498 - Vitamins for Memory?, Less Work After Work, Self-Connection

From the Literature

1)  Vitamin Supplements for Memory?

With an aging population, the threat of cognitive impairment is worrisome for families and will stress our healthcare and long-term care industries. The researchers for the COSMOS trial group are testing a variety of interventions to understand their effect on memory and cognitive function. The larger COSMOS study is a 2x2 factorial study of cocoa-derived flavanols (mmm…chocolate) and a multivitamin (MVI, Centrum silver) and their effect in the elderly on cognitive function. This report is about a sub-study, where the researchers examined just the MVI and its effects on web-based assessments of immediate recall at 1 year (primary outcome) and immediate recall, object recognition, and executive function at 3 years (secondary outcomes). The study used all the appropriate validity techniques (randomization, blinding with good placebo dummies, intention to treat analysis, and fairly rigid exclusion criteria). Subjects had to have an internet connected computer, and the study was funded by Mars Edge (the nutritional research arm of the Mars company) and Pfizer provided some support with the pharmaceutical preparations.

The results of this study are significant but underwhelming. Performance on the immediate recall task improved from an average of 7.10 to 7.81 words in the MVI group and 7.21 to 7.65 words in the placebo group. Both groups improved, but the MVI group improved statistically significantly more (p = 0.025) and the Cohen’s D effect size was 0.07, consistent with a small effect size.  None of the other results were significantly different – not the 3-year follow up, nor the executive function/object recognition tests. Nonetheless, the authors claim that the difference seen represents an improvement of “memory performance above placebo by the equivalent of 3.1 y of age-related memory change.”

John’s Comments:

We are just coming to terms with how to manage Big Pharma influence in clinical trials…I’m not sure I’m ready for the influence from Big Candy. Given that prior research on supplements and cognitive function have yielded mixed results, this study’s findings should be viewed as another set of data points, which will hopefully be merged into a systematic review that can sort all this out. I worry, however, that this study will instead be used by the supplement industry to bolster their claims of effectiveness. Even if these findings hold up, they promise only temporary, specific, and relatively small benefit in a narrow segment of the population.

Reference:

Yeung LK, Alschuler DM, Wall M, et al. Multivitamin Supplementation Improves Memory in Older Adults: A Randomized Clinical Trial. The American Journal of Clinical Nutrition. Published online May 2023:S0002916523489046. Link

From the Literature

2)  Reducing “Work After Work”

In the 2023 Medscape Physician Burnout and Depression Report, 57% of family medicine physicians reported feeling burnt out — up 10 percentage points in five years.  The top contributor was “too many bureaucratic tasks,” such as paperwork and charting requirements. Too many working hours and the increasing computerization of practice were also cited as key causes.  This includes an average of nearly 90 minutes of “pajama time” (work outside of normal working hours) per work day.

A recently published article provided some tips to help physicians decrease this “work after work” as well as allow for improved clinical efficiencies during the work day.  The author notes that implementing change can sometimes be difficult and team efficiency may decrease in the short term but investing in the present will pay off in the future.

Recommendations include:

·       Practice Strategic Delegation:  While the concept of “working to license” sounds good, delegation needs to happen based on an assessment of your staff and resources.  Creating a consistent medication refill workflow so that refills are queued up or addressed by staff (depending on state laws) can save significant time.  Additionally, empowering and training your medical assistants or nurses to handle most phone calls and electronic patient messages, and route only those that truly require a physician's training or input is essential. 

·       Train Your Patients:  This strategy is important both during a visit and also for the time between visits.  During the visit, being sure to both establish an agenda at the beginning of the visit (“Is there anything else?) and set expectations can save many of the “by the ways” at the end of the visit.  Over time patients will come in with their “list” and then you can triage the visit based on what is on the list.  For the time between visits, it is vital for you to set expectations and boundaries regarding patient portal messages and lab results.  Let them know that messages regarding new problems, extensive questions, and requests for medication changes will likely need to be converted to virtual or in-person office visits and be sure your care team reinforces this. 

·       Practice Lean Documentation:  “Note bloat” is epidemic in Family Medicine.  The recent evaluation and management (E/M) coding changes have simplified the items that are essential to the clinical note for billing purposes and should have resulted in briefer documentation.  For many clinicians, the mindset of a “complete note” based on their training can be difficult to leave behind.  Additionally, limiting keystrokes will decrease time spent writing notes and your future time spent reviewing the chart. Helpful techniques for this include the regular use of “smart-phrases” (dot phrases, quick phrases, macros, etc.), using short phrases rather than complete sentences, using voice recognition for documentation, and documenting during and at the end of the visit while details are still fresh rather than “batching” notes.

