It’s 9:30pm. Today, Dr. Smith saw 31 scheduled patients, managed to squeeze in six work-ins, spent about an hour on the phone with various pharmacies and insurance companies, spent another 90 minutes doing paperwork and updating charts, and he somehow even spared a few minutes to speak with a pharma rep. To find the time to do all this, he skipped lunch for the third day in a row, hasn’t been to the gym in days, decided that the “check engine” light flashing on his dashboard could be ignored for one more day, and had to miss his son’s soccer game. Dr. Smith has more than 75 e-mails and phone messages from patients, colleagues, and friends he hasn’t had the time to answer; his PDA just reminded him that he has to be at the hospital at 7:00am tomorrow to follow-up with a patient; not one but two staff members have handed in their notices in the past 36 hours; and he just realized that his professional society’s meeting is less than 10 days away and he hasn’t even begun to make plans for it. Oh, and the lawsuit in which he was named as a defendant, the one that his attorney assured him he didn’t have to worry about—“it’s ridiculous, a joke; it’ll get laughed right out of court”&mdash;has not only not been dismissed, it has recently begun producing additional allegations, complaints, summons, and paperwork at an alarming rate. It’s 9:30pm. And it’s only Tuesday.

The sad truth is that the scene described above is not a misrepresentation of a healthcare provider’s typical day. For physicians in just about every specialty, their 

time is an increasingly precious commodity as more and more demands are placed on them by patients, insurance companies and other payers, and the government. Physicians nowadays are providing more (and better) care for less money in an increasingly compressed amount of time, with more groups than ever complaining about how physicians deliver that care. It’s no wonder that physicians’ dissatisfaction with their profession is at an all-time high (see our 

 article for more on this ). Physician burnout is a very real possibility under such stressful conditions and poses a danger not just to the physician’s mental and physical health, but also to his or her ability to provide the best care for his or her patients. 

, Professor of Medicine and Psychiatry at the Vanderbilt University Medical Center and Medical Director of The Center for Professional Health (CPH) has extensive experience in treating physicians affected by the stresses and pressures unique to their profession. In September 2002, he and several colleagues 

 titled “Mid-Career Burnout in Generalist and Specialist Physicians” We spoke to him in preparation for this article and he was resolute in his belief that not only is the danger of physician burnout as great as it was four years ago when the article was published, but also that the pressures that contribute to physicians’ career dissatisfaction and burnout are intensifying, making it more important than ever to face the issue. 

“Physicians face more demands on their time and energies from more sources than ever before,” says Dr. Spickard. These stresses, in the absence of effective outlets, can lead to “emotional and physical exhaustion, cynicism, real or perceived clinical ineff ectiveness, and depersonalized relationships with colleagues and patients.” Dr. Spickard points to overwork as the catalyst, noting that physicians overwhelmed with work who also feel they have little or no control over their own work schedule face increased risk of burnout. “That’s when work becomes unrewarding, people begin to feel they aren’t being treated fairly, and the sense of community begins to break down.” In their 

 article, Dr. Spickard and his coauthors recommend that “the best prevention for physician burnout is to promote personal and professional well-being on all levels: physical, emotional, psychological, and spiritual.”

To help support these four pillars of burnout prevention, we offer the following 20 suggestions on ways to relax, unwind, and put a little distance between yourself 

and the cares and concerns of practice. Many of these were suggested, in whole or in part, by our readers, so you might say that they’re “doctor recommended.” We’ve also provided some additional links and information to help you get started.

After spending all day providing support and care to your patients, don’t forget about the people waiting for you at home. One of our readers’ favorite ways to relax is to spend time with family: helping out with Girl Scouts, coaching a Little League team, taking the grandkids to the park, sharing quiet time with a spouse or partner, playing with pets (they’re family, too)—anything to take their minds off work and reconnect with loved ones.

Want to Spend More Time With Your Family? Have You Considered Part-Time Practice?

Many, many studies have demonstrated the beneficial effects of regular exercise: improved cardiovascular health, increased strength, reduced stress. Another benefit of exercise is that practicing what you preach adds weight to your words when you are advising your patients regarding their diet and exercise habits. 

American Heart Association Fitness Center

Exercise Counseling and Personal Exercise Habits of US Women Physicians

3. Video Games: Not Just for Kids Anymore

Game consoles (Playstation 2/3, Xbox360, Wii); PC games, portable gaming units, MMORPGs—you name it and some not-insignificant portion of our reading audience is probably a devoted enthusiast of it. The current generation of video games boasts eye-popping graphics, immersive game play andvirtual environments, and a wide range of titles to satisfy most anyone’s tastes or interests. Not only that but contrary to some folks’ perceptions, video games are an increasingly social phenomenon that, thanks to online play, can help form and enhance community and interaction.

GameTap (subscription-based video game rental service)

“Traveling” was one of the more popular options for relaxing sent in by readers. No matter whether you take a cruise to an exotic locale, go for an extended stay in a far-off land, hop in the car for a marathon trip around this great land of ours, or just get out for a daytrip up the coast or out to the country or wherever, literally getting away from your current environment is one of the best ways we know to recharge your batteries.

Camping, hiking, fishing, hunting, mountain biking, canoeing, kayaking, and such ranked right up there with “travel” in our survey results as a favorite pastime and 

diversion. The Internet is an excellent resource for you outdoors types, replete with in-depth information on everything from where to find the best hiking trails 

and where to buy the best gear (the gear that you really need, not that flashy L.L. Bean crap), to how to properly tie a fly and how to ward off bears. 

The various forms of yoga and meditation are proven stress reducers and count many physicians and other healthcare professionals among the ranks of their practitioners.

The therapeutic powers of dance are well established. It’s a great way to blow off some steam, it gets the heart (and other body parts) pumping, and it is literally impossible to refrain from smiling while you shake yo’ thang (this is especially true if you’re cuttin’ a rug with one or more partners whose skill and abilities pale in comparison to their enthusiasm). It matters not which form of dance your muse calls you to—salsa, tango, Israeli folk dancing, West African dance, ballet, the Argentine tango, aerobic dance, anaerobic dance, disrobic dance (hubba hubba!), ballroom dancing, swing dancing, line dancing, break dancing&mdash;the important thing is to get up and get moving. 

