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Preventing children from dying in hot cars

One of the biggest lessons I learned a decade ago in public-health graduate school was that education was rarely enough, on its own, to fundamentally change behavior. Educating the public about health was “necessary but not sufficient,” as one of my epidemiology professors had put it. Weight loss, smoking cessation, safe sexual practices — education campaigns weren’t enough.

Decades of educating the public about the dangers of leaving children unattended in cars where the temperature can turn deadly — even on a sunny but not especially hot day — clearly have not been sufficient. The deaths of 11-month-old twins on July 26 in a hot car in the Bronx have brought a fresh sense of urgency to finding innovative technology solutions.

But even before that tragedy, bills had been introduced in Congress earlier this year to address the rising incidence of young children dying in overheated cars.

According to the No Heat Stroke organization, which tracks pediatric heatstroke deaths in vehicles, the average number of such deaths annually since 1998 is 38, with 53 deaths recorded last year — the most ever. Sadly, the nation appears certain to set a record in 2019, with 32 deaths already by the second week of August. The Kids and Cars safety group, another tracker, notes that “over 900 children have died in hot cars nationwide since 1990.”

Fifty-four percent of these victims are 1 year old or younger. In a little more than half of the deaths, children have been mistakenly left alone by their caregiver, in what is known as Forgotten Baby Syndrome. Other children die after climbing into hot cars without an adult’s knowledge, and others have been knowingly, sometimes criminally, left in hot cars.

The American Academy of Pediatrics recommends rear-facing seats for crash-safety reasons and last year removed the age recommendation, focusing instead on height and weight. But there is an immense irony in the safety policy: Rear-facing seats prevent the driver from occasionally making eye contact with the child in the rearview mirror, which would keep the child prominent in the adult’s mind. And when a rear-facing seat is often left in the car, regardless of whether a child is in it, the seat’s presence can be too easily taken for granted.

The father in the New York case said he had accidentally left the twins in rear-facing car seats. (A judge on Aug. 1 paused the pursuit of a criminal case against the twins’ father, pending the results of an investigation.)

As a pediatrics resident physician, I’ve seen hundreds of parents and caregivers of young children, and many are simply overwhelmed, sleep-deprived and vulnerable to making tragic errors. Some parents in high-stress professions may have an additional cognitive load, which can lead to distractions.

The American Academy of Pediatrics suggests several ways to help prevent these tragedies by retraining habits and breaking away from the autopilot mode that often sets in while driving and doing errands. But that’s not enough. The Post noted five years ago that automakers’ promises to use technology to prevent hot-car deaths went unrealized. Liability risks, expense and the lack of clear regulatory guidelines also discouraged innovation. Congressional attempts in recent years to legislate on this front have failed.

That all may be changing, given the rising number of child deaths. The Hot Cars Act of 2019, introduced in the House by Rep. Tim Ryan (D-Ohio), would require all new passenger cars to be “equipped with a child safety alert system.” The bill mandates a “distinct auditory and visual alert to notify individuals inside and outside the vehicle” when the engine has been turned off and motion by an occupant is detected.

The Hyundai Santa Fe and Kia Telluride already offer such technology, which is a welcome step in the right direction. But it would not identify infants who have fallen asleep and lie motionless; these detectors are not typically sensitive enough to detect the rise and fall of a child’s chest during breathing.

The Senate version of the hot cars bill proposes an alert to the driver, when the engine is turned off, if the back door had earlier been opened, offering a reminder that a child may have been placed in a car seat.

The development of sensors for autonomous-vehicle technology is promising — how much harder will it be to alert drivers to people’s presence inside the car, not outside? Other ideas to consider: A back-seat version of the passenger-seat weight sensor that cues seat-belt use, with a lower weight threshold to alert the driver (and loud enough for a passerby to hear) once the engine is shut off. Or try something that doesn’t rely on motion or weight — a carbon-dioxide detector that would sense rising levels (we exhale carbon dioxide, and this rises in a closed and confined space) after the engine is off, sounding an alarm while automatically cooling the vehicle.

No parent of a young child is immune to Forgotten Baby Syndrome — we are all capable of becoming distracted, with terrible consequences. Those who have been devastated by such a loss deserve our sympathy, not our scorn. To avoid future such tragedies, applying technical innovation to passenger vehicles is essential.

**Originally published in the Washington Post**

Climate Change is Making Us Sick

Climate Change is Making Us Sick

NO MATTER WHAT you think about the causes of climate change, we know the planet is getting warmer. What most of us don’t realize is the impact climate change has on our health, which is why it’s concerning that last week’s UN Climate Change Summit did not identify health as one of the key action areas.

While about 70 percent of Americans believe that climate change is real (and in Canada, where I live, it’s a key issue ahead of the upcoming election), the majority of Americans surveyed do not believe it will harm them personally, according to a recent Yale Climate Opinion Map of public opinion data. In an earlier survey, less than one-third could name an example of climate endangering health. It’s time for a reality-check.

A 2016 Global Change Research Program Report listed seven broad areas in which climate change can affect health: through temperature-related death and illness, air quality, extreme events (such as disasters), vector borne diseases, water-related illness, food safety and nutrition, and mental health. Particular populations – such as low-income Americans, people with chronic medical conditions, Indigenous peoples, and persons with disabilities — may be disproportionately affected, as climate change has a direct impact on worsening every social determinant of health. Hurricane Dorian, which devastated the Bahamas, is yet another reminder that often the poorest communities are hardest hit.

A warmer planet means more potential for death and illnesses related to higher temperatures. It means lower air quality, especially in densely populated areas. Mosquitoes, ticks, and other carriers of infectious diseases can cover a wider geographic range and for a longer span of the year.

Let’s take Lyme disease: due to global warming, the ticks that carry Lyme are appearing in many more states, notably in the Midwest and in much of Canada. Other vector borne diseases are also likely to increase, though, as one researcher pointed out, the exact impact is unclear without further research.

Global warming also raises the chances of suffering heat stroke and heat stress, both risk multipliers for heart attacks. Asthma sufferers experience worse symptoms from the additional carbon dioxide in the atmosphere as well as dust and other particulate matter.

