Episode 61 | Dr. Karsten Bartels, MD, PhD, MBA WELL-BEING IN THE PERIOPERATIVE SETTING

Dr. Karsten Bartels, MD, PhD, MBA is a health services researcher who also practices anesthesiology and critical care medicine. After his postgraduate training at Harvard, Johns Hopkins, and Duke University, he completed research training in the Department of Psychiatry at the University of Colorado. 

Karsten is now leading health services research at the University of Michigan, where he holds appointments in three departments:  Anesthesiology, Psychiatry, and Learning Health Sciences.

See Dr. Bartles links below:

The American Medical Association on Physician Burnout

https://www.ama-assn.org/amaone/why-we-fight-reducing-physician-burnout?utm_effort=DAPSRH&gad_source=1&gad_campaignid=9831349845&gbraid=0AAAAADDj8TJpDZL8hac8Wh2MJvpbWFsbh

Dr. Bartles – Profile

https://medschool.umich.edu/profile/14157/karsten-bartels

Transcript

SPEAKER_04 0:00

Well, I I think there is a big treatment gap. Um, you know, I'm I'm most familiar with the alcohol one. It's about one in ten US population qualifies for alcohol use disorder. Of these, only one in ten ever get ever gets offered treatment.

SPEAKER_00 0:15

Wow.

SPEAKER_04 0:16

And SAMHSA for just any mental health condition, um, I think the numbers are a little bit better, maybe something like one in four, one in five. But we we have a huge treatment gap. And and of course, I acknowledge that, you know, it that the treatment is not as simple as prescribing an antibiotic for a pneumonia. So there is, it is not the same in that regard. Um, however, uh our approach needs to be similar in terms of being willing to get our hands dirty and really engaging with those problems and not just writing them off as cannot be solved or, you know, I don't want to, I don't want to get involved.

SPEAKER_01 0:56

Our guest today, Dr. Karsten Bartles, is a health services researcher who also practices anesthesiology and critical care medicine. After his postgraduate training at Harvard, Johns Hopkins and Duke University, he completed research training in the Department of Psychiatry at the University of Colorado. Karsten is now leading health services research at the University of Michigan, where he holds appointments in three departments: anesthesiology, psychiatry, and learning health sciences. As always, I can be reached at Afton at Aftonhazit.com. Hi Karsten. We are delighted to have you join us today and hear more about your really critical research that you're doing health services um sciences.

SPEAKER_04 1:50

Thanks for having me, Afton. Excited to be here.

SPEAKER_01 1:53

So um, no, I don't know all that much about you. I mean, you're you've recently come to University of Michigan. What how long has it been now? Eight months? Is that right? Again, it was last uh July 4th. Yeah. So, you know, we're all getting to know you. And what I don't know is really kind of how you got here. So, you know, what is your backstory? How did you become a health sciences researcher with the interest that you have?

SPEAKER_04 2:17

Finished residency at MGH was which was a very um, you know, science-oriented uh program. However, at the time it was um very much focused on basic science. And uh I continued my clinical training in um critical care and cardiac anesthesia and pain. And uh one of the things that I took away from it that especially in our fields, um, one always has to balance you know therapy and intervention with risk for atrogenic harm. So when I had my first faculty position, although I initially thought I was um gonna go work for a basic science lab, I had my own little project. And this was you know early 2013. And um it was on opioid overprescribing because it was, you know, it was an observation I made that we were just giving out a lot of opioids. And I remember my wife actually having a cesarean section and coming home with like 40 percocets.

SPEAKER_00 3:19

Wow.

SPEAKER_04 3:20

And uh our job at the time, we were randomly drug tested, you know, and I'm an immigrant, and so I was very worried about all that, you know, that you know, I might just rub the bottle a little bit. That would be that. And so I, you know, I had this little IRB and the lab didn't develop, and but my own little project did. And then I started just doing, you know, what I would call my own stuff at a very small scale. And um, but then I I sort of noticed that the topic was taking off. And uh I I looked at at Colorado, who was funded sort of in in adjacent fields, and I was connected to a group in the Department of Psychiatry that you know took me under their wings and and mentored me. And then I got a career development award and and had a lot of time suddenly on my hands to um to do what I think was relevant and what I was passionate about.

