Category Archives: Articles, Publications, Research

October 8, 2015

Dan Siegel says I can use my mind to reshape my brain — or YOURS!

I’m in the middle of taking an on-line course by Daniel Siegel, MD.  I hope you do, too.   It’s called “Practicing Mindsight” — 6 hours consisting of 32 video mini-lectures delivered live to an audience of about 240 mental health professionals, physicians, educators, as well as organizational behavior and social policy wonks.   (I’ve also  heard a great TED talk by this guy).  He’s a famous psychiatrist, trained at Harvard Medical School and UCLA, now clinical professor of psychiatry at UCLA, an award-winning educator – and expert researcher in the emerging field of “interpersonal neurobiology”.

It’s on a website called www.Udemy.com.  I’ve listened to the first 9 mini-lectures so far.  He began by asking how many of the professionals in the audience think the mind is important in everyday affairs — and in their practices/organizations.  All hands went up.  Then he asked how many had any instruction on what the mind is?   Five percent raised their hands.   He says that the proportion has been similar in 85,000 professionals he has asked.   He  says the purpose of the course is:  How to see the mind and make it stronger.    I say the course is focused on STRATEGIES for changing the STRUCTURE of the brain (one’s own and that of one’s patients/clients) by using the mind.   Think of that:  USING the mind as a tool to INTENTIONALLY remodel circuits in the brain.

Here are three big points I have heard in his lectures so far:

(a) Key definition:   The mind is a PROCESS not a thing.  It REGULATES (monitors and directs) the flow of energy and information both within an individual and between people.  (Energy is roughly defined as stuff that makes things happen.  Information is both data and meaning or story.)  As part of his grant-funded work, he had put together a group of 40 researchers in a wide variety of fields who were all (eventually) able to agree on this definition.

(b) “Attention” – which is where the mind focuses, what it is paying attention to  – is what CREATES new neural pathways, and STRENGTHENS either existing or new ones by reinforcing the pathway.  As the saying goes: “neurons that fire together wire together”.  For example, the more we pay attention to our pain (assessing it, worrying about it, “fighting” it), the deeper we are carving that channel.  Common sense, grandmothers, and “New Agers” have been telling us for years to focus on what we DO want instead of what we DON’T want  — and now science is confirming it.

(c) Humans are genetically programmed to AUTOMATICALLY create internal experiences and capabilities that mirror or incorporate things they see or feel during interactions with others.  As we watch someone else raise a glass of water to his lips, the cells in our brains that move our own arms light up.  We sense his intention to drink, we may experience thirst, or the sensation of water or of refreshment.  We feel sad when someone cries, and are happy at their joy.  Others’ brains shape what goes on in ours —  what circuits are firing and being reinforced — and vice versa.  Simultaneous mutual (interpersonal) experience is a KEY part of the “social” in our “social species”.

So I got this:  The techniques we use to SHIFT our attention (or another person’s attention) away from bad stuff and towards more productive ways of thinking are actually MODULATING neural circuitry in the brain (which is neuroplasticity in action).  This has now been confirmed by rigorous research on techniques such as mindfulness, CBT, etc.   (I personally remember reading a study which showed that SIMILAR changes in the brain can be observed after either medication OR “talk therapy”.  In that TED talk by Siegel that I watched, he asserts that much of the circuitry in our frontal lobe is created and shaped by everyday INTERPERSONAL INTERACTIONS which DEVELOP it – and of course it is our frontal lobes which make us uniquely human.)

The takeaway for us as physicians in tangible organ-system-focused specialties is there is POWER TO HEAL in our words —  and in the human quality of our interpersonal interactions.  We have an opportunity to INTENTIONALLY HARNESS that power and explicitly add it to our therapeutic armamentarium.

Although the mental health professions already are aware of the power of words and relationships, physicians are on the front-line dealing with patients with PHYSICAL complaints and distress.  We are in the best position to use the power of words and relationships to start relieving those symptoms and easing that distress — even if all we do is alert the patient to the healing power of the mind and persuade them to accept help from a mental health professional.  Apparently, the only specialty these days that requires training in patient communication is family practice.  Thus, this appears to be a neglected skill area in all of the other medical specialties.