Greatest Musical (Song and Dance) Movie Moments and Scenes

Ah yes, two pastimes near and dear to our hearts. There’s nothing better than curling up for an hour or three with a good book. And to all you aspiring wordsmiths out there, we’re always looking for contributing writers. Drop us a line at 

 (discussion spot for the new Pynchon tome) 

 (50 years of Paris Review interviews with authors) 

All those jokes about doctors and golf? They’re funny because they’re true. A whopping 21% of our readers enjoy a day on the links. We want to hear more from you on why this is, so send us your best golf stories (heck, send us your worst golf stories, too). 

This was listed on a depressing number of survey responses. Only doctors would list as a leisure activity something which the rest of us regard as a necessity. Ya’ll work too hard. 

Articles

Feature Articles

We offer the following 20 suggestions on ways to relax, unwind, and put a little distance between yourself and the cares and concerns of practice. Links included to make your life, well, easier...

Fried at Forty: 20 Ways to Connect, Manage, and Relax

 employs "over 100,000 people, has more than 80 manufacturing sites in 37 countries, and makes almost four billion packs of medicines and healthcare products each year,” according to the 

 corporate brochure. In the area of R&D, the pharmaceutical company spends $14 million every day, or $562,000 every hour, on work performed by more than 15,000 people at 22 facilities and which includes more than 65 million screening tests a year. 

A major part of GSK’s R&D eff orts are in drug discovery, consisting of seven research units the UK-based company calls 

, which focus on cardiovascular and urogenital diseases; metabolic and viral diseases; microbial, musculoskeletal, and proliferative diseases; neurological and gastrointestinal diseases; psychiatric diseases; respiratory and inflammatory diseases; and biopharmaceuticals. Once promising targets are discovered, GSK researchers shepherd them through the pipeline, investigating biochemical and physical properties, bioactivity, and other characteristics using proprietary strategic technologies, novel analytical technologies, and other tools and resources. 

In the area of physical properties, a “team investigates the physical characteristics of the materials to make a medicine.” The team uses such techniques as x-ray powder diffraction (

 “is an instrumental technique that is used to identify minerals, as well as other crystalline materials,” used for fingerprint characterization and structure determination of crystalline materials 

, a thermoanalytical technique, is used as a quality control instrument for evaluating sample purity and studying polymer curing. 

 is used to test weight changes of samples in relation to change in temperature as a means of determining material characteristics, degradation temperatures, absorbed moisture content, and levels of inorganic and organic components, and solvent residues. 

, according to Ohio State, consists of a microscope using electrons instead of light to form images, resulting in a large depth of fi eld, and a large focus area for viewing closely spaced features at a high resolution. 

Strategic technologies provide “technology innovation primarily focused on new product development platforms with a three-year delivery timeframe,” concentrating on exploratory pharmaceutics and drug delivery systems. The former “deliver technologies that require intensive training, high capital investment, and/or tight networks with internal or external groups while also supporting current GSK projects through 

 and animal models.” The gamma-emitting radioisotope judiciously introduced through gamma scintigraphy allows, through the intended delivery site, the transit of a dosage form to be non-invasively imaged in vivo, which can in turn be correlated with the rate and extent of drug absorption.

Scientists working with GSK novel analytical technologies are at the very cutting edge of modern drug discovery. The tools at their disposal include high performance liquid chromatography (

. Used frequently in biochemistry and analytical chemistry, 

 separates, identifies, and quantitates compounds in any sample that can be dissolved in a liquid. Helpful in measuring mass-to-charge ratio of ions, mass spectrometry’s applications include identifying unknown compounds, determining a compound’s structure, “studying the fundamentals of gas phase ion chemistry,” determining elements’ isotopic composition in a compound, and “quantifying the amount of a compound in a sample." Near infra red spectorscopy is also used to identify compounds and investigate samples’ compositions. 

: www.gsk.com/responsibility/cr_report_ 2005/research/index.htm 

What's in the pipeline as far as new technologies for pharmaceutical giant GlaxoSmithKline? We investigate...

PharmaTech: GlaxoSmithKline

Today’s healthcare organizations face many issues and bottlenecks, including the impact of severe workforce shortages, longer and more detailed reporting requirements, and constrained financial resources. These issues could have a negative impact on the quality of care that a patient receives. That’s why some progressive healthcare organizations have started to utilize workforce technology solutions, like 

solutions, as a way to realize even greater operational efficiencies and to improve patient care. 

NextMail and SkyMail are mobile dictation and documentation solutions available nationwide. Both allow healthcare professionals to record, document, and share critical information from the field with their office via e-mail by simply using their voices. 

 is available to Nextel Walkie-Talkie subscribers only from Sprint Nextel, Inc. For customers who do not have Nextel Walkie-Talkie service, PDV developed 

, which works across all major US cellular carriers. Both services operate in a similar way. 

Here’s how the technology works (we’ll use SkyMail in our example): A healthcare professional meets with a patient. Once the visit is completed, the professional dials a pre-programmed number on his or her phone and records the patient’s charting information. This voice recording (yes, the treating physician’s actual voice) is sent directly to the e-mail inbox of the recipient as a hyperlink within an e-mail, along with a text reply box that enables the recipient to type and send an immediate text message back to the sender’s phone. The SkyMail is time/date-stamped and contains a customized e-mail “subject line” to provide more detail about the message before it is opened. 

By using SkyMail, healthcare organizations can more easily meet reporting requirements, while at the same time reduce paperwork and improve work processes, which can typically translate into hours of added administrative time. These solutions allow healthcare professionals to immediately dictate necessary information, rather than filling out forms by hand, enabling them to see more patients each day. 

With SkyMail and NextMail, there’s no software to download and no capital investment. Using the technology is simple: SkyMail is just another phone call, and NextMail is just another walkie-talkie call. Just scroll down the phone’s contact list, select a contact, press the button, speak your message, and hang up. The voice documentation is automatically sent. 