SPEAKER_01 4:18

Yeah. So, like many of us, so much of the pain research is taken off really in the wake of the opioid epidemic and the overdoses. And it really has been kind of a golden time for pain research where we've had the opportunity and the funding and the interest to be able to do a lot of um important work. So it seems like you kind of really caught that wave early, you know, being interested in this notion of over-prescribing.

SPEAKER_04 4:48

Yeah, uh, I agree. You know, that was the early wave. And I think now we've actually sort of we've entered a a phase where we've sort of, you know, realized um some of the atrogenic harm that was done. And and we've we've we've I think maybe actually pushed the pendulum a little bit too far to the other side. You know, it's not only about atrogenic harm and preventing what is wrong, but also, you know, effectively, effectively treating pain. And I think, you know, one should not forget opioids are very effective, analgesic. And in the setting of, you know, acute, severe pain, they are often the correct medication and the only correct medication. And I feel that we have to sort of recalibrate and also take a very critical look at medications that are that have been pushed, um, that may or may not have analgesic properties, but have other side effects that may be different from opioid side effects that are also harmful for patients. And just because they're not an opioid, they're being pushed and highly prescribed. And I think that has that is currently leading to, you know, to again to arrogenic harm.

SPEAKER_01 6:05

Yeah, yeah. Trying to correct a wrong with another wrong is rarely helpful, right? So, so a lot of your work's in the perioperative period. So let's talk about kind of post-surgical pain. And so a lot of our audience are clinicians and uh researchers, but also a lot of patients, for the lay audience that you know may have some pretty significant misconceptions about surgical pain. So, so talk a little bit about surgical pain. I'm not sure people are prepared well by their physicians or their surgical team for what pain they might experience and what that's about. Can you talk a little bit about that?

SPEAKER_04 6:45

Especially in the acute phase after surgery, but if it is not chronic, not an osteoplastic, it it has a very important physiologic function. Um, it protects us uh from harm. That's why, you know, we don't get burnt severely if we touch a hot plate in the kitchen. So pain is very, very important. And in the term in the context of surgical recovery, um, pain also plays an important role. It slows us down. And that per se uh might not necessarily be a bad thing.

SPEAKER_06 7:22

Right.

SPEAKER_04 7:22

And it's about striking a balance between you know slowing down, um, recovering, being able to do physical therapy, um, that effective analgesia is important. So I think um that's important for the patients. For the clinicians, on the other hand, I think one of the issues that is at the core of it is you know, we need to take responsibility. And it is not one size fits all. And um, we have to manage risk. And and that risk is uh present for opioid medications, it is present for non-opioid medications, it is it is present for non-pharmacologic uh interventions. And I I think the core of what we do is managing that risk. And we have to really go in deep and and recognize that you know it's not a one size fits all. We might have to um change course and be in some respects also very prescriptive. That is very true for opioids, you know. Uh while they they're might be very appropriate in the early phase, we do have to taper them down. And tapering them down might hurt more and will be difficult. But we have to be able to, you know, do that together with patients.

SPEAKER_01 8:43

Yeah. I I I agree with you. And and one of the most important elements, I think, is bringing the patient along with education, understanding that you might have more pain. You know, surgery is painful. I think that is an important message. And it's okay. We're gonna do our best to handle the pain, but some pain is okay because again, it's gonna keep you from ripping open your sutures or you know, doing more damage. And I think people are pretty okay with that and understanding that, you know, what the expectation is. It's not that I'm gonna be pain-free, but I'm all you're also not gonna leave me in um severe, severe pain. And I think that's you know, a common fear that a patient may wake up on the other side of surgery and have just unmanageable, unbearable pain. And that can cause some tremendous anxiety.

SPEAKER_04 9:30

Yeah, I concur with that.

SPEAKER_01 9:31

Yeah. So in just talking kind of about anxiety also, because you you have a strong interest in mental health. And um we've had Meg Rolfson on, one of your mentees, your Tall Star mentees, she did a co-podcast with us um uh, I don't know, maybe a couple months back, after we returned from the um scientific media, the USASP. Um, and she's really interested in mental health along with you. So talk a little bit about um pre-surgical anxiety or your kind of anxiety in the perioperative period. It's common, is it normal, or what what do you see?

