Tagged medicine and health

Choose a Thyroid Surgeon Who Does Dozens of Operations a Year

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For surgeons who do thyroid operations, practice makes perfect.

Thyroidectomy, the removal of the thyroid gland, is a common operation, performed more than 130,000 times a year in the United States, but doing it right is difficult.

Researchers, writing in the Annals of Surgery, studied 16,954 patients, about half of whom underwent thyroidectomy for cancer and half for benign conditions.

After adjusting for age, sex, diagnosis and other factors, they found that the risk of complications went down as the number of operations the surgeon performed went up. There was an 87 percent risk of complications for surgeons who did one operation a year; 68 percent for two to five; 42 percent for six to 10; 22 percent for 11 to 15; and 10 percent for 16 to 20. Only 3 percent of patients of surgeons who did 21 to 25 operations a year had complications; those who did more had a similar rate of complications.

Patients of high-volume surgeons had fewer complications not only with the thyroid gland itself, but also less bleeding and wound infection, and fewer respiratory problems. They also spent less time in the hospital after surgery.

The senior author, Dr. Julie A. Sosa, the chief of endocrine surgery at Duke, said that a patient has to be his own advocate. “If you can only ask only one question,” she said, “the most important is: ‘Who are the surgeons who do more than 25 thyroidectomies a year?’ ”

Why Doctors Care About Happiness

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

Working in a general medical practice sometimes feels like being at the greeting station of a Ferris wheel: Every few minutes another person gets off and brings a new set of medical issues into your office.

My first patient on a recent Thursday was a buoyant 71-year-old. Her rotator cuff tendinitis was an occasional bother, as was her allergic rhinitis, but neither got in the way of her picking up her school-age grandchildren every afternoon for a daily playground outing. On rainy days they danced to hip-hop music in her living room, and she showed me the video on her phone.

My next patient was only 43, but his kidneys were grinding to a halt under the weight of two decades of poorly controlled diabetes. Dialysis was looming in the near future, and he alternated between being depressed about it and being in denial of it. Every one of our visits had a funereal atmosphere as we discussed the logistics of something he desperately wanted no part of.

And so it went over the course of the day, changing gears on a dime with each new patient. Along with a swinging pendulum of medical conditions came a similar array, it seemed, of emotions.

The correlation of happiness and health — or unhappiness and poor health — has been noted over the centuries. “He who can believe himself well, will be well,” wrote Ovid, whose robust trope continues to find fertile ground in our current culture of wellness and self-help as well as in a burgeoning body of scientific research. But teasing out cause and effect is thorny.

On one hand, mood could drive health. Happy people are more likely to make salutary choices in their life — exercise, eat their veggies, get regular medical care — and so will become more healthy. When you are depressed or lonely, however, it can be hard to exercise, and that pint of cookie-dough ice cream may seem more welcoming than the chia-kale casserole wilting at the back of the fridge.

On the other hand, health may be the instigator of mood. If you are healthy, you tend to feel good. Having energy allows you to pursue the things you enjoy, and this makes you happy. When you are sick, though, you feel lousy and exhausted — not to mention saddled with medical bills — so it’s hard to pursue the joyful activities of life.

The latest entry in the health and happiness field — the Million Women Study — appears to poke a hole in the accepted dictum that well-being is a driver of good health. By far the largest study on the subject to date, it followed its cohort of middle-aged women in Britain for 10 years. The data showed an association of poor health and unhappiness. But after adjusting for medical conditions, demographics and lifestyle factors, unhappiness was not an independent predictor of increased mortality.

There have been critiques of the study methodology. The evaluation of happiness, for example, was based on a single question and focused on only one moment in time. Controlling for factors like smoking, exercise, income and marital status for the benefit of clean statistics may have ended up eradicating the very mechanisms by which happiness may improve health: quitting smoking, exercising, holding down a good job, staying married.

Small studies have hinted at causality by demonstrating that interventions to increase positive feelings yield improved physiological measurements. But we’ll never be able to answer the question in the purest scientific methodology — randomizing people to happy lives or miserable lives and then following them for a lifetime to see what happens.

Nevertheless, the association of happiness and health remains a potent touchstone in both popular and medical culture. In practical terms, which actually causes the other is less relevant than the fact that both are important. If a patient has poor health and is also feeling miserable, it’s not enough just to address the medical problem. How a person is feeling emotionally needs to be acknowledged and explored.

Doctors, of course, can’t solve the economic, societal and interpersonal challenges that cause unhappiness, but attention to the inner sense of suffering is helpful above and beyond our treatments for the disease itself.

But the opposite may offer an even more powerful payoff. When doctors notice unhappiness in their patients, they should be probing more carefully for hidden illness. Beyond uncovering disorders such as depression, for which unhappiness is a direct symptom, there may be other illnesses lurking.

On a busy clinic day, each time a new person steps off that Ferris wheel into a medical evaluation there are a host of boxes to check off — height, weight, blood pressure, pulse. Lord knows I don’t want to see a “happiness” check-box in the electronic medical record. But the patient’s sense of well-being is something that should definitely register beyond the minor afterthought that it typically merits.