For more information about NextMail and SkyMail, and for a free 30-day trial, visit 

. Resources are available to help the individual physician, the physician’s office, or a home healthcare agency become acquainted with these solutions.

We profile two innovative mobile dictation and documentation solutions that are sure to keep doctors connected to their office and patients.

TechSectors (Software): NextMail/SkyMail

—an organization founded at the Woodrow Wilson Center for International Scholars in Washington, DC&mdash;established 

 in an effort to bring together researchers, medical professionals, and game developers to promote the creation of video games that can help patients learn more about disease and illness. Although the concept may not be a new one (one of the first studies of interactive media in healthcare was conducted in 1985), technology today enables approaches and outcomes that were impossible even 10 years ago. This burgeoning industry is combining entertainment with education in a revolutionary approach to disease management with a focus on patient care, particularly that of children. 

Research has shown that many people have the ability to work harder, concentrate more, and learn more when engaging in an interactive game. Games for Health seeks to tap into this phenomenon in order to improve health outcomes. Whether in the form of virtual snowball fights designed to help reduce pain in burn victims, such as the Virtual Reality Analgesia Research Center’s 

™), interactive games promote healing in ways that are inaccessible to more traditional forms of medicine. 

. Inspired by 12-year-old leukemia patient 

 (who has since received a bone marrow transplant and is now in remission), 

, Senior Software Engineer and Technical Director at LucasArts in California. The object of the game is to destroy all mutated cells and collect seven shields for protection from the common side effects of chemotherapy. The game’s unique approach uses three levels of ammunition: health you obtain from the hospital; medication you obtain from the pharmacy; and “attitude” you obtain from home. The realistic gameplay helps teach about the patient’s symptoms, making it easy for children to learn about their disease in a manner that is both fun and distracting. Download the latest version of the game 

According to a November 2005 press release from the Make-A-Wish Foundation’s San Francisco office, the game is now available in nine languages (English, Dutch, French, German, Greek, Italian, Japanese, Russian, and Spanish). The game’s popularity is evident from the more than 200,000 downloads by worldwide Internet users since its official launch in June 2004. Ben and Eric were subsequently honored in a meeting with the Dalai Lama on November 6, 2005, where Ben was recognized as an “Unsung Hero for Compassion” because of his generosity. 

Another game specifically geared toward pain management is 

Believe in Tomorrow National Children’s Foundation

. The interactive game is designed to distract pediatric patients from pain (requiring cognitive attention) and anxiety; children tested while playing the game demonstrated greatly increased tolerance for pain (as measured by how long they could keep one hand immersed in ice water during game play). 

In addition to focusing patients’ attention away from pain, some health games are designed to improve cognitive functioning. A 

, a Palo Alto, California-based non-profit organization founded in 2001 by Pam Omidyar, showed that patients’ quality of life increased just by playing 

. Re-Mission takes players “on a journey through the bodies of young patients with different kinds of cancer.” In the 3-D game, players destroy cancer cells, battle bacterial infections, and “manage realistic, life-threatening side effects associated with cancer.” 

The game was officially released in April 2006. 

 in the United States, Canada and Australia have since emphasized the ability of Re-Mission to be both fun and educational, with the HopeLab website noting that the study found “playing Re-Mission produced significant increases in quality of life, self-efficacy, and cancer-related knowledge for adolescents and young adults with cancer. In addition, young people who played Re-Mission maintained higher blood levels of chemotherapy and showed higher rates of antibiotic utilization than those in the control group, both results suggesting that Re-Mission helps patients adhere to cancer therapy regimens.” More information about the game, including updates and ordering information, can be found online at 

 said young cancer patients “were more likely to keep up with their drug treatments and had a stronger resolve to fight their disease” after playing Re-Mission. 

Interactive video and computer games that focus on non-disease-related healthcare topics are also being developed. The 

 in Fall 2006. Designed to provide an introduction to basic concepts of immunology for high school and college students, the game is used in biology curriculums across the country. Interactive games such as 

 that video games offer “a lower-cost approach for teaching, educating, and motivating patients to better manage their own health. What previously occurred only in medical exam rooms now can be learned at home, customized to match the patient’s level of sophistication in an environment conducive to learning”. 

As the educational and therapeutic value of interactive video games becomes more accepted, developers and researchers at medical schools and other academic institutions, software design companies, and other organizations are creating games that promise a variety of healthcare benefits. 

, in response to concerns over the poor exercise habits associated with extensive video game play, has developed the 

, an isometric exercise device that relies on a player’s body strength to control the action in a video game—basically, the harder a player pushes on the system’s special controller, the faster his or her video game character goes. 

, which uses a story involving secret agents, top-secret neuroscience research facilities, and brain-invading nanobots to teach players about the structures of the human brain, explain how brain cells and synapses work, and demonstrate other brain functions. The company has also developed a game called 

National Institute of Mental Health’s Small Business Innovation Research Program

. The game teaches children key concepts of brain structure and functionality and about the effects of neurological disorders. 

 is working alongside video game developer 

. to educate young patients on the benefits of healthy diet and exercise in order to reduce the risk of diabetes and obesity through 

From Humble Beginnings to a Bright Future

Health-related video games have come a long way in the last two decades. 

 was one of the first cancer-based computer programs designed with patients in mind. It was a “computer-assisted instructional intervention” that taught children about blood cells, bone marrow, and platelets and “prepared them for possible side effects related to their chemotherapy treatment.” The program presented information using interactive text and graphics; a questionnaire study “revealed that children’s knowledge about blood significantly increased after playing the game.” 