SPEAKER_04 10:08

Well, if I if I may, like um start a little before how I got interested in that. So I, you know, I I went, I grew up in Germany and went um to medical school in Germany, and the the university was founded in 1457. Wow. And one of its very early um faculties was the faculty of medicine. And even today, if you go to Freiburg, there's the the academic medical center on the west part of town, and then on what used to be kind of you know the poorer eastern part of town, there's there's two of the departments. And one of the departments is psychiatry, and the other department is dermatology, and that's because historically those were sort of the the specialties that took care of um the poor and the ones who weren't going to be included in the main campus. Dermatology because it took care of venereal disease, you know, so now very different, of course. But but that's the historic reason. And so fast forward when I practice now, I'm an intensivist in the critical care unit. And the typical approach when you round on a patient is you go head to toe, you know, you go brain, um, and you end up maybe um with skin breakdown, and you do everything in between. But what we never talk about um is mental health. And and that in the setting where I practice, I take care of you know, heart transplants, lung transplants, mechanical support, the most highest resource-intensive facets of medicine that they are. And we usually um do not uh include any kind of mental health considerations for our patients. And that now can be very broad. That, you know, of course, mental health is very broad, but it can include it could reflect into very simple, straightforward things like how much alcohol does a patient drink? Yeah, um, do we know what their specific risk is? And are we prepared for withdrawal? And do we do that for every patient the same way every day? And we don't. Other aspects of mental health are just as interesting, and you know, anxiety, um, depression, one of them. There's this misconception that I think we cannot treat um these conditions effectively. And by all means, you could say we can treat them effectively, but we basically can treat you know things very effectively anyway, anytime. You know, we only have a success rate of X. But the other part of it, of course, is is you know what was the case in um 1457, is we don't we we sort of we don't want to engage in that part of medicine as much as we would like to as much as we're likely to engage, let's say, with things like hypertension or atrial fibrillation. Um, as perioperative clinicians, we have no qualms, you know, starting patients on long-term anticoagulation for post-type A fib, which is a pretty high-risk thing to do, you know, people can fall and have a head bleed because of that. That's no problem. But if you talk about, for example, identifying somebody who um has high-risk alcohol use and and would benefit from you know, uh referral to treatment or even some, you know, uh withdrawal precautions in the hospital, that is a lot less likely to happen. And and I think one of the reasons is less likely to happen is uh 1457 and and this mental barrier that clinicians have in their head that they they can't or shouldn't or don't want to get involved in anything mental health if they are primarily in a different specialty.

unknown 13:59

Yeah.

SPEAKER_01 13:59

I think you have opened up in a Pandora's box of problems within the practice of medicine that so many individuals um who treat patients, maybe as many as 20% of the patients they see have some appreciable psychiatric homorbidity with their illness. And it's one thing to make a decision that I don't know if I have the skill level, I don't know if I have the time, I don't know if uh this is even something I want to do. It's one thing to um make this decision that you don't you don't necessarily want to do this. It's another that we also don't prepare our clinicians with all the tools that they need actually to provide this level of care. I think uh very much short shrift is paid to mental health in medical care and even chronic pain in most um, you know, most medical school curricula. So I think the problem is widespread and um and really kind of thorny because does anybody want to change this? Is anybody willing to go to the mat to say, hey, we need to do a better job of treating mental health? I mean, what are your thoughts about that?

SPEAKER_04 15:11

I mean, I think you just you just said it. Like I I want to go, I'm ready to go to the mat. Yeah. And I think that's what we need to do. And there's lots of things we need to do. But I do think that is one of the core things we need to do in perioperative medicine is just you know integrate mental health into our practice just like we do other aspects of medicine that are not really at the core of you know doing surgery. Think of you know giving antibiotics for antibiotic proplex. It should be the exact same kind of threshold of getting involved. And by the way, also the same kind of threshold to ask for expert help. Yeah. If I'm in the ICU and I have somebody who has a fungal infection, um, I will consult the infectious disease doctor. But by the same token, I can't consult them for every pneumonia. We don't be, you know, I have to be able to do the basic things myself because we don't have uh we don't have the resources to to do a consult for every single thing. And that that shouldn't be the thing. I need to get my own hands dirty. And just like I do that for ID and and cardiovascular medicine, I I as a perioperative physician, I I need to have the exact same threshold to do it in mental health, and that's not happening, and that's what I want to change.