Those of us who have accepted the idea that sickness and disability are the COMBINED product of bio-psycho-socio-economic factors, and who are setting out to reduce the disruptive/destructive impact of injury/illness on quality of the patient’s everyday life and future – especially in at risk cases and “heartsink patients” — MUST master this stuff.  We need to practice the SCIENTIFIC ART of empathic therapeutic interaction.  We must learn how to effectively redirect the patient’s attention into more appropriate channels so they develop their own capability to adapt to / cope effectively with their own situations.

The tuition for the Siegel Practicing Mindsight course is usually $137, but if you follow the directions below, you may be able to get a $39 special rate.  It supposedly ends TODAY — although it supposedly ended yesterday, too.  Some people don’t seem to be able to find the $39 offer.  There’s probably a glitch of some kind that is making it show up only when you wend your way through the electrons a particular way.

Here’s how I found it again just now:  I use Firefox.  I entered  “daniel siegel mindsight” in the search box, then I clicked on the link for an Udemy ADVERTISEMENT that appeared in the top left corner of the search results.  The website that appears says the rate is $39 again today (coupon valid until October 8).   But when I went STRAIGHT to the udemy site, the cost is $137.

Go for it — fool around, and then REGISTER!   But bring your brain AND appreciation for quirkiness with you.   This is  fascinating material taught by a deep and independent thinker, serious expert and experienced researcher.  And, Siegel is a character with really colorful personal stories:  so far we’ve heard tales of misfittery in medical school, salmon fishery, dance, nudity in Greece, etc.


July 31, 2015

Tell us: Who should be helping workers with health problems keep their jobs?

The US Department of Labor (DOL) wants to engage YOU in dialogue (you employers, insurers, physicians/healthcare providers, managed care companies — and working age individuals whose jobs have been affected by new or changed health conditions.) The dialogue concerns some draft recommendations for Establishing Work and Full Participation in Life as ACCOUNTABLE Health Outcomes.

The recommendations are part of a larger report I have drafted.  It is focused on these questions:
1– How can we reduce the number of working adults who lose their jobs or leave the workforce after their ability to work has been disrupted by a health condition—and conversely, how can we increase the number who get the help they need to stay employed?
2– What will create widely-shared social agreement that preserving/restoring the ability to work and participate fully in life should be seen as KEY OUTCOMES of healthcare for the working age population?
3– Who should be helping working people KEEP THEIR JOBS after acquiring a new or changed disability?    Who should be held accountable when they needlessly LOSE THEIR JOBS?
4– How can that accountability be established—for real?

The DOL’s Office of Disability Employment Policy (ODEP) commissioned this paper.  Many ideas for how to accomplish those things emerged after interviewing about 20 experts in various fields and discussing these issues with a Policy Work Group within ODEP’s SAW/RTW Policy Collaborative.  Because the stay-at-work and return-to-work process is by nature a “team sport”, the reality is that SEVERAL parties will need to be held accountable.

The draft report actually makes more than 20 detailed recommendations, but for now, ODEP would like to get feedback from YOU on the 6 main ones.  This is a reality check, to see if we’re on the right track in your opinion.   I ENCOURAGE you to disagree, make corrections, or suggest things that are missing or would strengthen the proposal.   The purpose of this exercise is to IMPROVE the report – and increase the chances that it actually has a positive impact.  The ultimate goal is to help more people stay in the workforce, remain productive contributors, and enjoy the many benefits of economic self-sufficiency and full social participation.

You can look at the recommendations on ODEP’s “crowdsourcing” website even before you decide whether to vote/comment.  I hope you will.   See the invitation from ODEP below to get started.   Again, FEEL FREE to disagree, to point out mistakes, make additional suggestions, etc. etc.


From: Acting Assistant Secretary of Labor – Office of Disability Employment Policy
Sent: Wednesday, July 29, 2015 3:40 PM
Subject: ODEP’s Latest Online Dialogue Discusses Work as a Health Outcome

 ODEP epolicyworks masthead 2015-07-31

Second Stay-at-Work/Return-to-Work Online Dialogue:
Establishing Work and Full Participation as Accountable Health Outcomes

Do you have ideas on how to reduce the number of working adults who lose their jobs or leave the workforce after their ability to work has been disrupted by a health condition—and conversely, how to increase the number who get the help they need to stay employed? If so, the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP) needs to hear from you!