Nowadays, vastly more powerful computers make it possible for designers to create complex, immersive virtual worlds that engage players on so many more levels than the old text-and-graphics-based games. Thanks to the Internet and the greater availability of high-speed connections, kids can play with and against other players all over the world, and in the process connect with peers who are undergoing similar experiences with disease and illness. The new possibilities inherent in this technology are attracting attention. At the 

 conference—held September 2006 in Baltimore, MD&mdash;more than 250 health and healthcare professionals, game developers, government program managers, policy advocates, educators, and researchers gathered to exchange information regarding this innovative approach to disease management. The conference included on-site demonstrations of the latest technologies and advances in the medical field. Go to the Games for Health website at 

 to read day-by-day recaps of the presentations and other events (actual presentations can be downloaded 

. Organizer for the event, the Serious Games Initiative, targets two areas for continued Games for Health development: personal treatment (including disease management, physical therapy, and mental health treatment) and professional practice (health messaging, modeling, simulation, and training). Following the success of the 2006 event, there are already plans in motion to launch a games contest that will award cash prizes to two winners who develop the best storyboards and game treatments, with a grand prize going to the best working prototype/game. Go to 

discussed video games’ abilities to help soothe and heal the sick and talked about the promise of utilizing virtual environments as a method of combating illness. The piece also touched on the topic of expense. For example, it pointed out that the headset required for 

 (the snowball fight game mentioned previously; more information is available at 

) is priced at $30,000. Other games, however, are less costly. Re-Mission, which can be found at 

, is available free of charge. Many experts think a balance can be struck between high-cost systems that are more appropriate for the hospital setting, and low-cost systems and games suitable for use in the office setting or at home. 

With the health-related video game market currently estimated at approximately $50 million, health game sales are barely a blip on the radar when compared with the $7 billion commercial games market. However, rising healthcare costs and growing recognition of the games’ usefulness among patients, payers, and providers may combine with the proliferation of available games to produce a rapid increase in utilization. 

Although some case studies have demonstrated some adverse side effects associated with playing video games—including wrist and neck pain, decreased attention span, and obesity&mdash;there is no disputing the evidence of their ability to distract, leaving it to the discretion of the physician and patient whether to incorporate this technology into any treatment plan. Video game companies are left with the challenge of creating games that are equally as beneficial as they are engaging. 

How have patients responded when given the opportunity to use this technology as part of their treatment? Quite favorably, especially in the area of pain management, where the high degree of concentration required for playing the games provides patients an important element of distraction away from their pain. In fact, health game companies are pointing to the benefits of video games as aids in pain management as proof of their value. One 

 involved the use of a handheld video game to help prevent an eight-year-old boy from picking at the neurodermatitis on his upper lip. The game was originally given to the child simply to keep his hands occupied. The tactic was so successful that the boy’s lip healed after a couple weeks. Related studies have shown that patients who played similar games reported lower systolic blood pressure and nausea, and used fewer analgesics, as well. 

University of Medicine and Dentistry of New Jersey

using games to treat pre-operative anxiety in pediatric patients

 to be particularly effective. Whereas behavioral preparation is noted to be an effective method of coping with pain, health games have proven to be more obviously beneficial in increasing dopamine neurotransmission and absorption. The games are designed to divert attention away from the discomfort and pain associated with the patient’s disease or the treatment they are undergoing and on to the game. It’s a mind game in and of itself—one that tricks the brain into focusing on an interactive situation. 

The sky really does seem the limit when it comes to the ways in which video games can be applied to healthcare. According to a report by the 

, video games aid in the development of social and special ability skills in children and adolescents, particularly in those with severe learning disabilities or other developmental problems (such as autism or attention deficit disorder). Video games may also have preventive as well as therapeutic applications: studies have shown that people who maintain healthy cognitive loads—promoted by brain-intensive activities such as playing chess, doing crosswords, and perhaps playing some video games&mdash;appear to have lower incidence of dementia, Alzheimer’s disease, and other cognitive ailments. 

Because games have shown promise in a variety of healthcare applications, many different players and organizations are getting involved in development; funding for game development has been provided by such government agencies as the 

. As with the introduction of any new treatment, there is an element of risk involved; for example, a broad base of evidence to support the long-term benefits or possible side effects of health gaming has yet to be developed. Yet, it is difficult to dispute the readily apparent “fun” element and anecdotal evidence in support of the benefits to be gained by incorporating games into treatment. 

A video game that combats cancer via a virtual immune system? It may not be an instant cure, but ask young cancer patients what form of chemotherapy best "treats" their disease...

Battling Illness One Joystick at a Time

, Chief, Health Services Division, US Coast Guard Air Station, Cape Cod, MA; flight surgeon for Coast Guard District I, which extends from the Maine-Canada border to Northern New Jersey.

How would you describe your job to our readers?

My day-to-day job at the clinic includes seeing patients and performing physicals, but operationally I am involved in medical evacuation and search and rescue with the Coast Guard. If someone calls the Coast Guard and says, “We have someone injured,” the District Main Office will patch me through so I can talk directly with the person requesting medical support. Flight surgeons have a five-question mantra: 

I make a recommendation on whether a person needs medical evacuation, but I fi rst have to decide if it’s a valid mission. Th e last thing we want is to launch in horrible weather and dangerous conditions and get somebody who didn’t need saving. If we do launch, it’s my job to make sure that the patient is packaged correctly before putting him or her into our aircraft, and to provide needed care in transit. 

Is there extensive use of health IT in your field?

Most of the time we’re dealing with commercial fishing vessels out on the Banks, so usually there aren’t any IT resources. There was, however, one case when I was in Kodiak, Alaska, where a fishing vessel was hundreds of miles out in the Bering Sea. One of the crew had injured his ankle, and I was trying to figure out what I could do for this guy, so the captain asked if I wanted a picture e-mailed of the dislocated ankle. I was able to explain the process of how the crew was going to help reduce the  man’s ankle. When everybody was in the right position, the captain e-mailed me a picture, and I told them, “That looks right. Now start pulling like I told you.” I heard the patient moan, then the sigh of relief. “That sounds good. Now take another picture.”  I told them how to tape the ankle, received pictures of it taped, and communicated with them several times over the next couple of days while they got to port. 

Can you give us an idea of what search and rescue and medical evacuation entails?