SPEAKER_01 16:26

Yeah. I love that, Karsten. And it's not just that you want to be a do-gooder, it's that it's also good medicine, right? Because what do depression and anxiety and substance abuse do to your clinical outcomes?

SPEAKER_04 16:44

I mean, right talk about that. Yeah, but patients have um higher morbidity, so you know, for example, length of stay, they have um higher, like we did a study on colectomy, patients with alcohol, they have higher mortality. Um, so the the association of of you know mental health diagnoses and post-operative adverse outcomes is very strong. Now, the big question is, of course, how how are we going to improve that? And there's no simple answers there, you know, one can't be naive about that. However, I think, again, sort of relative in how we deploy resources and also um uh you know research funding, the fruits there are probably much lower than in other areas.

SPEAKER_01 17:34

Yeah. And I and again, you know, what level of priority is it? But I it the outcomes are just really compelling when you look, even like at heart disease, one of the most common uh conditions, you know, that you know, that for the which is you know significant surgical intervention, and what depression does to these kind of post-surgical outcomes. I mean, it's it's it's really striking. So it makes sense that we do this. And there is a period, there is a window where we can intervene. You know, you as as a you know, a surgical team identifies the patient if it's an elective surgery, you have years anywhere anywhere from two to four weeks, right? Often before the surgery is scheduled, depending on the surgical type. That's time where an intervention can take place.

SPEAKER_04 18:19

Yeah, absolutely. And and you know, anything might be better than nothing. And even if you have an intervention that might only be successful in you know five or 10% of cases, yeah. If it is, you know, low cost, low risk. Um if you if you are currently not offering it to anybody, but uh, let's say for alcohol use disorder, 10% of your patients will be affected, only 10% of those will ever get offered treatment. Those are huge opportunities for us to make a difference.

SPEAKER_01 18:50

Yes, I agree. And so this comes back to our question. That was that was a great detour, but a question that in the surgical period, it's pretty normal to have a little bit of pre-surgical anxiety, right? It's a foreign, kind of scary, um, sometimes, you know, maybe even truly kind of a life-changing um event when you go in for surgery. So some pre-surgical anxiety is normal, right?

SPEAKER_04 19:17

Absolutely. I I always say to my patients, you know, if they come in for, and a lot of my patients come in for massive surgery and they're anxious, um, that is physiologic, you know, that's physiologic and normal and uh and probably nothing we we should treat aggressively. Yeah. Um, it you know, I I remember had a surgical procedure myself and I was quite anxious because I work in the ICU. I see all the all I see everything that goes wrong. And you know, I got up at four in the morning to, you know, to have my shower with the CHG um disinfectant and whatnot because of that. So it's it's that you know, short-term anxiety, I would say, is is is is physiologic.

