My First Million

Meditation is my medication. I added Muse, the brain-sensing headband, to my meditation practice in July. I hit the 1,000,000 mark yesterday for “calm points.”

“Thanks a Million” is the alternate title for this post—as in, many thanks to InteraXon, the company that developed Muse and brought it to market. My quality of life so much better because of it.

Tech specs: I use Muse S in the constructive rest position with an iPhone 11 Pro, AirPods Pro and sleep mask. What’s going on inside my head is a little harder to describe, however, this post provides a general sense. ✸

Heal the Sick

Downtown Minneapolis is bleak right now. The towers have been empty since the shelter-in-place order was issued last winter. Many buildings are boarded up due to property damage from rioting. Sirens are constantly going off because of the sharp increase in crime. Street vagrancy is prevalent outside of my office building.

The world is upside down, however, this abandoned church reminds me every morning to continue healing the sick. ✸

Former Second Church of Christ Scientist
228 South 12th Street; Minneapolis, Minnesota

Meditation Challenge

Stress, anxiety, depression and substance use have increased during the Covid-19 pandemic. This has a lot people thinking about better self-care.

I’m helping one of my employers with a four-week “meditation challenge.” It grew out of a recent lunch and learn for employees that included some material on mindfulness. The more the merrier, so I’m sharing this with my entire social network.

Here’s the challenge: Meditate three times per day, generally in the morning when you wake up; sometime in the afternoon; and again in the evening right before you go to bed. Start with 5-minute sessions, increasing the duration week-by-week as follows:

  • Week 1: 5 minutes, 3 times per day
  • Week 2: 10 minutes, 3 times per day
  • Week 3: 15 minutes, 3 times per day
  • Week 4: 20 minutes, 3 times per day

In terms of technique:

  • Assume any comfortable position. I personally like a semi-supine position (see below)
  • Set a timer (e.g., on your phone) with a soft alarm
  • Close your eyes
  • Direct your attention to your breath. This might be your nose, chest or belly
  • Follow your breath in and out. Some people use simple mental mantras for each in-breath and out-breath. Examples are: in-out, deep-slow and calm-ease

Internal and external distractions will occur. Just let thoughts, emotions and sensations pass without judgment. Return to your breath, using a mantra, if needed. On the flip side, don’t worry if you feel sleepy or even doze off. Allow that to pass without judgment, too.

And that’s it!

Please let me know how you feel during and after the challenge.


I’ve greatly benefited from Alexander Technique lessons. One tip/trick is something called constructive rest, which involves the semi-supine position depicted below.

1. Head slightly supported by a softcover book (or two)
2. Arms slightly away from body (abducted), palms down (pronated)
3. Shoes off; feet about hip-width apart

Photo: Ayden Frenz

I’m also a fan of Muse, the brain-sensing headband, but that’s a post for another day. ✸

Zoom Security

I’ve been closely following media reports about Zoom security — for example, unauthorized people “zoombombing” (infiltrating) meetings. Although some of the identified security concerns are real, experts note that Zoom has been responsive and rapidly implemented fixes. And I have yet to see a story specific to Zoom for Healthcare, the paid, HIPAA-compliant plan. At this point, I don’t think that we need to throw out the proverbial baby with the bathwater

According to David Nield at Wired, “[T]here are plenty of settings you can tweak to make Zoom a safer place for you and everyone else on the line.” Kate O’Flaherty, a cybersecurity journalist with Forbes, Nicole Nguyen at the Wall Street Journal, and the Federal Bureau of Investigation (FBI) all outline the same basic precautions

Zoom hosts should:

  • Allow Zoom to generate random Meeting IDs. Don’t use your Personal Meeting ID
  • Protect Meeting IDs. Don’t post them publicly
  • Allow Zoom to generate random passwords for each Meeting
  • Share passwords securely with invitees
  • Restrict screen sharing
  • Enable Waiting Room. This allows you to manage who enters your Meetings
  • Lock Meetings after everyone has entered. This prevents additional people from joining

The following screenshots demonstrate these settings and features (orange rectangles). Some of these are already default settings, but please verify that everything is in order in your Zoom dashboard

Zoom also allows hosts to remove participants at any point. ✸

Telehealth — How To

I’ve been doing telehealth for a few years. Now everyone wants in due to the coronavirus pandemic. My partner, John Sutherland, Ph.D., and I have been furiously spinning up mental health and addiction clinicians at Allina Health. We transitioned at least 75 providers this week and more will soon follow.

This post will provide some practical advice for those new to telehealth. It comes straight from the trainings that John and I have delivered in recent days.

Keep it Simple
I use a number of telehealth platforms including Vidyo, Epic Warp Drive and Zoom for Healthcare. I recommend Zoom for Healthcare if you need to get up fast and don’t have an IT department supporting you. It’s literally purchase and practice. Patients just need the Zoom app, which is device and operating system agnostic (and free!). Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency).