Prior to being stationed in Cape Cod, I was at Coast Guard Air Station, Kodiak, Alaska. It’s a huge geographical area with a fairly small population, so the Coast Guard was relied on a little more heavily compared to Cape Cod, particularly for aero-medical evacuation. We frequently would launch and fly to remote Native American villages, particularly in the Aleutian chain, when women would go into unanticipated labor. I was also Medical Unit Leader for the Coast Guard Incident Command System in downtown New Orleans following Hurricane Katrina. My job was to make sure that Coast Guard personnel responding to the crisis had a medical intervention evacuation treatment plan and appropriate protective equipment, and to set up medical aid stations at the larger Coast Guard response areas and staff them with corpsmen. In 2005, I spent three months on the hospital ship Mercy in Banda Aceh, Indonesia, after the tsunami. My job was to go ashore every day and visit all of the on-land hospital facilities to identify the patients who needed to come aboard the ship for care.

Was it always your intention to become a flight surgeon? 

I went to medical school on a Navy Health Professions Scholarship and was a medical officer for eight years in the Navy. In 1988, I left the Navy and went into private civilian practice in Alabama. In 2002, I got a call from the Coast Guard, who told me about their critical shortage of medical officers and flight surgeons. My kids were grown and gone, my wife and I were interested in the idea of adventure, and our parents were healthy and retired. We looked at it as an opportunity to return some service to the country. I’m having a great time. I love what I do. The best decision of my career was to have the courage to leave a very comfortable, fun, private practice and do this, because it’s a blast. I would also be very happy and enthusiastic if you would mention to your readers that we are short on qualified individuals for Coast Guard medicine and flight surgery. 

Who can our readers contact for information on becoming a flight surgeon?

Readers can contact Commander Wade McConnell at the following address: 

The job is for people who like challenges, problem solving, and are willing to take some risks. If you like adventure, if you like a challenge, if you like never having a dull moment, it’s a great job.

We talk to Dr. Kenneth R. Harman, Chief, Health Services Division, US Coast Guard Air Station, Cape Cod, MA; flight surgeon for Coast Guard District I, which extends from the Maine-Canada border to NJ

So You Wanna Be a...Flight Surgeon

Personal Health Records are an important component of electronic medical records that allow patients and physicians to communicate quickly and effi ciently, enabling patients to access the information they need to make better-informed decisions and take a more active role in their care. Here, two professionals discuss their experience with implementing such a system at the Cleveland Clinic.

Compared to other industries, such as banking and finance, healthcare has been slow to take advantage of the improvements in data storage and record keeping, automated customer service capabilities, and other services and functionality made possible by the rapid advances in computer technology in the last 20 years. But that may be about to change. Not only have many studies demonstrated the improvements in safety and quality that can be gained from employing an electronic medical record (EMR) in medical practice, but incorporating information technology into practice has recently been championed by a wide range of leaders and executives, culminating with President George Bush’s pronouncement of a national goal for all providers to use EMRs in caring for patients by 2015. Seeking to stay ahead of the curve, several leading institutions that have “e-transformed” their clinical practice through the use of an EMR system have also implemented a secure 

personal health record (PHR), fully integrated to the EMR system, to meet the growing demands of their consumers.

Surveys over the last several years have demonstrated the growing desire of healthcare consumers to become more actively involved in managing their healthcare, communicate more frequently with their providers, and access healthrelated services online. Consumers have embraced the Internet and quickly become accustomed to ordering goods and services and conducting their banking online. Th e exponential growth of the Internet has fueled consumers’ desire for both the 

convenience and empowerment that comes with having electronic personal health records (ePHRs). An ePHR provides information for patients, healthcare-related patient services, patient tools, and a secure means of communication with the patient’s provider. At the Cleveland Clinic, we implemented our EMR in 2000. The EMR is now used throughout our health system by more than 5,000 physicians, more than 1,500 fellows and residents, and 26,000 nurses and support staff . We began the implementation of an ePHR (fully integrated with our EMR) in 2003, and currently have more than 70,000 patients registered for the system. This integrated solution allows for the flow of information and messaging to our end-user constituents, enables secure patient messaging and lab and test result information, and the timely management of patient services, such as prescription renewal and appointment requests. 

These services are delivered quickly, allowing for improved quality of care, tremendous practice effciencies, and improved patient satisfaction. In the world of paper charts, for example, a physician receives a paper lab or test result that has been transported from a printer in the lab to her “in” basket. After reviewing the result, the physician may want to review that patient’s record before she dictates a letter to the patient, so she requests a chart pull. After waiting for the chart to arrive, she reviews the record and dictates a letter to be typed by a staff member. The letter is transcribed, delivered to the physician, corrected by the physician, and signed 

and mailed to the patient by the staff member. It is difficult to imagine the patient receiving the letter in less than a week or two. With the integrated EMR/ PHR, this process is dramatically simpliflied; the physician receives the result in her in-box, adds an explanatory comment for the patient and sends the result with the attached comment securely to the patient, who receives it nearly instantaneously. The patient receives an e-mail advising him or her that there is new information and prompting him or her to log on securely to the PHR. While online, the patient is able to explore his or her personal information, including diagnoses, age- and gender-specific health reminders, etc. and view upcoming appointments or request new appointments online when he or she is due for a test or procedure. The patient can also view a wealth of personalized, patient-friendly health information related to his or her diagnoses, medications, and results. 

Practice efficiencies are realized because the system enables pertinent information to be securely “pushed” to the end-user constituents, rather than the end-users needing to “pull” information from a variety of sources. Patient result information is pushed to the physician’s in-box as soon as it is ready. The physician in turn is now able to push the result securely to the patient’s PHR, or at the very least send a message to the medical secretary to arrange a follow-up appointment with the patient. When the secretary receives the message, all of the required information to manage the next steps of the workfl ow is at his or her fingertips. The secretary can view the physician’s schedule to look for an open appointment, look up the patient’s phone number, or push a message to the patient through the PHR. The secretary may either call or send a message via the PHR to the patient to arrange the appointment. Along with any message sent through the PHR, an automated “tickler” e-mail including the URL of the encrypted PHR website is also pushed to the patient. The e-mail alerts the patient to log on to the PHR and informs him or her whenever new information has been pushed into the system. To maintain security and privacy the patient uses a personal user ID and password to log on. 