SPEAKER_01 20:02

Yeah. And but e even some of that anxiety can result in um and worse outcomes. And so I think we can, I think twofold. I think we can intervene on more significant anxiety. So if people a person has, you know, kind of some anxiety disorder, a larger level of anxiety coming into the surgical um period, they're more likely to have kind of pre-surgical anxiety and layered on their standard anxiety. And then just for regular patients, just for anybody coming in, a little bit of anxiety, we can do some good work knocking that back too. So there's only a little bit of anxiety to help outcomes. You know, it's it's an app we kind of drove an app that we developed some years back with part of the team at uh Michigan Open or Open to just create an app that provides education, just talks about, you know, what to expect in a surgical setting. Pain is normal, this is how we'll treat it. We'll do our best to make you comfortable. And here's some skills, here's some things that you can do yourself to help, you know, help you kind of refocus and you know, and decrease your anxiety and provided some guided imagery and some uh some breathing techniques and things that they could do. And we got wonderful feedback from the patient participants saying, oh my gosh, I'm actually still doing those activities. And what we saw is, you know, two weeks before the the surgery, they had the app and many of them used it quite frequently. I think people are motivated. And so they they use the app, some almost daily or twice a day. And um, what we saw is that the day of surgery, their anxiety was way down, it was way lower than it was when we first met them a couple, two to three weeks before. And usually that's when it's the anxiety is the highest. But what we saw that was so striking is at the follow up period, it was like I think it was 28% of the participants that we that that we could. paired them to that did not have the app were still taking their opioids at a long period probably the period where they should not still be taking opioids post-surgically whereas only like seven to nine percent of the people who got the app were still taking opioids and so it was kind of a striking difference and it it to us it it just went to show that if you give some folks education let them know that surgical anxiety is normal having some pain is normal having a little fear around pain is normal it can go a long way in giving them a few tools so I think that's a simple hands free I mean there were no therapists involved they downloaded an app I think we can do more of this I 100% concur you know I think that that example is really a great example of of you know how impactful um mental health mental state your well-being is on on other outcomes like that are so difficult to treat and yet how how you know an intervention that is um low resource and low risk um has an impact it's not going to you know solve the problem entirely yeah but given given the low resource and and the low side effect profile it's it's really something we should do much more widely and the success you know as you outlined really speaks for itself. Yeah it it it was striking and I know blue cross blue cross california did a similar study well before ours and it was the same thing too it was actually just giving um uh patients pre-surgically a um a series of guided imageries that was even more hands off less education and again they they saw really significant effects the question is why isn't this everywhere if if blue did this and then there's more and more uh groups showing that kind of some of these mental health prehabilitation strategies are helpful why don't we see this everywhere yeah I mean you know we we have a we don't have a single paid health system yeah but on the other hand you know um we also have lots of different approaches that sort of compete with each other and and and drive innovation um so I you know I wish we would see the the good things everywhere but I think you know that's just that's our daily uh our daily mission is is to you know do what we can to to promote those those best practices. Yeah it I think the first step is detecting it. So I don't know how frequently um other settings collect information on anxiety and depression and even post-operatively you know are those questions asked and then what's done with that.

SPEAKER_04 24:44

So for example um as a physician and you determine that you know post-surgically uh you know a patient now has some pretty significant depression what do you do do you have resources that you can lean on to get that patient care I you know I think that that is really an an area of ongoing research right now um you know the first step as you said is is to do standardized screaming screening rather than just you know ICD-based um pre-op diagnoses or even you know a lot of the pre-op questionnaires are homegrown like you know they have just been developed in an institution they've stayed the same for 20 years um whereas you know primary care is very much switching to standardized assessments validated assessments that that give you uh you know a scale um for anxiety depression you know alcohol use what have you and the scale then can then trigger um interventions referrals rather than you know assessing something in a non-standardized way that really leads to nothing except scratching your head yeah so that's useful and you also mentioned you know alcohol and drugs i i know you think a lot about kind of substance use and abuse in our in patients in this setting um what are some of your observations um well i i think there is a big treatment gap um you know i'm i'm most familiar with the alcohol one it's about one in ten US population qualifies for alcohol use disorder of these only one in ten ever get ever gets offered treatment wow and SAMHSA for just any mental health condition um I think the numbers are a little bit better maybe something like one in four one in five but we had we have a huge treatment gap and and of course I acknowledge that you know it that the treatment is not as simple as prescribing an antibiotic for pneumonia so there is it is not the same in that regard um however uh our approach needs to be similar in terms of being willing to get our hands dirty and really engaging with those problems and not just writing them off as cannot be solved or you know I don't want to I don't want to get involved.

SPEAKER_01 27:00

So how do we make this happen?