We in the health care professions need to notice and inquire about happiness the same way we do other aspects of our patients’ lives. Lately I’ve started asking about it, and besides getting a much more nuanced understanding of who they are as people, I learn what their priorities are (often quite different from mine as their physician).

I also inquire about obstacles to their happiness, and brainstorm with them on ways to ease some of these. I don’t presume that these challenges are facile to solve, but hopefully our conversation helps let patients know that their happiness matters as much as their cholesterol.

And if increasing happiness does in fact improve health — well, why not try to help our patients achieve it. The side effect profile and cost surely beat most of our current medications, and, at least for now, you don’t have to get prior authorization from an insurance company.


Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Our Perception of Perfection at TEDMED.

Getting Pregnant After a Miscarriage

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Credit Alice Proujansky for The New York Times

A woman who miscarries early in pregnancy is often told to wait at least three months before trying to get pregnant again. But a new study suggests it can be fine to try again as soon as possible.

Researchers studied 998 pregnancies lost at 20 weeks gestation or less. (They included spontaneous losses only and excluded ectopic or molar pregnancies, which are known to require extended care.)

They followed the women for six menstrual cycles after the loss, or until pregnancy outcome for those who became pregnant, recording the time from pregnancy loss to the time of attempting a new conception. The study controlled for the prior number of pregnancy losses, age, B.M.I., smoking, alcohol use and other factors.

Among those who began to try in less than three months, 53.2 percent gave birth successfully, compared with 36.1 percent of those who waited longer. The study, in the February issue of Obstetrics & Gynecology, found no increased risk for pregnancy complications among women who began trying less than three months after a loss.

“Anyone who wants to become pregnant has to be emotionally ready,” said the senior author, Enrique F. Schisterman, an epidemiologist with the National Institutes of Health. “But if you’re emotionally ready, and there are no other complications, there is no physiological reason to wait.”

How Meditation Changes the Brain and Body

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Credit Illustration by Anna Parini

The benefits of mindfulness meditation, increasingly popular in recent years, are supposed to be many: reduced stress and risk for various diseases, improved well-being, a rewired brain. But the experimental bases to support these claims have been few. Supporters of the practice have relied on very small samples of unrepresentative subjects, like isolated Buddhist monks who spend hours meditating every day, or on studies that generally were not randomized and did not include placebo­control groups.

This month, however, a study published in Biological Psychiatry brings scientific thoroughness to mindfulness meditation and for the first time shows that, unlike a placebo, it can change the brains of ordinary people and potentially improve their health.

To meditate mindfully demands ‘‘an open and receptive, nonjudgmental awareness of your present-moment experience,’’ says J. David Creswell, who led the study and is an associate professor of psychology and the director of the Health and Human Performance Laboratory at Carnegie Mellon University. One difficulty of investigating meditation has been the placebo problem. In rigorous studies, some participants receive treatment while others get a placebo: They believe they are getting the same treatment when they are not. But people can usually tell if they are meditating. Dr. Creswell, working with scientists from a number of other universities, managed to fake mindfulness.

First they recruited 35 unemployed men and women who were seeking work and experiencing considerable stress. Blood was drawn and brain scans were given. Half the subjects were then taught formal mindfulness meditation at a residential retreat center; the rest completed a kind of sham mindfulness meditation that was focused on relaxation and distracting oneself from worries and stress.

‘‘We had everyone do stretching exercises, for instance,’’ Dr. Creswell says. The mindfulness group paid close attention to bodily sensations, including unpleasant ones. The relaxation group was encouraged to chatter and ignore their bodies, while their leader cracked jokes.

At the end of three days, the participants all told the researchers that they felt refreshed and better able to withstand the stress of unemployment. Yet follow-up brain scans showed differences in only those who underwent mindfulness meditation. There was more activity, or communication, among the portions of their brains that process stress-related reactions and other areas related to focus and calm. Four months later, those who had practiced mindfulness showed much lower levels in their blood of a marker of unhealthy inflammation than the relaxation group, even though few were still meditating.

Dr. Creswell and his colleagues believe that the changes in the brain contributed to the subsequent reduction in inflammation, although precisely how remains unknown. Also unclear is whether you need to spend three uninterrupted days of contemplation to reap the benefits. When it comes to how much mindfulness is needed to improve health, Dr. Creswell says, ‘‘we still have no idea about the ideal dose.”

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Getting People to Exercise Requires the Right Incentive

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Credit Karsten Moran for The New York Times

People will exercise more if you give them money — but only if they are paid in the right way.

For a 13-week study, researchers randomly assigned 281 people to one of four groups. The goal for each person was to achieve 7,000 steps a day, recorded on a smartphone accelerometer.

Those in the first group got $1.40 for each day they reached the goal. In the second group, the reward for success was entry into a lottery with a possible payoff of $100. Those in the third were given $42 the first day of every month, deposited in an online account, and had $1.40 automatically deducted each day they failed to achieve 7,000 steps. A control group received only daily feedback about their performance. The study is in Annals of Internal Medicine.