Throughout our entire PHR system at the Cleveland Clinic, patients have access to context-sensitive personal information. For example, patients can look up a variety of articles pertaining to their diagnoses, view information explaining the rationale for their health maintenance tests, and read additional information that can help them better understand their medications or test results. The information is written in patient-friendly terms, and is provided either through mass personalization, context-sensitive system links, or as specific information for the patient delivered directly from his or her provider. Patients can even take online interactive patient education modules and respond to satisfaction surveys through the Clinic’s PHR. 

When President Bush visited the Cleveland Clinic in January 2005, a patient who was on the podium with the President shared her experiences using our PHR system. The patient had recently been diagnosed with hyperlipidemia, and she used the PHR system to better understand her condition. In reviewing her record in the PHR, she recognized that she had slowly been gaining weight (about five pounds a year), and she had gotten to the point where she was considered obese. She used the diagnoses-related links provided in the PHR to find articles about hyperlipidemia, cholesterol, and obesity. Through the educational links, she found exercise and diet tips and advice that helped her control her weight. The patient also learned that she was at increased risk for type 2 diabetes, which further motivated her to exercise to lose weight. Using the PHR, she followed her weight loss and lipid results, and over the course of a year was able to lose weight and control her lipids without taking medication. She and many others who used the PHR system reported that it made them feel “empowered.” 

Not all patients are ready for an online PHR. Our experience, as well as that of many other organizations that provide PHRs, shows that the number-one reason patients enroll in a PHR is because their doctor recommended it. At the Cleveland Clinic, patients who wish to sign up with the PHR must have a minimum level of experience with technology and the Internet and have reliable Internet access and an e-mail account. In order to activate their account, they must agree to a set of terms and conditions that requires them to always keep their e-mail address up-to-date to receive the e-mail “ticklers” and always log on to the PHR when they receive a prompt or message. 

If you are thinking about implementing a PHR into your own practice, it is necessary to determine who among your patients responds well to this technology and who does not. For the most part, people adopt technology if they believe that they have suffi cient skills to do so, if they believe that there is a benefit to them personally, and if they are encouraged by important people in their lives and care about meeting the expectations of those people. Not surprisingly, the easier to use and the more useful a technology is perceived to be, the more likely patients are to have a positive intention toward using it. Of course, the more a patient uses the PHR system, the more his or her expertise and comfort level with the system will increase. 

So, the challenge is to implement a PHR system that is easy to use and has the features and functions that the majority of patients want and will find useful and time saving. Then you have to encourage people to try the system and to keep using it. In addition, security of the site and patient information is paramount. In a business setting, employees are compelled to use the work-related computer systems even if they don’t like them because it’s important to their jobs and careers. Patients are not similarly compelled to use an electronic PHR system. If the system is diffi cult to use or is disappointing, patients may use the PHR but will probably continue to use more familiar methods, such as the telephone, to communicate with their physicians. If the patients try the system and have a positive experience it will build their confi dence, encourage them to use all of the features and functions of the PHR, and promote their continued use. Initial success and approval will cause patients to grow more accustomed to the system and more dependent on it. 

, is Managing Director of eCleveland Clinic. She also coordinates the development of Clinical Internet Strategy at the Cleveland Clinic and manages the development of e-Cleveland Clinic MyChart, MyMonitoring, and Virtual Visit projects throughout the Cleveland Clinic Health System. She is actively involved in funded clinical research about patients’ use of ePHR systems, and is a nationally recognized leader in health information technology. 

, is Associate Dean of External Relations and Executive Education at the Weatherhead School of Management, Case Western Reserve University. She researches and writes about the impact of information technology on individual and organizational performance and has collaborated with the Cleveland Clinic Foundation to explore whether its ePHR system can serve as a surrogate for labor-intensive manual interventions and improve compliance and outcomes in patients.

MDNG's Editorial Board members examine issues facing physicians today. This month, Drs. Holly Miller and Betty Vandenbosch examine the world of Personal Health Records (PHRs) at the Cleveland Clinic.

Sounding Board: Medicine Just Got Personal

	It’s 9:30pm. Today, Dr. Smith saw 31 scheduled patients, managed to squeeze in six work-ins, spent about an hour on the phone with various pharmacies and insurance companies, spent another 90 minutes doing paperwork and updating charts, and he somehow even spared a few minutes to speak with a pharma rep. To find the time to do all this, he skipped lunch for the third day in a row, hasn’t been to the gym in days, decided that the “check engine” light flashing on his dashboard could be ignored for one more day, and had to miss his son’s soccer game. Dr. Smith has more than 75 e-mails and phone messages from patients, colleagues, and friends he hasn’t had the time to answer; his PDA just reminded him that he has to be at the hospital at 7:00am tomorrow to follow-up with a patient; not one but two staff members have handed in their notices in the past 36 hours; and he just realized that his professional society’s meeting is less than 10 days away and he hasn’t even begun to make plans for it. Oh, and the lawsuit in which he was named as a defendant, the one that his attorney assured him he didn’t have to worry about—“it’s ridiculous, a joke; it’ll get laughed right out of court”&mdash;has not only not been dismissed, it has recently begun producing additional allegations, complaints, summons, and paperwork at an alarming rate. It’s 9:30pm. And it’s only Tuesday.

	The sad truth is that the scene described above is not a misrepresentation of a healthcare provider’s typical day. For physicians in just about every specialty, their

	time is an increasingly precious commodity as more and more demands are placed on them by patients, insurance companies and other payers, and the government. Physicians nowadays are providing more (and better) care for less money in an increasingly compressed amount of time, with more groups than ever complaining about how physicians deliver that care. It’s no wonder that physicians’ dissatisfaction with their profession is at an all-time high (see our 

 article for more on this ). Physician burnout is a very real possibility under such stressful conditions and poses a danger not just to the physician’s mental and physical health, but also to his or her ability to provide the best care for his or her patients.

 titled “Mid-Career Burnout in Generalist and Specialist Physicians” We spoke to him in preparation for this article and he was resolute in his belief that not only is the danger of physician burnout as great as it was four years ago when the article was published, but also that the pressures that contribute to physicians’ career dissatisfaction and burnout are intensifying, making it more important than ever to face the issue.