Air pollution currently causes up to 7 million premature deaths, according to the World Health Organization, and millions more visits to hospitals: One study points to the increase in amounts of near surface ozone as our planet warms as the cause. This issue was highlighted by the WHO at the UN Youth Climate Summit through immersive experiences in “air pollution pods.

And those of us who enjoy seafood are at risk of neurotoxin exposure, due to increases in ocean algae blooms caused by warming temperatures. One study found that the toxic “domoic acid” increased as sea conditions became warmer.

Pregnant women are also at risk. In 2017, an extensive review of previous research on maternal health and climate change found that there are significant connections between extremes in temperatures and premature birth, low birthweight, and stillbirth.

We know that the US is one of the most sleep-deprived nations in the world, and a landmark paper has even linked warm temperatures related to climate change to insufficient sleep among those surveyed.

Lastly, we can’t forget the toll that climate change takes on mental health. The American Psychological Association summarized the effects in an extensive report, linking climate change disasters such as droughts and flooding to increased incidence of posttraumatic stress disorder and depression. And they found that worry about global warming can increase anxiety and depression, as well as substance abuse. This can be especially the case in places that have faced an environmental disaster.

Globally, no one is untouched. The WHO compiled a comprehensive set of resources that detail country-specific ways in which climate change affects human health. It estimates that between the years 2030 and 2050, 250,0000 additional deaths globally could be related to climate change, costing billions. The WHO hosted the first humanitarian conference on health and climate change in April.

In a 2017 article for the New England Journal of Medicine, the authors suggest a few ways in which doctors and patients can combat the effect of climate change on human health. For one, there is a unique opportunity to advocate for ‘green’ hospital design and eating less meat (which may also have health benefits, and have an impact on greenhouse gas emissions).

Earlier this summer, over 70 prominent medical organizations, including the American Academy of Pediatrics and the American Medical Association, called climate change the “greatest public health challenge of the 21st century,” and published a series of recommendations which include reducing greenhouse gases and improving access to clean water. In late August, the Doctors of British Columbia identified climate change as a major health care issue, which was followed by a similar alarm sounded by the Australian Medical Association.

Yet these calls to action can only go so far. Globally, all of us share the aspiration to obtain the highest level of health and well-being possible, however climate change has made this goal unreachable for many, and poses new challenges that even the best medicine won’t be able to fix. And as with most public health challenges, the most disadvantaged in society face the highest burden of risk. A public health approach values “upstream,” or preventative approaches to health disasters, which is why the WHO’s emphasis on the health impact of climate change matters.

While it’s unclear why it was not a core area identified in this year’s UN Climate Change Summit, weaving the health impact into the discussion will be crucial to setting much needed priorities for change before it’s too late.

**Originally published in the Boston Globe**

Use and Perceived Effectiveness of Complementary Health Approaches in Children

Use and Perceived Effectiveness of Complementary Health Approaches in Children

All residents doctors in Canada are required to work on a research project, and I was excited to apply my research/epidemiology training towards an issue that is particularly important in pediatric medicine: why parents use complementary/alternative medicine, and more importantly, perceptions on how effective various therapies and approaches might be.

My research team, led by Dr. Roger Zemek and Dr. Sunita Vohra, was excellent, and brought a variety of expertise in both emergency medicine (which was the population we surveyed) and integrative pediatrics. We worked with some excellent biostatisticians and epidemiologists as well, and were able to present at two different conferences, publish two papers, and write about our findings for the New York Times. It was a testament to the power of having a great team with skills that complement each other, with shared goals and values.

Here’s what we found:

~ About 62% of participants used complementary health approaches (CHA) for their children over the previous 12 months, with vitamins/minerals and massage being particularly common. And higher parental education was associated with a higher odds of using CHA, and most parents believed that the CHA used was effective.

~ When it came to acute conditions that required an emergency room visit, about 29% of caregivers used CHA within the previous 72hours specifically for that complaint, and use for gastrointestinal complaints was most common.

~ Open and honest discussions between parents/caregivers and their doctors about CHA are crucial, and in our NYT article myself and my research supervisors outline some of our suggestions.

Interview: Jessica Harthcock

Interview: Jessica Harthcock

This is part of a series of interviews by physician and journalist, Dr. Amitha Kalaichandran, exploring purpose, resilience, healing, and brushes with the healthcare system by trailblazers in the health and wellness community.


Jessica Harthcock is the Co-Founder and Chief Executive Officer at Utilize Health, a neuro care solution that focuses on creating a better healthcare experience for patients with neurological conditions while delivering quality-driven medical cost savings for key stakeholders.  Astounded by how much of the work her family had to do on their own; Ms. Harthcock vowed to create a service that assists patients and caregivers in locating and obtaining optimal care while minimizing expenditures for individuals, families and payers. To learn more about Utilize Health visit She spoke with me in July from Nashville Tennessee.

So what is Utilize Health, and who does it serve?

Utilize Health offers a neurological care solution to lower care costs for health plans while maximizing overall health for members. The end user of our program is the patient who has a severe neurological condition such as a stroke, spinal cord injury, brain injury, and other condition.

After my accident I spent years searching for highly specialized rehab treatments. I saw how disconnected and fragmented the healthcare system is for patients like myself and variable recovery for patients. Patients would reach out to me and ask for advice. As I saw this happen I knew there was a tremendous opportunity.

Tell me more about what happened on that fateful day while you were doing gymnastics.

It was 2004 and I was 17 practicing gymnastics in order to improve my springboard diving skills. I went to do a front double tuck with a layout twist. The last one involved going up in air; when I came down, I landed on my head. I heard a crunch and my body went numb. I had landed on my head which broke my neck as well. I was in a state of shock and couldn’t feel anything or speak. In that moment I thought about Christopher Reeves, that I would be paralyzed like him. I didn’t have sensation but I was fully conscious. Later on we found that a cyst formed around the spinal cord so it looked as though the spinal cord had herniated in the scan, which ultimately did most of the damage at T3. This accident left me to function as a T3 paraplegic.

And what was the healing process like?

