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.
A 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**
“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**
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 Mindup, Mindfulness 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 Huffingtonpost.ca**