SPEAKER_04 27:04

If you know if other clinicians and certainly um mental health professionals see this quite passionately how do we start to turn the tide amongst physicians I think the first thing is is really um changing from home grown and especially in the perioperative space changing from homegrown um screenings for uh or assessments let's call them for uh depression anxiety and substance use to validated ones and you know they don't have to be asked five times um uh by different people they they can be asked once um during the perioperative encounter and then be referred to by everybody currently what's happening with we have you know five people and anybody who's been a patient knows this you you get asked the same questions by five people um five times yet we're only scratching at the surface so I think that's the first thing that has to change we have to uh come to an efficient standardized screening and you know primary care has led the way on how to do that um in in most primary care practices once a year you'll get a PhD 9 and and that and if you do that at scale or the VA the VA is very good at doing that too for example um I think that's that's probably the first step. And then it really depends on what the what the diagnosis is, what the risk is of where you go next but like an obvious like example that anybody could appreciate is if you do um standard alcohol risk screening is that you um that you determine a high cutoff and then uniformly assess patients uh who score high for alcohol withdrawal in the hospital I think anybody could get behind that any any health system would probably be doing some form of that already but it's usually dependent on you know patient X drink drinks a lot let's screen him somebody if you're lucky picks up on it but overall considering the the fidelity you know and we apply it to the technical aspects of medicine we are really doing you know we could do so much better.

SPEAKER_02 29:13

There are 86 billion neurons in the human brain complex networks connect these remarkable cells so we can breathe move thinking feel pleasure and pain changes in some of these brain muds are not to underline my pain these mudworks are not underlined stress fear and loneliness and thank brain mud works and make your pain worse healthy eating sleep and exercise can help your brain make new connections and so can mindfulness joy friendship and love because this is true the power to create a new tomorrow with less pain and a more rewarding life already resides within you Dr.

SPEAKER_01 30:33

Hassett's book Chronic Pain Reset can be found on Amazon and independent bookstores everywhere this takes me to another area that of research that um that you do and I'm very interested in and that's also the mental health on the other side of the table of our clinicians and our providers um so when we think about the problem of burnout and other mental health concerns of providers um this is an interesting an area of interest do you talk a little bit about what you have done in this area and what do you think is important?

SPEAKER_04 31:08

Yeah thank you um for that question I think it's a it's a huge issue and um you know to set the stage there I I I have the pleasure to now work with some folks at the University of Michigan who who have pioneered this work. And you know um Sri Jan Sen and also Amy Bonnet's group they have shown that in medical interns so those are physicians who are fresh out of medical school in their in their first year of practicing as a physician.

SPEAKER_01 31:39

So think think about these individuals those are you know kids who I call them kids young adults who uh who have worked really hard um to get to where they are who have taken like a series of you know um of tests and assessments and and have really achieved you know their first sort of professional um position after a very long road you'd think um they should feel like good about themselves for the next five years but but in you know in in a 2010 Jama psychiatry paper what they showed was that if you do depression screening on these young professionals when they start they have a depression uh or a rate of um uh depression uh moderate I think moderate depressive symptoms of uh four percent and then once they're done with internship it goes up to like a quarter yeah so something's not right yeah and and and you know it is it is of course that is a simple observation yeah um that is that is very uh strong the answers of course are not simple um it is it is things how how we work how we how we take work home um and of course also it is what does the institution do how um how is work like balance managed how is how are how hierarchical is the system um our voices being listened to um all these things so so it's a it's a it's a complex issue yeah yeah it is and and I'm very impressed I mean I I've been in Michigan now for like 17 years and I look back at the strides that have been made in recognizing physician burnout and I think it really was emphasized on steroids during the COVID-19 pandemic and it was such a hard time for for physicians and other healthcare workers that a huge emphasis now has been put on physician and healthcare worker wellness. And that is so important you know to at an institutional level say we actually really care deeply about this and embrace this. So I the interest is there the efforts are there um but there's you know what what really can be done right so you have a mental you have a wellness event and not everybody shows up to it right so it's it's also kind of getting buy-in and so you did a really kind of cool study that I had an opportunity to kind of play a small role in can you talk a little bit about um the study that you conducted kind of in the context of how much uh time we all spend on our screens yeah so you know this was sort of a little side project um that a medical student in in uh Omaha actually spearheaded and and helped a lot with so I you know uh screen time and being present in the moment I think we're all very familiar with with how that that is a dilemma um the advantages of always like being able to connect um I mean look at you and me prior to this interview we we connected at least five times today and yesterday to schedule things to go over the screen and that happened um during all times of day and that's convenient and and on the other hand when we sit down with our our loved ones or um or we walk uh in nature um those are definitely conflicting opportunities and uh I feel strongly about that and I I remember at the time when when before I conceived the study um I had you know a discussion with my son about the his screen time contract you know he had a screen time contract and as you can imagine with how I feel about this is a very strict contract and he negotiated it you know very astutely and then he ended the negotiation by saying like look look at yourself like you are you're constantly on your screen all the time for work.