It was long. I was in rehab for nearly 3 years with leg braces, electrical stimulation, at times someone  was holding on to me.  My foot first just advanced an inch. It slowly turned into an actual step. You’re shaking, your muscles are trying to function. It took me six years to walk completely unassisted. I eventually moved to having just one forearm crutch, and now I don’t need any assistance. I used gait training as well as biofeedback that was linked to the gait training. Gait training was harder to come by back then, but today it’s much more easily accessible.

What would most people be surprised to know about having that particular physical challenge? 

The biggest thing I see is how uneducated much of the public is when it comes to understanding physical differences. I always grew up conscious of people that had differences in their abilities. One of my cousins has cerebral palsy so she was in wheelchair since she was little. I never thought much of it, and my dad always talked about the ADA [American Disability Act] and how important that was, and how people with different abilities want the same things we all do.

Especially early on after my accident people would point and stare — a mother with her child in a stroller once pointed to me and said, ‘look she’s in a Stroller too.’

When I got my service dog I noticed how ignorant people were. I felt I needed to educate people about was service dogs could be used for and how mine help me. It was particularly tough when Ozzie and I would get kicked out of healthcare facilities and public spaces, even though it’s against federal law. So I to become my own advocate, and realized I needed to educate others on a larger scale so I started speaking at schools and local businesses.

There is a lot of misinformation out there around what works best for spinal cord injury. Are there any myths you would like to clear up?

The biggest misconception about spinal cord injuries and neurological conditions is that recovery is not possible. In the past 15-20 years research has advanced such that it IS possible. We now see patients make incredible strides in recovery, whether it’s regaining bowel, bladder control, whether it’s walking or sitting up and balancing again. We did believe 30 years ago that spinal cord injury meant someone would never walk again, but the fact that many patients are still told they will never recover and shouldn’t even try, and are sent home to live the rest of their life without hope doesn’t make sense to me. That’s where I get angry. I would like to see this addressed in the healthcare community. Conversations like, “this is what your prognosis is can be challenging, and this is what it can mean, but others have recovered even if we don’t fully understand why.” We still don’t know all the elements and facets and we’re at the tip of the iceberg. More research has to be done. At Utilize we’re collecting outcomes from every patient in the program, looking at countless factors: through social determinants, spiritual, and how it all plays a role in recovery. We get patients from all walks of life and we’re now looked at how we can use big data to tie it together.

Now that we talked about myths, what are some new and surprising areas of research spinal cord injury and the role of rehabilitation (as well as other components of treatment?)

The different simulators that they can implant in your spinal cord and brain are exciting. There’s some great work out of the Fraizer Rehab Institute in Kentucky for instance, led by Dr. Susan Harkema which holds a lot of promise. It complements other research, like gait training. There are also other, more controversial, research areas such as using stem cells in spinal cord injury, which will be an area to watch over the coming years.

Was there anything else that helped you, other than surgery and rehab wise through the healing process?

I separate healing into three areas: physical, emotional and spiritual. Physical healing for me involved rehab, exercise, nutrition, and rest. Emotional healing involved handling the traumatic injury, knowing I was going to be ok in the end and the stress aspect.  Spiritually I knew something terrible had happened, but had to find a bigger purpose for it. For anyone who believes in a higher power, they have to feel something greater. I know a lot of people might not feel this way, but for me, the emotional and spiritual healing aspects were things I had to consciously focus on, to remind me that I couldn’t let this accident get the best of me. As well, I needed to surround myself with supportive people. I was lucky to have an entire army of people and support and helped me heal in really beautiful ways. My family was and still is today my rock. 

Returning back to Utilize, what has the response been?

The response has been overwhelmingly positive. We have high engagement results and our health plan partners have had fantastic results. We post great outcomes and consistently show lower costs of care. If any business can create a win-win for everyone, that’s the sweet spot.

How did that experience change who you are today, and how you see life?

I was lucky because I saw the potential of the research that was happening. Sometimes that’s all it takes, to see recovery is possible. I think that people go through adverse times and you can let it get the best of you. You can drown in it or say ‘I can conquer this.’ Having that attitude up front is key. I’m a pretty positive person anyway, but I chose things to be grateful for every day. The adversity I faced led me to the work I do today and the ability to work with amazing people. It led me to my husband who helped me to walk again (he was actually one of my trainers!). I have an incredible service dog Ozzie because of it. It’s hard to see the good in a traumatic event when you are in the thick of going through it, but I always knew there was a bigger purpose and bigger plan — I hung on to that. 

What does well-being and ‘Thriving’ mean to you?

Well-being to me encompasses six areas – physical, mental, spiritual, emotional, environmental, and intellectual. I have not achieved full balance in these areas. But I certainly try to be conscious of these areas in my life. Thriving for me means thriving in all these areas. I can be off in one and it can impact the other things.

What are you most looking forward to now? 

Serving more patients through the plans we work with through Utilize. We have an entire team that is so excited to help them, and we’re just getting started.

AI Could Predict Death. But What If the Algorithm Is Biased?

AI Could Predict Death. But What If the Algorithm Is Biased?

Researchers are studying how artificial intelligence could predict risks of premature death. But the health care industry needs to consider another risk: unconscious bias in AI.


Earlier this month the University of Nottingham published a study in PloSOne about a new artificial intelligence model that uses machine learning to predict the risk of premature death, using banked health data (on age and lifestyle factors) from Brits aged 40 to 69. This study comes months after a joint study between UC San Francisco, Stanford, and Google, which reported results of machine-learning-based data mining of electronic health records to assess the likelihood that a patient would die in hospital. One goal of both studies was to assess how this information might help clinicians decide which patients might most benefit from intervention.

The FDA is also looking at how AI will be used in health care and posted a call earlier this month for a regulatory framework for AI in medical care. As the conversation around artificial intelligence and medicine progresses, it is clear we must have specific oversight around the role of AI in determining and predicting death.

There are a few reasons for this. To start, researchers and scientists have flagged concerns about bias creeping into AI. As Eric Topol, physician and author of the book Deep Medicine: Artificial Intelligence in Healthcare, puts it, the challenge of biases in machine learning originate from the “neural inputs” embedded within the algorithm, which may include human biases. And even though researchers are talking about the problem, issues remain. Case in point: The launch of a new Stanford institute for AI a few weeks ago came under scrutiny for its lack of ethnic diversity.