	“Physicians face more demands on their time and energies from more sources than ever before,” says Dr. Spickard. These stresses, in the absence of effective outlets, can lead to “emotional and physical exhaustion, cynicism, real or perceived clinical ineff ectiveness, and depersonalized relationships with colleagues and patients.” Dr. Spickard points to overwork as the catalyst, noting that physicians overwhelmed with work who also feel they have little or no control over their own work schedule face increased risk of burnout. “That’s when work becomes unrewarding, people begin to feel they aren’t being treated fairly, and the sense of community begins to break down.” In their 

	To help support these four pillars of burnout prevention, we offer the following 20 suggestions on ways to relax, unwind, and put a little distance between yourself

	and the cares and concerns of practice. Many of these were suggested, in whole or in part, by our readers, so you might say that they’re “doctor recommended.” We’ve also provided some additional links and information to help you get started.

	After spending all day providing support and care to your patients, don’t forget about the people waiting for you at home. One of our readers’ favorite ways to relax is to spend time with family: helping out with Girl Scouts, coaching a Little League team, taking the grandkids to the park, sharing quiet time with a spouse or partner, playing with pets (they’re family, too)—anything to take their minds off work and reconnect with loved ones.

	Many, many studies have demonstrated the beneficial effects of regular exercise: improved cardiovascular health, increased strength, reduced stress. Another benefit of exercise is that practicing what you preach adds weight to your words when you are advising your patients regarding their diet and exercise habits.

	Game consoles (Playstation 2/3, Xbox360, Wii); PC games, portable gaming units, MMORPGs—you name it and some not-insignificant portion of our reading audience is probably a devoted enthusiast of it. The current generation of video games boasts eye-popping graphics, immersive game play andvirtual environments, and a wide range of titles to satisfy most anyone’s tastes or interests. Not only that but contrary to some folks’ perceptions, video games are an increasingly social phenomenon that, thanks to online play, can help form and enhance community and interaction.

	“Traveling” was one of the more popular options for relaxing sent in by readers. No matter whether you take a cruise to an exotic locale, go for an extended stay in a far-off land, hop in the car for a marathon trip around this great land of ours, or just get out for a daytrip up the coast or out to the country or wherever, literally getting away from your current environment is one of the best ways we know to recharge your batteries.

	Camping, hiking, fishing, hunting, mountain biking, canoeing, kayaking, and such ranked right up there with “travel” in our survey results as a favorite pastime and

	diversion. The Internet is an excellent resource for you outdoors types, replete with in-depth information on everything from where to find the best hiking trails

	and where to buy the best gear (the gear that you really need, not that flashy L.L. Bean crap), to how to properly tie a fly and how to ward off bears.

	The various forms of yoga and meditation are proven stress reducers and count many physicians and other healthcare professionals among the ranks of their practitioners.

	The therapeutic powers of dance are well established. It’s a great way to blow off some steam, it gets the heart (and other body parts) pumping, and it is literally impossible to refrain from smiling while you shake yo’ thang (this is especially true if you’re cuttin’ a rug with one or more partners whose skill and abilities pale in comparison to their enthusiasm). It matters not which form of dance your muse calls you to—salsa, tango, Israeli folk dancing, West African dance, ballet, the Argentine tango, aerobic dance, anaerobic dance, disrobic dance (hubba hubba!), ballroom dancing, swing dancing, line dancing, break dancing&mdash;the important thing is to get up and get moving.

	Ah yes, two pastimes near and dear to our hearts. There’s nothing better than curling up for an hour or three with a good book. And to all you aspiring wordsmiths out there, we’re always looking for contributing writers. Drop us a line at 

 (discussion spot for the new Pynchon tome)

 (50 years of Paris Review interviews with authors)

	All those jokes about doctors and golf? They’re funny because they’re true. A whopping 21% of our readers enjoy a day on the links. We want to hear more from you on why this is, so send us your best golf stories (heck, send us your worst golf stories, too).

1. What major goals do you hope to achieve during your tenure, and which is the number one issue on your list?

	My goal during my tenure is to help move the health IT agenda from one phase to another. When 

 was here, he and his staff were setting up the 

Office of the National Coordinator for Health Information Technology

 and put a lot of effort into establishing a solid foundation. Now we’re shifting to the next phase, where we need to execute and begin delivering on the plans that are underway. For example, when the 

 recommended in October 2006 its first set of EHR interoperability standards to the Secretary of the Department of Health and Human Services, it was the end of the initial phase of development; we went from proposing ideas to identifying and creating the standards that are needed to support interoperability. We’ll also move forward with the EHR certification process and identify what we call “prototype use cases”—hypothetical ways in which EHRs would be used in various healthcare scenarios&mdash;and then establish the core set of use cases, based on which we will develop the certification standards for these products. As we continue to grow those standards over time, developers will move forward with products that incorporate those standards. We will also continue to make progress toward the Nationwide Health Information Network; we will complete the prototypes and demonstration projects and draw from those to create the next phase of development.

2. What are the biggest challenges facing the HIT Industry?

	I think that HIT companies have been making important advances, but since until recently not enough attention was paid to healthcare information technology, patients and providers have not received the full economic benefit of the health IT that is already in place. That’s why we’ve been moving forward with the agenda to create EHR interoperability standards, with the ultimate goal of establishing a nationwide network.

3. What role will the tech industry play in your efforts as National Coordinator?

	It will play a very active role. In order for us to succeed with our national health IT agenda, we are absolutely dependent on participation from all parts of the healthcare sector. The health IT companies need to be at the table, helping us identify and create the standards, participating in aggressive and achievable plans by which those standards can be incorporated into electronic health records, personal health records, and other products, and delivering them into production. The next few years are going to be a very interesting environment and create a growing opportunity for health IT vendors.

 certification process for EHRs played out with the industry?