·       Using the EHR as a Database, Not a Paper Chart:  Use customized note templates that automatically pull in needed information that is contained elsewhere in the chart, remembering much additional information may not need to be included in the note at all if documented elsewhere in the chart.  Use the search function to find needed information quickly.  If your EHR has a quick action function, learn how to use this to allow for one-click responses to common messages and lab results.  If your EHR doesn’t have this function, smartphrases can serve this role as well.  Additionally, customizing the EHR to better suit your practice style is an often-underutilized strategy that can yield huge benefits.  Options might include rearranging tabs or sections to fit your workflow, creating buttons to quickly populate fields for common levels of service or follow-up intervals, changing defaults when opening a new chart, and saving your commonly ordered labs and commonly used diagnoses for quick selection on a preference list. 

The author additionally advises patience with the process, help seeking to take advantage of all available resources, and learning from colleagues who are more successful at these processes.   If you are able to obtain data from your EHR (e.g., your time spent on documentation, prescriptions, or inbox messages), see how you compare to national and local data when available.  This may provide context and perhaps some extra motivation for change. 

Mark’s Comments:

If your process is working, good for you, but the data regarding work after work indicates that many of us would benefit from refining and evolving our present interface with the EHR.  While none of these recommendations will likely be new to you, this article serves as both a good reminder and for some, a needed “nudge.”  Remember, work after work is not inevitable.  It is true that changing documentation and work-flow habits can be challenging for many, and it is also true that it is quite doable based on my observations and personal experience.  For instance, using a well-functioning voice recognition product was an absolute game-changer for me when it come note completion.  And don’t try to change everything at once.  Pick one challenge at a time and refine that prior to moving on to the next.  In time, you will likely see significant progress in decreasing or even eliminating your “work after work” time. 

Reference: 

Bacigalupa A.  Clinical Workflow Efficiencies to Alleviate Physician Burnout and Reduce Work After Clinic.  Fam Pract Manag. May/June 2023;30(3):21-25.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  The Importance of Staying Connected – With Yourself

“Let him who cannot be alone beware of community... Let him who is not in community beware of being alone...  Each by itself has profound perils and pitfalls.”  Dietrich Bonhoeffer in his book Life Together

 When was the last time you spent an extended period (even an hour) alone and completely “disconnected” technologically from the world (no cell phone, computer, radio, television)?  If your answer is “a long time” or “can’t remember,” please read on.  While the foundation of the PeerRxMed process is interconnection, wisdom literature across many cultures indicates the necessity of regular time alone in solitude (and often in the natural world) if one is to attain psychological resilience and spiritual depth.   Yet such guidance is antithetical to our “always connected” culture. 

In fact, being alone without external stimuli can, for many, cause great psychological angst.  A study done with college students published in 2014 found that participants were so averse to spending 15 minutes sitting quietly in a room by themselves that many preferred to administer electric shocks to themselves as a distraction, even though they had indicated previously that they would pay money to not be shocked.  Fifteen minutes!  

Over the past 2 months I have spent some much-needed time alone and disconnected while paddleboarding at dawn on a local lake.  It has been during these times that I have found myself quieted enough to be able to hear what I would consider my “soul’s voice.”  And according to that voice, we were long overdue for a chat.  As we have become re-acquainted, what I have heard has spanned the continuum from disturbing and chastising to humorous and annoying to humbling and challenging and finally to empowering and life-giving.  Indeed, this important time “together” has already catalyzed a reprioritization of some of my time, energy, and focus.   Most of all, like reconnecting with a dear friend from your past who knows you “almost too well,” there’s been a depth and richness to our conversation that has been grounding and “heartful.”  Indeed, I’m feeling more like my whole-hearted “true self” again, and look forward to connecting with my PeerRxMed partners and others to share what I’ve heard.

How about you?  In the midst of all the “swirl” of the world, are you carving out some extended, undisturbed time to be sure you’re hearing your “soul’s voice?”  If not, what’s keeping you from doing so?  Consider starting with something simple, like a regular “unplugged” walk in the woods, just listening and noticing.  Don’t focus as much on hearing revelations as noticing how you are feeling emotionally and physically during your “time away” and when you return.  If the two of you haven’t talked for a while, it may take some time to become reacquainted.  The soul will speak when it is ready, and you will hear it when you are ready.

With the end of the COVID-19 public health emergency, the last 3 years have provided ample reasons as to why regularly checking-in with yourself to clarify what is important to you and living from that place is more vital than ever.  That can’t happen without some undistracted space to be able to listen.  It may take more than 15 minutes, but the only “shock” will be likely be that your own soul is much wiser than often given it credit for … and hopefully that will prompt you to schedule more regular buddy checks with your “original” PeerRxMed buddy!

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org