Then there is the issue of unconscious, or implicit, bias in health care, which has been studied extensively, both as it relates to physicians in academic medicine and toward patients. There are differences, for instance, in how patients of different ethnic groups are treated for pain, though the effect can vary based on the doctor’s gender and cognitive load. One study found these biases may be less likely in black or female physicians. (It’s also been found that health apps in smartphones and wearables are subject to biases.)

In 2017 a study challenged the impact of these biases, finding that while physicians may implicitly prefer white patients, it may not affect their clinical decision-making. However it was an outlier in a sea of other studies finding the opposite. Even at the neighborhood level, which the Nottingham study looked at, there are biases—for instance black people may have worse outcomes of some diseases if they live in communities that have more racial bias toward them. And biases based on gender cannot be ignored: Women may be treated less aggressively post-heart attack (acute coronary syndrome), for instance.

When it comes to death and end-of-life care, these biases may be particularly concerning, as they could perpetuate existing differences. A 2014 study found that surrogate decisionmakers of nonwhite patients are more likely to withdraw ventilation compared to white patients. The SUPPORT (Study To Understand Prognoses and Preferences for Outcomes and Risks of Treatments) study examined data from more than 9,000 patients at five hospitals and found that black patients received less intervention toward end of life, and that while black patients expressed a desire to discuss cardiopulmonary resuscitation (CPR) with their doctors, they were statistically significantly less likely to have these conversations. Other studies have found similar conclusions regarding black patients reporting being less informed about end-of-life care.

Yet these trends are not consistent. One study from 2017, which analyzed survey data, found no significant difference in end-of-life care that could be related to race. And as one palliative care doctor indicated, many other studies have found that some ethnic groups prefer more aggressive care toward end of life—and that this may be related to a response to fighting against a systematically biased health care system. Even though preferences may differ between ethnic groups, bias can still result when a physician may unconsciously not provide all options or make assumptions about what options a given patient may prefer based on their ethnicity.

We know that health providers can try to train themselves out of their implicit biases. The unconscious bias training that Stanford offers is one option, and something I’ve completed myself. Other institutions have included training that focuses on introspection or mindfulness. But it’s an entirely different challenge to imagine scrubbing biases from algorithms and the datasets they’re trained on.

Given that the broader advisory council that Google just launched to oversee the ethics behind AI is now canceled, a better option would be allowing a more centralized regulatory body—such as building upon the proposal put forth by the FDA—that could serve universities, the tech industry, and hospitals.

Artificial intelligence is a promising tool that has shown its utility for diagnostic purposes, but predicting death, and possibly even determining death, is a unique and challenging area that could be fraught with the same biases that affect analog physician-patient interactions. And one day, whether we are prepared or not, we will be faced by the practical and philosophical conundrum by having a machine involved in determining human death. Let’s ensure that this technology doesn’t inherit our biases.


**Originally published in Wired**

The Power of Surfing, as Therapy

The Power of Surfing, as Therapy

Surf therapy programs often focus on children with autism or anxiety, or groups like veterans or cancer survivors.


Agatha Wallen’s son, Mason, has autism, and when he was 7, she heard about an initiative in San Diego aimed at children with special needs. It involved an unlikely tool: a surf board.

She wasn’t sure how it would work for her son, who struggled with behavioral and sensory issues. “Even getting the wet suit on was difficult for him because it was a brand-new sensory sensation,” she recalled. “From the beach I could see the surf instructors calmly speaking to him, and his whole body seemed to change and relax,” Ms. Wallen said. “He was able to stand up and catch a wave, with a big smile on his face, and ran up to shore and said ‘Mommy, I want to do it again.’”

Mason has been surfing for five years, and now his younger brother, Trevor, 9, is also an active participant in the same program, A Walk on Water. It is a California-based surf therapy nonprofit that primarily focuses on children with special needs — mostly with neurological disabilities. Ms. Wallen serves as an ambassador for the program, helping explain surf therapy to other parents.

“In the ocean there are no cars or planes or people shouting or things buzzing around,” she said.

“It might be the calmness of the waves, but it’s also being with instructors that he could trust and who were patient with him as well.”

A Walk on Water’s executive director, Sean Swentek, points to the importance of serving the whole family, including the child’s siblings, while also offering respite for parents.

“Surf therapy often provides bonding time for them, and our events are meant to be a full day of healing for the whole family,” Mr. Swentek said. The group recently released a short documentary about the role of surf therapy in the lives of three children with special needs.

“In a nutshell, surf therapy is a structured method of surfing utilizing elements of ocean and using its therapeutic benefits for those in need,” said Kris Primacio, the chief executive of the International Surf Therapy Organization, which acts as an umbrella organization to bring together surf therapy programs and researchers. “We tend to focus on underserved populations and exposing surf therapy to those who wouldn’t otherwise have access to an instructor.”

Each surf therapy organization develops its own program. In general, groups meet on the sand before a surf lesson, discuss ocean safety and often discuss mental health struggles as a form of group therapy. They then surf for a few hours and have a debriefing session.

In Britain, children with referrals for anxiety can participate in a free six-week program called The Wave Project. The program, which has received National Health Service funding in the past, gathers data before and after through questionnaires using the Stirling Children’s Well-being Scale and the Rosenberg Self-Esteem Scale.

“We focus on children who have anxiety disorders or are at risk of developing issues. Some may have autism or A.D.H.D. and are at risk of developing more series mental health problems, and most of these children feel isolated,” said Joe Taylor, the program’s chief executive. “Our approach is similar to an occupational therapy approach, and we don’t see ourselves as an alternative to support for care, but part of a package of mental health care.”

In 2014, John Newkirk started Salt Water Therapy L.A., which emphasizes mindfulness as well as surfing. As a certified drug and alcohol counselor with his own history with addiction, Mr. Newkirk wanted to share a mindfulness practice while also structuring the program with ocean safety and surf instruction.

“What happens with mental struggles, including addiction, is that there is an element of self-medicating. Surfers have called it ocean therapy for decades, because of the spiritual benefits. It’s a high with dopamine, but a safer healthier kind,” Mr. Newkirk said.