SPEAKER_04 35:52

And you know of course he was right. And then that morning after we had that discussion I was ready to go to work and and it was like six in the morning and I was in the uh you know getting ready and my phone went off informing me about like you know that my patients had just checked in which is nice but completely you know irrelevant to anything. And I just felt you know this is sort of digital overreach. And um yeah so we we we designed a little little study where we we we wanted to see if we can do anything about you know this digital overreach and if it would affect stress. And that's when I reached out to you to to teach me a little bit about like how can I measure stress and you said well that's the scale perceived stress scale and you can just ask patients a small battery of questions and that'll give you a population level validated measure of stress. And then what we did that and you had to be a healthcare worker you had to have a weekend off we measured stress on Friday and Monday and then half half the participants were in this intervention where the intervention was essentially like you know put your phone down. You know the nutshell was a bit more sophisticated than that. But it was put your phone down, don't engage with work, be present in the moment. And then yeah we we we enrolled uh almost 500 patients and per arm and then we found that the people who were in the put your phone down group um had a look had more stress reduction so 20% after weekend off compared to everybody else who had 10% you know not surprisingly you'd have hopefully some stress reduction from a regular weekend off. Yeah and I I always joke it's like the first time like any of my studies actually worked you know trying to do all those things very complex very difficult but um you know it was a it was a fun project yeah yeah I have to admit you know I'm I'm I'm I'm not the best you know practicer of my own beliefs in that in that regard I'm definitely uh you know I can do better myself.

SPEAKER_01 37:56

It's you know right it's it's is practice not perfection right try try try try and see if we can adopt more of the uh of these habits so yeah so we see screen time associated with all bad things right so you know in young individuals especially you know anxiety and depression but and you you you said patients but you actually meant healthcare workers we are actually looking at clinicians right yeah yeah and in the study but you know that's a big difference right that you know that just by not looking at your screen all the time just disengaging or being more mindful and aware of the time that you have when you are off that can make a difference right so um I think it's important and sometimes it's just little things right that's not a huge deal that's not sending people to a group for all day long or doing you know some expensive intervention with a with a uh known speaker or it is a little thing it's setting your phone down and being present with family. So um I think how we make big change is through little teeny incremental bits. And I love that you did this study because it's one of these bits that gives us a little bit of evidence that we can say hey small things can make a big difference. So there's one last topic I wanted to get to you do something that I don't know a lot about but I think is uh fascinating and probably extremely relevant in this day and age talk a little bit about the work that you do in de-implementation.