The control group achieved their goal 30 percent of the time, and the lottery and paid-every-day groups performed statistically no better, at 35 percent. But the group paid upfront, risking a loss every day, succeeded 45 percent of the time.

“There’s a presumption that tracking your activity will help you change your behavior,” said the lead author, Dr. Mitesh S. Patel, an assistant professor at the University of Pennsylvania. “But it typically doesn’t work unless it’s combined with behavior change strategies. Our study shows that the design of the incentive is critical to its success.”

Opening Up About Depression

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Credit Arianna Vairo

I have slogged through a number of difficult situations in recent months, among them the ongoing crises of my elderly parents’ illnesses and the suicide of a friend. I never lost my appetite nor burst into tears, and I didn’t suffer from any of the other typical symptoms of depression. Maybe I was more irritable than usual, a bit more prone to snap. And yes, I buried myself in my work. But I didn’t think I’d tripped down into the rabbit hole of depression.

You would think I would have been more self-aware, both personally and professionally. As a health journalist, I have often used my own stories to write about difficult-to-discuss medical conditions, includinglearning I had testicular cancer at age 26 and my misdiagnosis with H.I.V./AIDS — back when it was a death sentence. But I had never written about suffering from depression, even though it’s plagued me since I first put pen to paper, at age 11, when I started keeping a diary.

Still, I’m far from alone. At least six million men in the United States suffer from depression, according to the National Institute of Mental Health. The true number is likely to be even higher, said Dr. Matthew Rudorfer, the institute’s associate director for treatment research, since men are less likely than women to report classic symptoms like low mood, sadness or crying, so they often go undiagnosed. Men, he told me, more often demonstrate “externalizing” symptoms like irritability, anger and aggressiveness, substance and alcohol abuse, risk-taking behaviors and “workaholism.”

Oh, that macho thing: Men don’t get depressed; they just work, drink and compete harder. Andrew Solomon, author of the pathbreaking memoir about depression, “Noonday Demon,” told me that ridiculous attitude is part of the mind-set that guys should “cover up our moods with militarism or athleticism.”

So why speak up now? If there was a specific catalyst, it would be the death of my friend (his family asked me not to disclose his real name), a personal trainer who, one August morning, worked out his regular clients — and then went home and killed himself with a single gunshot to the head.

Even with 20/20 hindsight I never would have guessed he was at risk for serious depression, let alone suicide. Just three days before his death, alive with excitement, he’d talked with me about buying his first house and applying for a management role at the health club. Still, as one of his closer friends told me later, “You never know where depression lives.”

Most people, even those who know me well, don’t see my depression. I’m a “high-functioning” depressive, for sure, and perhaps an artful one, too, obscuring its symptoms with a mix of medication, talk therapy, exercise and knowing when to close the door on the world. And unlike my surgical scars (thank you, cancer), those left by depression are invisible.

I wonder, had I talked with my friend about my own struggle, if he might have said, “Me, too.” Indulging in some magical thinking, I imagine he would be alive today if we had shared our stories.

It’s encouraging that new studies are refuting previous ones that showed women to be twice as likely as men to experience depression. For example, a 2013 University of Michigan study concluded, “when alternative and traditional symptoms are combined, sex disparities in the prevalence of depression are eliminated.” In other words, men and women may be equally at risk.

The first step in recognizing depression in men is diagnosing it properly, which means establishing accurate criteria — and making sure mental health practitioners know what to look for. The second step, which may be even more difficult, is getting men to speak up about it.

Which leads back to my own silence. One reason I’ve been unable to talk about my condition until now is that, as the Cymbalta ad says, “depression hurts.” When I first heard that tagline I rolled my eyes, but I’ve since come to appreciate the copywriter’s genius. Imagine suffering from a bad flu, the kind that seems to have poisoned your blood, physically incapacitating you. For me, depression can feel like the worst flu ever, with no end in sight. It is tough to talk about when you’re in that much pain.

And then there’s the stigma. As much as I understand that illness is illness, whether mental or physical, and that there is a greater openness about depression now than a generation ago, I feel shame.

My own encounters with stigma have been profound. I once dated a fellow who dumped me unceremoniously when he found out I took Lexapro, an antidepressant. Before the Affordable Care Act became law, I was rejected for health insurance — not because of my cancer history, but because of my medication history. Having sought help, I was penalized. “It doesn’t make any sense,” my primary care doctor said to me.

So I have decided to be more truthful. Last fall, when I needed to beg off from a commitment, I didn’t fabricate some physical ailment, as I had in the past. Instead, I emailed: “The depression I’m suffering from right now makes it difficult for me to be there as promised. I’m sorry.”

Depression need not be the loneliest fight, as Mr. Solomon has so well characterized it. But if I don’t tell you, you can never really know me — or help. Now I can appreciate it when friends ask me how I’m feeling (but not in that dreadful way: “How. Are. You?”). And I appreciate those who offer: “Is there anything I can do?”

Steven Petrow, a regular contributor to Well, lives in Hillsborough, N.C.