Surf therapy is not a substitute for medical care, and surfers can still struggle with mental illness. Indeed, the surf legend Sunny Garcia talked about his depression and has been hospitalized since attempting suicide this spring.

However, the evidence for surf therapy seems to validate what we know about movement and exercise, therapeutic effects of water and mindfulness. For instance, two years ago, a paper out of California State University described that just one 30-minute surf session improved mood, but the researchers didn’t distinguish the impact of surfing compared to other sports.

A qualitative study of 22 youths participating in The Wave Project, published in June in the International Journal of Environmental Research and Public Health, noted that surf therapy may work through offering a safe physical and emotional space, peer mentoring and positive reinforcement. Similarly, in 2017 a British study looked at the effectiveness of a three-month surfing program for youth and found that some elements of self-reported well-being improved. However neither study matched participants with a control group.

In June, research with 74 active duty military personnel from the Naval Health Research Center in San Diego found that depression, anxiety and PTSD symptoms decreased after surf therapy, but all participants were simultaneously receiving another form of therapy, making it hard to measure the impact of surfing alone.

Naturally, surfing is not without dangers: drowning, rip currents, sharks, just to name a few.

“The ocean is unpredictable, but leading organizations try to mitigate the risks by making sure staff are C.P.R.-certified and know how to prevent and deal with emergencies,” Mr. Swentek told me. “I think part of the reason it’s so powerful is because of those risks. It is not easy to do, so when these kids for instance are able to surf a wave and overcome their fear, there’s huge growth.”

Is the trend of surf therapy meaningfully different from exercise or mindfulness techniques? The evidence isn’t quite there. But its popularity is a sign of broader interest in a variety of tools that might improve mental fitness. Notably, a Los Angeles-based study from 2014 found that surfing may have a positive effect when delivered in combination with other forms of exercise, medication if needed, and group or individual therapy.

In Jon Kabat-Zinn’s book on mindfulness “Wherever You Go, There You Are,” he writes, “You can’t stop the waves, but you can learn to surf.” Dr. Kabat-Zinn, a physicist by training, was one of the first academics to standardize and research mindfulness approaches. In surfing, much of the challenge involves facing a real wave and pushing forward anyway, even when the easy thing to do is back away.

When I reached out to Dr. Kabat-Zinn to say that one of his best-known sayings was being taken quite literally, he replied in an email:

“The beauty of mindfulness is that you can bring it into anything, and then everything becomes your mindfulness teacher and contributes to waking you up fully. Surfing is no exception. When you are really present, the world (and the wave) can wake you up, and bring you into the timeless present moment, even in the midst of complex, unpredictable, dynamical circumstances.”

**Originally published in the New York Times**

The Doctor is Cooking

The Doctor is Cooking

Here we were, 80 eager physicians from across North America in a large teaching kitchen in Northern California.


Surgeons have the best knife skills.

That might sound obvious in the operating room, but here we were, 80 eager physicians from across North America in a large teaching kitchen in Northern California in February.

Our white coats had been traded in for white aprons as we learned the first lesson of the day: The best way to dice an onion is to keep the root intact.

The veteran surgeon from Alaska was encouraging as I attempted to chop the onion into even cubes, as he had humbly done in less than 15 seconds flat. No tears were involved.

Next we went on to preparing grains like farro and cooking plant-based proteins like quinoa and lentils.

Much of the day was also spent addressing nutrition myths (for instance, low-fat diets don’t necessarily lead to weight loss), learning motivational interviewing techniques to help patients identify their readiness to make diet and lifestyle changes, reading nutrition labels, and most important, cooking nutritious meals on a budget — all with the aim of teaching doctors so that they can better educate their patients.

This wasn’t exactly cooking school — it was a three-day “culinary medicine” conference, which just completed its 15th year this past spring. Called Healthy Kitchens, Healthy Lives, there are several others that work along similar lines: Nutrition and Health ConferenceFood as Medicine Conference, and most recently the Health Meets Food Conference.

Culinary medicine is an emerging field that teaches doctors to cook while also imparting practical nutrition information, and is defined as “a new evidence-based field in medicine that blends the art of food and cooking with the science of medicine.”

A 2008 study found that doctors coming out of medical schools in the United States lacked the knowledge to effectively counsel patients about nutrition. Similar findings have been reported among Canadian medical students and European residents. Even specialties like gastroenterology and cardiology, which often deal with diseases that have a large dietary component, include little training in nutrition.

I can relate: once in clerkship and residency, it struck me that what I thought I knew about nutrition was totally inadequate to address the questions patients would ask, and left me unprepared to understand and decipher the myriad new nutrition research and ever-changing recommendations that patients get bombarded with everyday.

The movement is gaining ground across North America as well as around the world, with researchers looking into how it could improve health outcomes for chronic diseases such as diabetes, obesity and heart disease.

As physicians themselves aren’t typically the best models for nutrition — long hours and on-the-run meals are common — bringing doctors into the kitchen may also be a way to encourage self-care as well, both through the mindfulness inherent in food preparation and the consumption of wholesome foods.

There are at least 10 culinary programs in the United States that are backed by a hospital, medical school or school of public health. As part of the medical education curriculum, they reach more than 2,500 doctors and other health professionals each year.

Each school approaches the field slightly differently. For instance, since 2012, Tulane University School of Medicine has offered a compulsory culinary medicine curriculum for its medical students while also reaching over a thousand medical residents through online courseware it has licensed to seven American residency programs. Dartmouth School of Medicine provides culinary medicine workshops to medical staff members, patients and the community through teaching kitchens. And Baylor College of Medicine’s Choosing Healthy, Eating Fresh (CHEF) program is a medical student led elective course which facilitates nutrition and cooking workshops for medical students and patients at Texas Children’s Hospital.

Stanford is one of the latest medical schools to jump on board. Co-founded by Dr. Julia Nordgren, “The Doctor is In … The Kitchen” program began last spring. The group meets one evening a week to learn about how culinary medicine is implicated in a real clinical story — for instance, a busy mother with a toddler who is a picky eater, or a patient with diabetes who is on a tight food budget. To be effective, culinary medicine cannot ignore the issue of food insecurity, which affects 12.7 percent of Americans.