	From what I can tell, it’s played out very nicely. We started with standards and certification for ambulatory care assistance, which is a subset of all of the systems. We called for two rounds of certification and now have more than 35 products that have passed certification based on the current criteria. Then, starting sometime in 2007, we’ll go into the next round, which will be expanding to inpatient EHRs and upgrading to version II of the criteria for ambulatory EHRs. In 2008, we’ll move toward a network of providers (network services) and criteria for that as well.

5. What tangible outcomes in HIT can practicing physicians expect to see in the next couple of years, and what can they do to help promote greater health IT adoption and implementation?

	Providers who are already using EHR systems can help to communicate to their colleagues the benefits that they’ve seen and the practical lessons learned in terms of what it takes to successfully implement the systems. Currently, there are a number of useful products that enable providers to do several things, including electronically prescribe and exchange some laboratory information. That will become more and more widespread as we move forward with implementing the standards for interoperability. Providers that have tools that support quality measures will be able to get feedback and see how the quality of care they provide is improving.

6. Is the hype surrounding HIT detrimental at this point because of the high expectations it creates?

	I think that the interest in health IT is well worth it. We have non-healthcare, non-IT industries participating in order to create incentives for adoption, because they understand the important impact that adoption of this technology will have on their bottom lines. The traditional statistic that people give is that General Motors pays more for health insurance annually than it does for the steel it uses to make its cars. The cost of healthcare is interfering with the competitiveness of American companies. We need to do something to improve the quality and decrease the cost of healthcare in this nation.

7. What needs to happen in order for a nationally interoperable network of EHR systems to be developed?

	The activities we’ve been working on are designed to achieve that. We need to set standards that are implemented in a variety of systems (both EHRs and personal health records), and we need to enable secure, confidential exchange of information among those standardized islands of information. As part of this effort, we will have to identify quality standards and further integrate decision-support mechanisms into these systems, so that they enable providers to deliver higher-quality, safer care, which translates into more efficient care. Doing all this will help enable us to address rising healthcare costs in the future. After we get all of the technologies in place and those tools become an integral part of physicians’ practices, there will be a very subtle but important shift in the delivery of care. Finally, I think we will also see increased use of personal health records by patients and the community, and that particular technology will fundamentally transform the relationship between providers and patients in a very positive way.

Before becoming interim National Coordinator, Dr. Kolodner was the chief health informatics officer of the Veterans Health Administration. We chat with him here about his tenure as Coordinator.

7 Questions...with Dr. Robert Kolodner

 robotic system years ago, enabling “healthcare professionals to provide more effective and efficient healthcare by allowing them to 'be in two places at once.'" Standing at 5'5" with a price tag of $4,000-7,000 per month, the 

 is guided by a joystick from a computerized ControlStation, typically located at a physician’s home or office, through the Internet and an 802.11 wireless network. It is equipped with a flat-screen computer monitor that displays the physician’s face, infrared warning sensors to avoid bumping into people or objects, and two-way cameras, microphones, and wireless technology that allow the physician to review the patient’s chart, lab work, and x-rays without being at the hospital. 

, chairman and CEO of InTouch, about the RP robotic system, upcoming improvements, and physician and patient feedback.

	Dr. Wang explained that his inspiration for creating the RP robot was based on his knowledge about robots and the healthcare industry and problems associated with the overall delivery of healthcare. He said these problems are “created by our aging population where the demands on healthcare are [increasing] dramatically [and] healthcare resources are shrinking simultaneously, so you have this perfect storm happening.” To provide quality healthcare at lower cost in facilities short on physicians, InTouch merged robotics, the Internet, and wireless technology to better leverage available healthcare resources.

	InTouch is focusing on four scenarios in which the RP robot can assist hospitals and physicians:

 — “There’s a big shortage of intensivists and there’s a lot of literature that says if intensivists monitor ICU patients on a 24/7 basis, it greatly helps to reduce costs and reduce morbidity and to reduce mortality and length-of-stay,” said Dr. Wang. “Since you can’t hire the intensivists, you get better outcomes if you leverage this technology.”

Shortage of specialty specific physicians in the emergency department (ED)

 — “Hospitals are struggling to be able to have what’s called the call-panel for their staff ,” Dr. Wang explained. “When a patient comes into the ED and needs a consult from an orthopedist, cardiologist, neurologist, or general surgeon, hospitals are using these robots in order to enable these specialists to beam in because often it can take hours for the specialist to get to the ED.”

 — “The system [can] connect a larger hospital to a smaller hospital that doesn’t have all of the expertise it needs. It brings the expertise into these outlying rural communities."

 — “When physicians are rounding on patients, [they] typically stop by once for maybe fi ve minutes in the day. Our system allows the physicians to easily come back and see the patient again from their clinic or their home for whatever reason—a new test result could be back, the family members could be there who also wanted to talk to the doc, or [if] discharge is possible,” Dr. Wang said.

	Feedback on the RP robot has been encouraging. In 2004, 

 using the RP-6 to determine how comfortable patients were with being treated by their physician through a robot and found that “many hospitalized patients prefer visits from their own physician to those of the physicians on duty, even when those ‘visits’ are virtual ‘telerounds’”. Physicians who use the RP robots find that they are more efficient in their medical practice. Dr. Wang told 

, “They can actually be in their clinic, [with] five minutes between patients, and go see their hospital-based patients and get something else done in a period of time they otherwise wouldn’t be able to. In fact, I got an e-mail from the Chairman of Surgery from the Los Angeles Children’s Hospital who was at a conference in India and he rounded on a patient in LA.”

We profile InTouch Technologies' Remote Presence (RP) robotic system, a modern-day 

January 2007

Fried at Forty: 20 Ways to Connect, Manage, and Relax

PharmaTech: GlaxoSmithKline

TechSectors (Software): NextMail/SkyMail

Battling Illness One Joystick at a Time

So You Wanna Be a...Flight Surgeon

Sounding Board: Medicine Just Got Personal

Fried at Forty: 20 Ways to Connect, Manage, and Relax

7 Questions...with Dr. Robert Kolodner

TechSectors (Hardware): The Remote Presence Robotic System

A Day in the Life: Soccer Doctor