ODEP is hosting the second in a three-part series of important online dialogues, Establishing Work and Full Participation as Accountable Health Outcomes, to gather input on policy recommendations aimed at establishing work and full participation in life as accountable health outcomes. Through the use of an online crowdsourcing tool, interested stakeholders can provide feedback on these six draft policy recommendations.

Participation is easy. Just review the policy recommendations, register, then share your feedback.

Visit http://WorkAsHealthOutcome.ePolicyWorks.org/ before the dialogue closes on Friday, August 14th. If you have any questions, please contact ePolicyWorks@dol.gov.

Looking forward to your participation,
Jennifer Sheehy
Acting Assistant Secretary of Labor for Disability Employment Policy


July 9, 2015

Here is where healthcare delivers VALUE — at the most fundamental level

When Professor Michael Porter did some “deep thinking” about where value is actually delivered in healthcare, he created a simple table that displays three tiers.   I found his second value tier EXCITING:   a Harvard Business School professor was validating my own “gut feel” about what really counts.   I summarize Porter’s three tiers this way (you can see his own table below this post):

Tier 1:   Delivering a desired health status — Avoiding death; optimizing health or extent of recovery.
Tier 2:   Minimizing the time it takes to restore the normal rhythm of everyday life — the cycle time required to produce a return to full participation in life (or best attainable level).
Tier 3:   Sustaining health or recovery, minimizing recurrences and iatrogenic (care-induced) illnesses and consequences.

Porter’s free article appeared in the December 23, 2010 issue of the New England Journal of Medicine.  In his comments on Tier 2, Porter said:  “Cycle time is a critical outcome for patients — not a secondary process measure, as some believe.”  I have focused most of my professional energy for the last couple of decades on shortening cycle time — because it clearly produces better overall life outcomes.  I hoped Porter’s article would catalyze a lot of discussion and much more attention to Tier 2 — but not much luck so far.

Personally, I believe that the purpose of being alive is to live a fully human life.  From that perspective, the most VALUABLE healthcare services are those that minimize the impact of illness or injury on the rhythm of everyday life.  I want all healthcare professionals to START here:   Our FUNDAMENTAL purpose is to avert premature death, relieve fear and suffering, and to enhance, preserve,or restore as quickly as possible every patient’s ability to participate in the specific activities that make life worth living — which for many includes productive engagement / work.

We are a social species.  We have an innate drive to be useful in some way, to have a role to fulfill.  We are happier when we have a clear purpose in life. Those of us in the middle years of the human lifespan are DESIGNED to work — to hold up our end and contribute to the well-being of our family, clan, community or nation.  The well-being of our country, and even more broadly, the survival of our species depends on maintaining the right balance between dependents and contributors.

The AFL-CIO’s website says this about work:  “Work is what we do to better ourselves, to build dreams and to support our families. But work is more than that. Work cures, creates, builds, innovates and shapes the future. Work connects us all.” As the Episcopal Book of Common Prayer‘s Order for Compline (an evening prayer service) poetically puts it:  “Grant that we may never forget that our common life depends upon each other’s toil.”

From What is Value in Healthcare by Michael Porter, NEJM 363;26 Dec 23, 2010, p 2479

From What is Value in Healthcare by Michael Porter, NEJM 363;26 Dec 23, 2010, p 2479


July 7, 2015

#1 of 3 fleeting opportunities to influence policy recommendations

Between now and July 10, you have the first of three time-limited opportunities to preview and maybe influence the recommendations being made in three different policy papers that the Stay-at-Work and Return-to-Work (SAW/RTW) Policy Collaborative is producing this year.  Your input (as an experienced professional in this arena) will make it more likely that their FINAL recommendations are realistic and help accomplish their intended purposes.  Participation is easy.

The dialogue opportunity for the FIRST SET of recommendations will remain open just a few more days — until July 10.   The topic of this first paper is Expanding Access to Evidence-based, Early Intervention SAW/RTW Services and Supports, authored by David Stapleton of Mathematica.  His DRAFT main recommendations have been posted on-line at a “crowdsourcing” website for public review and comment, the National Online Dialogue.

To participate, simply register, read the policy recommendations, give it a thumbs up or down, or go deeper and make a substantive comment.  And please forward this email to any colleagues with an interest in the topic!