My alma mater, the University of Toronto, started a mandatory culinary medicine program for medical students last year under the direction of Dr. John Sievenpiper. It involves an interactive cooking class, open-access lectures and a grocery store tour led by registered dietitians and chefs, where students learn to read labels and prepare simple meals. Late last year, more experienced physicians eager to advance their nutrition knowledge were offered a chance to enroll in an “update” on clinical nutrition which, among other things, will help separate fact from fiction with respect to popular diets for chronic diseases.

“Nutrition evidence is protean; it changes as we learn more,” said Dr. David Jenkins, a professor in the department of nutritional sciences at the University of Toronto whose research played a key role in the development of the glycemic index. “We need to allow students to critically think about nutrition, and extending this teaching into the kitchen could be one good way to do that.”

Studies show that physician beliefs about the role of food in preventive medicine, and cooking specifically, can translate to effective nutrition counseling for patients, leading to better dietary choices. In 2013, researchers reported that participants in a culinary medicine program reported a higher comfort level with cooking and were better able to assess patients’ nutritional status and advise them regarding nutrition changes, and in 2015, a culinary program at New York University reported improved culinary skills and budget-appropriate meal preparation.

Some medical educators question the effectiveness of nutrition counseling at a time when doctors are so pressed for time, or whether the 10 to 15 minutes allotted to a patient visit can cover the primary medical concerns and additional information about diet and cooking. But Dr. Nordgren notes, “it doesn’t take any more time to discuss a technique to cook a vegetable than it does to write a prescription.”

Still, she acknowledges it’s an imperfect system. She and others have reported that nutrition science is an emerging and difficult to research field. Programs across the country would do well to standardize objectives and curriculums. Recently, the European Society for clinical Nutrition and Metabolism and the American College of Lifestyle Medicine have called for a standardized nutrition curriculum in medical schools.

If Hippocrates really did say, “let food be thy medicine and medicine be thy food,” the culinary medicine movement takes it one step further with a nontraditional take on the traditional medical education adage: ‘see one, do one, teach one.’ And perhaps bringing more doctors into the kitchen could lead to fewer patients being brought into the hospital. Wouldn’t this be the sweetest of ironies?

**Originally published in the New York Times**

Protecting Sleep in the Hospital, for Both Patients and Doctors

Protecting Sleep in the Hospital, for Both Patients and Doctors

What if sleep were considered a continuous infusion of a medication that helped patients heal faster?

It was 11 p.m. and my 2-year-old patient was sleeping peacefully in her hospital bed, snuggled up with her mother and several stuffed animals. Her breathing was quiet and soft. Her bedside heart rate monitor, which glowed a faint yellow in the dark hospital room, was turned to “silent.”

“Sorry, I have to take a listen to her heart,” I whispered to her mother, tapping her shoulder lightly. Her mother and I had a good relationship: I had served as an advocate for her daughter several times during her seven-week stay in the ward. She had a rare disease that had been a medical mystery for many months, but she would be transferred to a more specialized center soon.

I hated to wake her, but recently, when I had offered to wait to examine a child until after a nap, my attending physician had scolded: “You can’t care about that. If you do, you’ll never examine them. They have to get used to it — they’re in the hospital, after all.”

But the poor girl was tired. She was poked three times a day for blood and taken to the M.R.I. or CT scanner at various times. I completed my exam: her vital signs, her heart, perfusion (how well her heart was pumping blood to her body), and palpated her abdomen to check her liver and spleen (which were enlarged, but no more than they had been). She seemed stable. I backed out slowly.

The next morning, the girl’s mother mentioned that it had taken another hour for her to fall asleep again. Was there anything that we could do to allow her to sleep through the night? Wouldn’t a good night’s sleep help with her condition? She had a point.

This is a fundamental question we have to ask about all of our patients, as research now shows that sleep disruption isn’t just inconvenient and doesn’t merely affect our moods or increase risk of disease. Disrupted sleep can in fact drastically affect how well patients heal from the condition that brought them into the hospital in the first place.

If sleep were regarded as a continuous infusion of a medication that helped a patient heal faster, provided them with emotional stability, and ensured they were in the best mind-set to understand the risks and benefits of that care, we would think twice about disrupting it.

Matthew Walker, a professor of psychology and neuroscience at the University of California, Berkeley, and the author of “Why We Sleep,” explored this issue in his research.

“Sleep is one of the most powerful, freely available health care systems you could ever wish for,” Dr. Walker told me. “But the irony is that the one place a patient needs sleep the most is the place they’re least likely to get it: in a hospital bed on the ward.” This year, his research found that a lack of sleep can worsen pain perception.

Recently, a study in Nature found that sleep disruption is directly linked to atherosclerosis, a buildup of plaque in blood vessels. As such, it doesn’t just increase the propensity for a heart attack or stroke, but in patients admitted for a condition related to clogged arteries, interrupted sleep could actually affect how well they heal in a hospital.

study published last year found that sleep affects wound healing, including wounds from surgery or any type of procedure. Using the Pittsburgh Sleep Quality Index score, the researchers looked at patients with inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease. These diseases are characterized by wounds primarily in the bowel, treated most often by medications to suppress the immune system. The wounds took longer to heal among the patients who had lower sleep scores.

Similarly, researchers have hypothesized that the healing of diabetic foot ulcers may be affected by undiagnosed obstructive sleep apnea.

And recently, a study on sleep and healing published in the Journal of Applied Physiology concluded that wounds were less likely to heal when sleep was disrupted.

Sleep fragmentation or disruption is not just an issue for patients, of course. It also affects health care workers — particularly medical residents who may be on call for a 26-hour shift several times a week — or nurses and emergency medicine doctors who work irregular hours that often disrupt their circadian rhythms.

A recent study in the journal Anaesthesia found that sleep deprivation among health care workers was directly linked to DNA damage. Research has found that a lack of sleep among residents can be a predictor for depression. Sleep-deprived doctors are also over eight times more likely to omit a crucial patient-care issue. Extended shifts even put people at risk outside the hospital: They triple the risk of a hazardous driving event, with 40 percent of attending physicians reporting that they’ve fallen asleep while driving.

