some spicy California rolls today! She then told me she is ready to reduce her breakthrough dose. I did a little happy dance as a way of acknowledging her monumental decision! She laughed and asked me if I was high! Lol!

Biases in medicine

I am constantly prone to biases in judgement because of what I don’t know.  What I know is finite and what I don’t, infinite. I think research aimed to study how people are treated differently due to their gender, race, social economic status, etc.  reminds me to be more mindful and slower to judge. I think the solution to diminish these biases is to be continually open to new perspectives and possibilities. I have noted certain recurring themes around the topic of pain.

I find pain to be a common humanity and provides valuable opportunities to share the wellness perspectives with my patients.  Pain is a warning signal of one, or more often, many common root causes. It is important to identify all these root causes and apply their true solutions.  Diagnostic challenges are relatively uncommon given the many investigations now available. What is much more common is the scenario where root causes are not identified and discussed, true solutions not applied and only symptoms reactively treated with substitutes.
A 45 year old man who injures his wrist the third time weight training (this time doing 300 lb chest presses ) presents with wrist pain.  He is built like a tank and obese. He is surprised that his wrist is not better after 2 weeks. I ask him if his purpose of exercise is to be healthy.  He tells me he “loves” weight training and can’t possibly stop as I ask.
Challenge (after investigations): chronic traumatic arthritis in the wrist aggravated by inappropriate usage.
Root causes:
Poor dietary and physical habits dues to misplaced and misguided attention on what brings pain and suffering rather than true wellness.
Eating in ways the mind wants rather that what the body needs (he is no doubt prediabetic or one in the making)
Mental craving and compulsion to use his body inappropriately without control and regard of consequence to his body.  His behavior meets the “4 C’s” definition for addiction.
In this case his pain, suffering and wrist injuries are all just partial symptoms and evolving consequences of these common root causes.
The real solutions are interventions that helps him develop mindfulness in eating, appropriate exercising, waiting (for the body to heal) and self-compassion.  Eg. Individual or Group Self-management education and support.
As for substitute solution, there are too many to enumerate.  Block the symptom with analgesic, anti-inflammatories, allosteric mu receptor modulators (CBD), etc.  Become attached to some other object of addiction with similar or more esoteric, more harmful and more delayed symptoms and consequences.



Insomnia

  1. A non-addictive approach to insomnia created by one of my student.
    BODY SCAN FOR SLEEP
    Begin by bringing your attention into your body, close your eyes.
    Notice your body wherever you’re lying down, feeling the weight of your body on the floor.
    Take a few deep breaths.
    And as you take a deep breath, bring in more oxygen enlivening the body. And as you exhale, have a sense of relaxing more deeply.
    You can notice your feet on the bed, notice the sensations of your feet touching the bed. The weight and pressure, vibration, heat.
    You can notice your legs against the bed, pressure, pulsing, heaviness, lightness.
    Notice your back against the bed.
    Bring your attention into your stomach area. If your stomach is tense or tight, let it soften. Take a breath.
    Notice your hands. Are your hands tense or tight. See if you can allow them to soften.
    Notice your arms. Feel any sensation in your arms. Let your shoulders be soft.
    Notice your neck and throat. Let them be soft. Relax.
    Soften your jaw. Let your face and facial muscles be soft.
    Then notice your whole body present.
    Repeat. 
    Modified from https://ggia.berkeley.edu/practice/body_scan_meditation
    (audio included in above link)

  2. I also share with my patients the perspective that insomnia is a symptom of an inability to direct attention away from thinking. The tendency to think compulsively with little control is the challenge. One solution is mindfulness training:
    1. It’s is to exercise the intention to focus attention on a sensory experience such as the breath;
    2. during this exercise, spontaneous appearance of thoughts are recognized but let go by resuming the exercise in step 1.
    One ideal time for mindfulness training is during insomnia. In letting go of the thoughts of trying to go to sleep by intentionally focusing on the present moment of each breath, the ability to choose the object of attention grows stronger. Quality sleep is just one of the many healthy consequences of mindfulness training.
    Thanks

Reflection on wellness

My individual responsibilities

1. keep my body well by eating properly and staying appropriately active.
2. to tame my mind so it works for me rather than against me, irrespective of external circumstances.
3. to share perspectives with others and to be open to others perspectives - realizing what I know is finite and what I don’t, infinite.
These are some perspectives I personally learned later in life.  I believe they can be formalized and shared...

Reflection on Harm reduction in Addiction.

I think there needs to be a clear distinction between treating symptoms and treating cause.  I believe harm reduction is necessary to delay death long enough to treat the cause. I also think maintenance programs are fantastic way to create a stable therapeutic relationship based on which patient transformation may begin.