The SAW/RTW Policy Collaborative was created to advise the US Dept. of Labor’s Office of Disability Employment Policy (ODEP).   Members are invited by the project contractor, Mathematica, after approval by ODEP.  I have nominated many members all of whom have been accepted (as far as I know).  If you have expertise in this arena and would like to join and actively contribute to the Collaborative, please let me know.

I’m drafting the second policy paper entitled Establishing Work and Participation in Life as Accountable Health Outcomes.  Towards the end of July, my major recommendations will be put into the on-line dialogue.  Y’all come and give my proposals a thumbs up, thumbs down, make a suggestion or leave a comment!   Third in the line-up for dialogue will be the main recommendations from the third paper entitled Job Retention/Creation for Workers Who Experience Productivity Loss by Kevin Hollenbeck from the Upjohn Institute later in the summer.

Before the July 10th deadline, go to this link and provide feedback on Stapleton’s draft policy recommendations:  http://TargetingEarlyIntervention.ePolicyWorks.org/    If you have any questions, please contact ePolicyWorks@dol.gov.   And do remember to let other colleagues know about this SHORT-LIVED opportunity.


July 7, 2015

Free on-line CBT course helps Australians living with pain feel better

An Australian study in the journal Pain reports that a FREE on-line course that employs CBT techniques has worked well in helping patients with chronic pain reduce both distress and other symptoms  — no matter how much contact the patients had with a clinician during the several week course – and it clearly outperformed “usual care.”

The Pain Course was developed by psychologists as part of a non-profit initiative of the Centre for Emotional Health, part of Macquarie University in Sydney, Australia.  Their tagline reads:  “Developing effective, accessible and free psychological treatments …”   Before you get TOO excited, this particular course and the other on-line offerings of ecentreclinic.org which developed it are only open to residents of Australia.

Here’s a bit more about this group from their website:   “We comprise a team of psychologists, psychiatrists, and research staff….The eCentreClinic is a specialised research clinic that develops and tests state-of-the-art free online treatment Courses for people with symptoms of worry, panic, social anxiety, OCD, PTSD, stress, depression, low mood and other health conditions including chronic pain. We built the eCentreClinic because millions of Australian adults suffer with these symptoms and conditions each year. But, most do not seek help or see a mental health professional. We believe that people have a right to helpful information and to know about practical, proven, skills that help. We hope that by providing this information and supporting people to learn these skills via the internet more people will learn to master their symptoms and conditions. By doing this we hope they will also improve their quality of life and that of their families and communities.

Here’s a link to the abstract.   It is is an open access (free) article, so you can also download a pdf of the entire article here.


June 18, 2015

Nancy’s super-simple guide to pain

Nancy Grover’s June 15 column on Work Comp Central is a super simple guide to pain for anyone who isn’t really interested in the latest science of neurophysiology — but who wants a basic understanding of how the science of pain is changing our view about how to treat it.

Nancy interviewed me and wrote her column after reading a white paper entitled Red Herrings and Medical Over-Diagnosis Drive Large Loss Workers’ Compensation Claims released by Lockton Companies.  I am one of the co-authors, along with Keith Rosenblum, senior risk consultant at Lockton Companies and Dr. David Ross, a Florida neurologist who is CEO of NeuroPAS Global,

Our goal was to draw attention to an issue that is driving UP costs for payers and driving DOWN quality and outcomes for patients.  In short, all of us (physicians and patients, claims payers, employers, lawyers, judges, etc.) have been getting seduced by the false certainty created by “objective findings” of diagnostic imaging, especially by MRIs.

Before proceeding with invasive procedures and expensive/risky surgeries (that often fail to relieve the pain or create worse problems), we really should be making a good faith effort to identify (and treat) other things that are either causing or worsening the patient’s distress.  Before that first cut is made — are we sure all soft tissue problems have been identified, and then treated by skilled professionals using evidence-based methods?   Have all emotional, psychological, and other human issues known to manifest as bodily distress been identified, and then treated by skilled professionals using evidence-based methods?