Dr. Michael Farquhar, a sleep expert based in Britain, writes that many hospitals remain unaware of the impact of this issue. Particularly for night shifts, he writes: “We are not evolved to be awake at night. Our circadian rhythm, the powerful drive that helps regulate wake and sleep, means that we are at a physiological low when working at night.” One London-based campaign, “HALT: Take a Break,” offers ways to reduce fatigue.

As Austin Frakt noted in The Upshot last year, several hospitals are taking steps to address the problem. For example, nurses at Yale-New Haven Hospital try to give patients their medications before they go to sleep to minimize sleep disruptions.

Dr. Walker has suggested giving patients ear plugs and an eye mask if they stay overnight in a hospital, and having doctors be more mindful about when they wake patients for a question or an assessment.

As to the standard argument that American doctors have to work brutally long hours to be properly trained, Dr. Walker counters, “Countries such as France, Switzerland and New Zealand train physicians in the same amount of time despite limiting resident shifts to less than 16 hours, yet these countries continue to rank in the top 10 for quality of medical care and practice.”

He added: “It’s worthwhile remembering that after being awake for 22 hours straight, you are as cognitively impaired as if you were legally drunk. Nobody would accept medical care from an inebriated doctor. Yet we must accept medical care from doctors who are similarly impaired due to the lack of sleep the system imposes on them.”

As for my 2-year-old patient, she was transferred to a different hospital a few days later and eventually discharged. She is now getting outpatient care and is back on a regular sleep schedule at home.

Would she have healed faster if her sleep had been less frequently interrupted in the hospital? I can’t say. Maybe the sleep interruptions were justifiable for other reasons that could have improved her care. But the opportunity to have stretches of restorative sleep in a more comfortable environment at home will probably be a big part of keeping her well. And knowing that, I sleep better, too.

**Originally published in the New York Times**


Take a Walk in the Woods. Doctor’s Orders.

Take a Walk in the Woods. Doctor’s Orders.

“Forest bathing,” or immersing yourself in nature, is being embraced by doctors and others as a way to combat stress and improve health.

On a damp Saturday morning last August, I joined 10 others in the woods outside Ottawa, Canada, as part of a “forest bathing” session offered by a local wilderness resort.

First we sat in a circle on the leafy ground, each sharing a moment in nature from our childhood that filled us with joy. Next our guide, Kiki, a newly trained forest therapist who insisted we call her by her first name, led us on a mindful — and very slow — walk through the forest.

“What do you hear, smell, see?” Kiki asked, encouraging us to use all five senses to become deeply “immersed” in the experience.

An older woman in the group told us that she was undergoing a difficult and stressful period in her life, and that being among the trees felt “healing.” Others mentioned that the activity reminded them of walks they took as part of Boy Scouts or commented on the sounds: insects, birds, the rustling of leaves. I noticed the bright green acorns that dotted the forest floor, which reminded me of my childhood collection of acorns and chestnuts. Admittedly, I was also worried that the early morning rain was fertile ground for vicious mosquitoes (West Nile!) and ticks (Lyme!).

We ended the two-hour forest walk with a tea ceremony, sipping a concoction of white pine needles steeped in hot water.I left feeling relaxed and more at peace, though with at least two dozen bites from mosquitoes that seemed immune to DEET.

Kiki had been trained according to standards set by the Association of Nature and Forest Therapy, a professional group that has certified more than 300 people across North America to be forest therapy guides, among them psychotherapists, nurses and six M.D.s. The sessions are modeled after the Japanese tradition of shinrin-yoku,or forest bathing.

Over the years, I’ve had physician mentors recommend Richard Louv’s books, “The Nature Principle” and “Last Child in the Woods,” which describe the benefits of time spent in the wilderness, from stimulating creativity to reducing stress. Florence Williams’s best-selling book, “The Nature Fix,” has a chapter dedicated to the benefits of forest therapy. And now, it appears that more North American doctors are starting to incorporate spending time in forests into their practice.

Some small studies, many conducted in Japan and Korea, suggest that spending time in nature, specifically in lush forests, might decrease stress and blood pressure (especially in middle-aged men), improve heart-rate variability and lower cortisol levels while boosting one’s mood. An analysis of studies from 2010 that focused on exercising in nature found improvements in self-esteem, particularly among younger participants. Overall effects on mood were heightened when there was a stream or other body of water nearby.

But other studies have shown mixed results. A cross-sectional study from Korea found no change in blood pressure with forest bathing, and a systematic review from 2010 found that while time in the forest may boost mood and energy, any effects on attention, blood pressure and cortisol may not be statistically significant. Another recent review from Australia underscored the challenges of drawing causal links to disease prevention, with the authors calling for robust randomized controlled trials.

Several theories have been proposed as to why spending time in forests might provide health benefits. Some have suggested that chemicals emitted from trees, so-called phytoncides, have a physiological effect on our stress levels. Others suggest that forest sounds — birds chirping, rustling leaves — have a physiologically calming effect. Yet evidence to support these theories is limited.

On a recent visit to Japan, I met with Dr. Hiroko Ochiai, a surgeon based at Tokyo Medical Center, and her husband, Toshiya Ochiai, who is currently the chief executive of the International Society of Nature and Forest Medicine. Dr. Ochiai is trained in forest therapy and currently conducts most of her sessions with volunteers within a forest in Nagano, about three hours from Tokyo, with the help of a local guide, and plans to offer forest therapy soon at one of Tokyo’s largest hospitals.

“I usually encourage participants to sit or lie down on the forest ground and listen to the sounds,” she says. “The hypersonic natural world can be soothing, and things are always moving even while we are still. It can be very calming.”

Last June the Northside Hospital Cancer Institute in Atlanta began to formally offer forest therapy as part of a pilot project in collaboration with the Chattahoochee Nature Center. Twelve patients with newly diagnosed cancers recently signed up for a session, according to Christy Andrews, the executive director of Cancer Support Community Atlanta.

“It was a four-hour session that seemed to have an impact on the patients,” she said. “I remember one participant telling me afterward that it was a way to ‘steer away from cancer,’ and the group became very cohesive. I think it helped reduce the isolation in a way that’s different from a regular support group.”