I think in general treating symptoms only without addressing the cause has been harmful.  It’s financial cost is unsustainable and human cost staggering.

About research and evidence:

Having witnessed EBM about-faced many times in the span of my career, I am more cautious about “evidence”.  I am thinking of HRT for menopause, Oxycodone “The one to start with and the one to stay with”an evidence based solution to “Pain, the fifth vital”.  How about drugs that lowers glucose but causes heart failure? I think there are many more.

At the same time, I am also mindful that some solid intervention without the potential for profit will attract substantially less research fundings.
Furthermore, first-line non-pharmaceutical interventions even if backed by evidence and credibility of regulating bodies are still obscured by agenda of powerful profit driven marketing forces.  

First-line recommendations in “CANMAT 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments” and “CDA 2018: Section 7. Self-Management Education and Support” are seldom part of physician education I have attended (perhaps other have different experiences).
I would appreciate more attention on studies such as “Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis”. by Goldberg SB, et al. Clin Psychol Rev. 2018.
which showed the most consistent evidence in support of mindfulness for depression, pain conditions, smoking, and addictive disorders. Results support the notion that mindfulness-based interventions hold promise as evidence-based treatments.

UK-funded “Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial” published Dec 5th 2017 in Lancet revealed that more than a third (36%) of people with Type 2 diabetes who took part in the weight management programme, delivered in GP practices, are in remission two years later.  Should not this information be topic at every conversation about Type 2 diabetes management? I couldn’t find it in CDA 2018.

I appreciate EBM’s power in protecting me as a physician.  When it comes to really looking after the patient’s interest; I find that the rules often don’t fit and the solution requires common sense and individual considerations.

About addictions:

Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism. Carl Jung
I think I used to be “addicted” to my work for its constant mental engagement anesthetize my mind’s fear of letting go (or mind’s equivalence to death);  I have since learnt to let go through mindfulness training. I now work because I am grateful and curious.

How to build capacity for transformation

“One starfish at a time” vs groups?
According to CDA 2018 Guidelines, Chapter 7: Self-management Education and Support, Recommendation 4.  “SME interventions may be offered in small group and/or one-on-one settings [Grade A, Level 1A”]
So I do both.  Group is a good way to build capacity and to teach medical learners.

Life Purpose:

My father have contently retired for many decades.  He still cooks every meal, plays Go ( a ancient Chinese board game), reads newspaper and looks after himself and my mom (still cooks for me!).  I think my father produces value by simply being; being healthy, being there for me. My mother retired and began studying; she is still taking classes at U of T.  She goes to coffee shops daily to sketch people. She is hard of hearing; yet, she connects with people through her being. I think producing value is a natural consequence of being well; so my work is to help others be well.  I also think one day I’d also learn to be ok with doing less; ok with thinking less; ok with simply being.

Gratitude

I am grateful for my patients for their diversity taught me to accept myself and their struggles taught me to appreciate life.

Education

I think distressed University students were all once school children ill prepared by a society ill prepared.  I think if I can learn to eat healthy, exercise appropriately, meditate and develop self-compassion at my age; a school child can learn these basic life principles as well, given the context.  Culture is the collective norm and behavior. So I think if we have a cultural problem then the solution must involve everyone. The people who lead, teach and heal need to be those who are willing to live and learn. I think positive changes are happening in schools.  One of my patient told me she now begins each class with meditation for her grade one students. She said the kids are behaving better and other teachers in her school are doing the same. Another patient who is taking Social Work at Fleming college told me that in her program, every class begins with meditation.  I think the idea that learning to manage the mind is important for everyone is no longer mythical. I think it’s gathering momentum and will happen with or without me.(like most things in life). I am just grateful to go for the ride. I am looking for a chance to share my perspectives with educators. Anyone have their ears?

Community engagements

I gave a talk to the Ajax garden club this past weekend on opioid crisis and diabetic crisis.  They appreciated my perspectives. I am to speak to PTA at a local school this month. I will meet VP in charge of employee wellness programing at our hospital systems next week.  I have offered to talk at large corporations (no takers yet) I think the MDs still have a privilege place in society; it can be leveraged to transform other leaders in our society.  Pain, suffering and illness affects everyone including our leaders; opportunities will surely present.

Why do I recommend 150gm of non-starchy vegetables 3 times per day BEFORE meals?

Why do I recommend 150gm of non-starchy vegetables 3 times per day BEFORE meals?


https://www.who.int/news-room/fact-sheets/detail/healthy-diet



New study showing the many benefit of weight reduction including the possibility of reversing Type 2  diabetes


What is happiness, complacency and oneness

I am grateful for my life and my life as a family physician. I tell my patients happiness are transient moments and so are sadness. T...