If you’re a WorkCompCentral subscriber, read Nancy’s excellent column Low Back Ache: A Pain in the Brain.  If you’re coming to the SIIA conference which is October 18-20 in Washington DC, plan to attend our session on Medical Red Herrings — I’ll see you there!   (SIIA = Self Insurance Institute of America)


June 15, 2015

Introducing Dave Clarke MD & the Psychophysiological Disorders Society

I had the honor of meeting a innovator in medical CARE on Sunday:  David Clarke, MD, founder of the Psychophysiological Disorders Society.   He is a gastroenterologist by trade who has developed expertise in diagnosing and compassionately treating what he calls “stress illness”  — distressing symptoms and even physiological upsets  — without any actual evidence of disease.  Stress illness is an extreme version of the body expressing what is going on in the brain (upsetting thoughts, feelings, emotions, memories, etc.)  However, we are ALL familiar with the more common everyday versions of this same thing:  sweaty palms and butterflies in stomach when worried, blushing when embarrassed, diarrhea or constipation before or after a stressful event.  Although we don’t THINK of these things as the brain expressing itself through the body, that’s what it is.

Stress illness occurs for many reasons, but one of them is because other communications channels are blocked.  Long before I got my professional education, my family taught me that people who bottle up their feelings —  who won’t let themselves cry or be angry — are going to have those feelings leak out somewhere else.  It’s a form of pent-up tension..

Dr. Clarke’s book (and audio CD) are on Amazon, entitled “They Can’t Find Anything Wrong“.  You will find many case stories that illustrate (a) the power of stress to cause bodily dysfunction / symptoms; (b) the healing impact of simply noticing then acknowledging the contribution that stress is making to symptoms; and (c) the various sources of stress:  current life predicaments; childhood trauma; PTSD; anxiety and depression.  As Dr. Clarke said, some of his patients were “cured” as soon as he listened and ask questions until they SAW the connection — and accepted it.  Others needed to learn more — read a book or two, look things up on the web.  A third group needed to spend some time working with a good mental health professional to learn how to feel and release the pent-up stress, and then learn better ways to deal with the ups and downs of life.

There are several medical terms for this puzzle of distress without disease:   medically-unexplained physical symptoms (or MUPS), somatization, and functional disorder are among the most widely used.  They all describe cases in which the patient feels sick and is complaining of symptoms but there is no objective evidence of pathology .  Often, an organ or system is not functioning normally, but there is no sign of any disease process.  In other words the “doctors can’t find anything wrong!”

I wondered if there are any estimates for how frequently this occurs.  Turns out this type of disorder accounts for a surprisingly large fraction of all visits to doctor’s office — estimated by various researchers as 25 to 60%.

Maybe we should think of it this way:  Just like our facial expressions sometimes betray us even when we’re trying to keep a poker face — our bodies do the same thing.  The body is just another channel the mind / spirit / brain can use to express itself — whether we are aware of it or not, and whether we want it to or not!


May 31, 2015

Overkill describes the problem PERFECTLY!

Dr. Atul Gawande’s new article called Overkill is a great asset for all of us change agents. The tagline is:  “An avalanche of unnecessary medical care is harming patients physically and financially.  What can we do about it?”   It appeared in the May 4 issue of the New Yorker magazine.  The topic is “no value” healthcare, and he describes both over-diagnosis and over-treatment.  Me and my gang know that those things also create over-impairment and over-disabling — and ruined lives!

Recommendation:  Use this article as a tool to educate yourself – and others!  It is much better than most of the stuff on this general topic in medical journals and august scientific publications  – because he explains things so clearly and in such simple yet vivid language.   There’s a powerful vignette of a guy with two prior spine surgeries whose local doctor recommends a third one – and how the story turns out.    A happy aspect of the Overkill article is that Gawande also describes how the dark forces that are driving these things are being countered by more positive ones.  Things are slowly and spottily changing FOR THE BETTER!

I am ashamed at my petty jealous hatred for this man — because he is handsome, brilliant, insightful, incredibly talented, articulate, frank, and a fabulous writer.    He has been a columnist for the New Yorker since 1998.  Based  on his photograph, he must have been a baby then.   I’ve read several of his articles and books, and recommend them to you.   In particular, if you want to be sickened at how the constant emphasis on money has corrupted the physician culture, read his earlier article entitled The Cost Conundrum – like the White House did.   I’ve just finished his latest book Being Mortal.  It is wonderful — richly informative yet with a very positive tone and personal feeling.    See more about Gawande on the New Yorker’s Contributors webpage or on Gawande’s own website.