Be Professional
I remind providers that they are health professionals, not creepy basement YouTubers. The following are small touches that make a big difference

  • Use good lighting. Cheap solutions are readily available on Amazon
  • Place your camera at eye level. Options include putting your laptop on a few reams of paper
  • Use a headset microphone. I like Sennheiser gaming headsets with noise-cancelling microphones
  • Select a bland background. If none is readily available, blow in a virtual background
  • Minimize environmental distractions. Under the current circumstances, that might include your kids and dog
  • Look into your camera often. That’s where your patient is, not elsewhere on your screen (even if that’s where they appear to be)

Documentation
Payment for telehealth requires that certain elements appear in your visit documentation. The following is the header of my charting templates, where *** are elements that are populated for each encounter

  • Date of Service: ***
  • Start Time: ***
  • End Time: ***
  • Type of Service: Evaluation and management (E/M)
  • Type of Encounter: Telehealth [or: Virtual health]
  • Mode of Transmission: Secure, synchronous, real-time audio and video communication via Vidyo
  • Originating Site: *** [patient location — city and state]
  • Distant Site: Minneapolis, Minn.
  • Basis for Service: Virtual health, in my judgment, is an appropriate and effective means for providing this service secondary to the current COVID-19 pandemic and the need for social distancing. I have previously seen the patient for traditional in-office care and consider their mental status, including the absence of imminent danger, amenable to virtual care

Good luck! ✸

Think Like a Health Plan

In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.

I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.

This post contains my key teaching points and didactic materials.

Suggested Thought Process

  1. Is the health care service a covered benefit? (cf. benefit plan)
  2. Does the carrier have a policy concerning the health care service?
  3. In the absence of a specific policy, is the health care service medically necessary?
  4. Does the member (patient) and/or evidence meet criteria?

Benefit Plan

At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).

Medical Policies

Medical Necessity

Group Exercise

# # #

Demystifying Suboxone

Suboxone was approved by the FDA way back in October 2002. Nearly 17 years on, there’s finally growing interest in its use. Primary care providers are prescribing it. And some emergency medicine physicians. Hospital medicine seems to be the next frontier.

I’m pleased to be partnering with Allina Health’s hospitalists on education and order set creation. The latter includes a presentation at their annual CME conference, offered on a repeating basis on April 5th, April 10th, April 26th and May 2nd.

Hospitalists frequently care for patients following overdoses and other opioid-related misadventures—trauma, endocarditis, and so on. Buprenorphine is a very nifty widget in these circumstances.

Another common scenario is acute pain management for patients who take buprenorphine in the community. Pain control is neither hard nor complicated, so long as you follow a few simple rules.

Special thanks to Drs. Saul Singh and David Beddow for their partnership on this.

Additional Resources
Suboxone Dosing Guide [pocket reference]
Buprenorphine Therapy for Opioid Use Disorder [journal article]
Use of Medications in the Treatment of Addiction Involving Opioid Use  [pocket reference]
Buprenorphine: How to Use It Right [journal article]

Drinking Less = Longer Life

How much alcohol is too much? For years, we’ve been using numbers from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It defines low-risk drinking as:

  • Women
    No more than 3 drinks per day; and
    No more than 7 drinks per week
  • Men
    No more than 4 drinks per day; and
    No more than 14 drinks per week

where 1 drink = 14 grams of absolute or “pure” alcohol. This corresponds to 12 ounces of beer, 5 ounces of table wine or 1.5 ounces of distilled spirits (e.g., vodka).

us.standard_drinks
National Institute on Alcohol Abuse and Alcoholism

All that is about to change. A new study involving about 600,000 people found that drinking targets should be a lot lower—probably no more than 100 grams of alcohol per week. This corresponds to just 7 standard drinks.

The study found that people who consume more than 100 grams of alcohol per week had a higher risk of dying. They also had more heart attacks, strokes and other cardiovascular diseases.

Here’s the flip side: drinking less appears to add years to your life. For example, 40-year-olds increase their life expectancy by at least 1 year when they reduce alcohol intake from NIAAA’s current upper limits to no more than 100 grams per week.

I’ve loaded these data into my longest running PowerPoint slide deck (Slides 14–16) and am encouraging my students to change the advice they give to patients. Please pitch in and start spreading the word!

The Accidental Psychiatrist

I’m honored to be the keynote speaker at the Minnesota Academy of Family Physicians’ Spring Refresher. Here’s a fairly final version of my PowerPoint.

mafp_spring_refresher_2018_title_slide

The bulk of my presentation will be devoted to the systematic management of major depressive disorder. The STAR*D Study, which has only become more relevant over time, will provide the overall framework.

I’ll also be discussing suicide assessment and how to monitor various psychotropic medications.

SBIRT

I attended Hazelden Betty Ford’s Professionals in Residence (PIR) program in 2002. I started the week thinking I was going to be a family physician—I was a resident at the time—but was hooked on addiction (bad pun intended) by the end of the experience. And so began my odyssey to an eventual career in addiction medicine.

I returned to PIR as faculty in 2009 and have been teaching for the program ever since. I lecture on Screening, Brief Intervention & Referral to Treatment (SBIRT—not to be confused with Ernie and Bert!).

My slide set has evolved considerably over the years. This blog post contains the latest and arguably greatest.

sbirt_title_slide