SPEAKER_04 39:26

Yeah um there's been a big focus on choosing wisely in medicine we tend to you know again to use this analogy of the head to toe and the daily rounding on patients um we round on patients and we create a problem list and every problem gets a solution and usually the solution in the hospital is a drug and um if patients come to the hospital a lot um then they end up with longer and longer lists of medications and um even if you practice very evidence-based medicine that is up to date as soon as you like combine certain medications that have um similar targets uh the polypharmacy of these type of components is basically completely unstudied and you're in uncharted territory um taking on the example of pain medications and the the opioid pendulum and the the the sort of anti-opioid pendulum um one of the medications that's gotten a lot of scrutiny recently is are gabapentinoids in the context of acute pain and so gabapentin um or pregabalin if used for its FDA approved indication with it which is postherpatic neuralgia um in the case of gabapentin will be usually titrated into effect over a course of six weeks um and the common side effects are somnolence dizziness drowsiness and then depending on whether it works or not for the patient you should stop the medication or continue it often it gets continued and this is even for patients who get it for neuropathic pain for it's FDA approved indication that's how it works and in that context these medications have a clinical efficacy to treat pain meaning reducing average pain by 30 or 50 percent number needed to treat of seven so I have to seven patients to get one who benefits from it. Now that you know that shows you how big of a problem chronic pain is yeah because it's still considered one of the better medications in that context hence that's approval but now it's because other people found that opioids were harmful they sort of like anything that's sort of remotely analgesic we're going to give to patients in the hospital for acute pain and one of them is uh our are gabapentenoids in the hospital there's no time to titrate for six weeks there's no time to measure um adverse effects and of course in the context of recovery from surgery adverse effects from gabapentenoids could be very bad drowsiness think of aspiration think of falls um and and yet this the use of gabapentenoids has really exploded gabapentin is now in the United States the number nine prescribed drug um and in the context of acute pain after surgery the clinical efficacy is not there um and that's being shown in prospective studies there was a big study a gap trial out of the UK that just showed that and then because side effects aren't as well captured and are less common we only know from observational data that um that gabapentin is associated with adverse effects in in in when it's used for acute pain after surgery so so here is an is a problem that probably at least for select patients requires de-implementation yeah we don't need a new drug we don't need a new mechanism we just need to stop doing something that doesn't work and that is an area that of course sort of is the whole de-implementation uh world is is not going to be driven by pharma for example you know nobody's nobody's gonna invest in de-implement that's antithetic yeah um so but of course others are interested in you know obviously foundations federal funders but also payers should be interested in something like that so I do feel uh regardless of you know who pays for this type of research it is it is highly highly highly relevant because it's about avoiding astrogenic harm and especially in in the context of you know very highly developed medical system like ours um that has That it always drives on new intervention and adding an adding something to the battery of problem-solving agents. Stopping stuff that doesn't work or stopping stuff because other stuff now works better is something we really need to do more of.

SPEAKER_01 44:21

So it's fascinating. I was watching kind of the arc of our conversation here and kind of what it feels like is as we start, mental health is a serious consideration in the perioperative setting as is in most places. It leads to worse post-surgical pain, chronic pain, and more pain post-surgically often results in chronic pain. We need to ID the problem. That's the first thing. Identify the problem, use good measures, get a sense of what's there, have a process in place. So we need to do something, right? What we do ideally is scalable, is pragmatic. If it's effective, we keep it. If it isn't, we get rid of it. Deimplementation, right? Let go of these things. Um but I think it always comes down to recognize that there is a problem. And that's what you've done a lovely job with today is highlighting the need for us to do a better job for our patients in the peroperative setting in regard to their mental health.

SPEAKER_04 45:28

Thank you, Afton. This was lovely.

SPEAKER_01 45:29

Oh, so before I let you go, uh, do you have any resources you we'd like to recommend? Anything that you kind of come up with with we can link to in show notes?

SPEAKER_04 45:39

Um, I think uh since we talked about burnout and a lot of the listeners here might be uh clinicians, the the AMA American Medical Association has a great uh website on burnout that we can post.

SPEAKER_01 45:53

Yeah, glad to do that. Um and I know I always I always end our podcast with two questions. The first question is did I is there anything that I didn't ask you that you were hoping that we would get to today?

SPEAKER_04 46:09

Are you going to Dan Claw's happy hour today?

SPEAKER_01 46:13

I will be there. Okay, see you later. That's awesome. Great for our listeners. The Dan Claw happy hours are really something of special. Um uh we love these things. Wonderful food, great friendship, a beautiful studying on a lake. And so I'll see you there. And then lastly, um, Karsten, what brings you joy?

SPEAKER_04 46:37

Um my family and being outside.

unknown 46:42

Yeah.

SPEAKER_01 46:43

Well, we'll be outside in a couple hours, then.

SPEAKER_04 46:46

I'm bringing my family.

SPEAKER_01 46:48

Excellent. Look forward to it. All right. Thank you so much. It's really been a treat to have you on.

SPEAKER_03 46:53

Thanks so much, Afton. This was wonderful. If the Chronic Pain Reset Podcast series has brought you some inspiration and hope, please consider joining the community of listeners who have helped fund our production. Your support is important for us to keep creating content for those impacted by chronic pain. Look for the Support the Show link in our show notes in each episode. Today's episode was produced and edited by William Hassett, made possible by listeners like you, Son of a Books, and the team at Venue by 4M. Our music score, Just Being, was produced by Bohemian Roosters. That's it for today. Join us in two weeks for another episode of Chronic Pain Reset.