Dr. Suzanne Bartlett Hackenmiller, an obstetrician-gynecologist based in Cedar Falls, Iowa, began guiding patients in her practice through the Prairie Woods in Hiawatha Iowa, though she has also led groups in forests around Des Moines. She became a certified guide through the Association of Nature and Forest Therapy three years ago and tries to tailor her offerings based on the group she is leading.

“I generally get a sense of where people are at. For some, it’s best for me to stick to the science, but others may literally want to hug a tree. The traditional tea ceremony at the end might turn some people off, so I’m conscious of that and adjust accordingly,” she says.

In one exercise, she has participants close their eyes as she guides them through experiencing the different senses, imagining feeling their feet growing into the ground like roots of a tree, for instance, listening to nearby sounds and observing how far they may extend, or smelling the air. It’s similar in many ways to a guided meditation.

“I recently held a session where four out of the 20 participants were in wheelchairs, so I found a local park that had plenty of trees and a paved sidewalk so everyone could enjoy it,” she says.

At the University of California, San Francisco, Benioff Children’s Hospital in Oakland, Dr. Nooshin Razani, a pediatric infectious disease doctor and director of the Center for Nature and Health, has offered a similar program for the past four years. The “Shine” program, linked to the East Bay Regional Parks District, offers “park prescriptions,” a movement that is growing in popularity, and aims to improve accessibility to nature for low income children.

One Saturday a month, Dr. Razani leads a group of up to 50 people through a lush forest of redwood trees and lakes on the outskirts of Oakland. The groups consist of patients ranging in age from a few months to 18 years, accompanied by at least one adult family member. A few of her medical colleagues — an orthopedic surgeon and primary care doctor — have also attended, and the Oakland-based pediatrics residency program at the medical centers invites doctors in training to join the group. Shine recently celebrated its 60th park outing.

“The accessibility part is huge for me. Many children don’t have access to green spaces in their community,” Dr. Razani says. “We also have evidence that supports the mental health aspects of spending time in forests, and for the resident doctors who participate, it’s a way to show them how children interact with nature based on the developmental stage. Sometimes the doctors’ need is just as much as the patients’.” In February, Dr. Razani published findings of a randomized trial that found that park visits — regardless of whether they were led by a guide or not — were associated with a decrease in stress three months after the visits.

A few hours after my own forest walk, the woman in our group who had mentioned her stress emailed me to say that she had checked her blood pressure afterward and noticed it was lower than usual. “It would be nice to see if there was a meaningful change from before, if they collected that information,” she wrote.

She had hit on one of the biggest issues around guided forest walks and forest therapy. Is it an evidence-based activity with proven clinical benefits?

The science is still lacking to prove it. But there is some evidence — as well as good old common sense — to suggest that spending time in nature is good for both the mind and body, whether done as a group or alone. It may be something we all need more of.

**Originally published in the New York Times**

4 Mindfulness Practices Your Kids Can Try

4 Mindfulness Practices Your Kids Can Try

For youth and children, there is a plethora of scientific evidence for mindfulness practices in this group, allowing programs to develop evidence-based initiatives for schools, while also incorporating evaluation of their programs.

Mindfulness has been defined by Susan Kaiser Greenland as “the capacity to be alert and open to life experience as it occurs in a non-reactive, resilient, and compassionate way.” Popularized in the west by Dr. Jon Kabat-Zinn, mindfulness may also be described as “paying attention on purpose, in the present moment, nonjudgmentally.” While secular, it derives its origins from Hinduism and Buddhism and has gained popularity in recent years, both as a tool for self-care but also within structured initiatives to manage stress, anxiety, and depression.

There have been a number of studies looking at the effects of mindfulness for a variety of things — anything from stress, overeating (and eating disorders involving food restriction), memory, and self-esteem. In particular, for youth and children, there is a plethora of scientific evidence for mindfulness practices in this group, allowing programs to develop evidence-based initiatives for schools, while also incorporating evaluation of their programs.

New initiatives such as MindupMindfulness in Schools, and Mindfulness Without Borders have flourished, as they offer unique curricula that can be used in the classroom to improve mental health and coping strategies among students.

Over the last two years, books such as A Still and Quiet Place by Dr.Amy Saltzman and The Mindful Teen by Dr. Dzung Vo have provided teachers, parents, and healthcare providers with techniques to incorporate mindfulness practices with children and youth.

This past summer I had an opportunity to complete a facilitator workshop with Mindfulness Without Borders (MWB), a Canadian charity, that teaches youth, educators, professionals and parents essential skills and strategies to increase attention, regulate emotions, build resilience, and be more compassionate towards others in a high stress world. The workshop focused on their robust evidence-based curriculum on mindfulness techniques for youth, and prepares facilitators to lead what is traditionally a 12-session workshop in classrooms and other youth settings. MWB’s programs are active within the Toronto Catholic District School Board, YMCA Academy, select Toronto District School Board High Schools and the York Regional Police. There is an upcoming training in Toronto through the Applied Mindfulness and Meditation Program at the University of Toronto, and a number of online opportunities to learn more about mindfulness techniques for youth on the website.

Here are just four of the techniques we covered, that are described in more detail on the MWB website. They can be tools to use on yourself, or with a child or youth in your life who expresses interest. I have linked to an audio example of each practice below.

1.Mindful Listening: This technique brings awareness into the way we typically listen (usually with a purpose and agenda to formulate our own responses), and encourages us to stay open to the speakers perspective while releasing our own personal agendas.

2.Tuza: Tuza means “slow down and relax,” in a Rwandan dialect, and is a breathing technique used to restore a sense of calm and balance in challenging situations.

3.Take Five: This is a breathing technique intended to center our mind and our breath (both which tend to become frantic during stressful situations), bringing regularity to our breathing. It begins with a deep inhale, a pause, and a slow exhale, followed by another pause. This can be repeated at least four other times (hence “take five”) in overwhelming situations.

4.Body Scan: The body scan is a popular mindfulness technique used anytime during the day, and can be particularly helpful before sleep, in an effort to relax the mind and body. This tool involves “intentional attention” placed on one part of the body at a time, encouraging openness and curiosity.


**This blog was originally published on**