Transcript The Health Risk of Overload: The Therapeutic Benefit of

The Health Risk of Overload:
The Therapeutic Benefit of Margin
Session I
Northeast Association of Occupational Health Nurses Conference
September 23, 2010, Meredith NH
Richard A. Swenson, M.D.
A New Epidemic
 Signs
of the times
 Prediction
 Reality
 Signs
of the 60’s: boredom
of new millennium: not boredom
and symptoms
We Live in a Special Moment in History
We Live in a Special Moment in History
A Special Moment in History
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Gutenberg
Columbus
Anesthesia, antibiotics, germ theory
Wright brothers
Radio, television, computer, Internet
Historically Unprecedented
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The math is dramatically different
Large numbers
Exponential curves
J, S Curves; Turning Point
1992
$4.0 trillion
Health Care Costs
$2.5 trillion
$1 trillion
1900
1950
2000
Historically Unprecedented
 Consistently
underestimated
 Double paper 40x, 100x
 Pacific Ocean
 Count to a million, a trillion
 Mismatch between day-to-day linearity and
cultural/global exponentiality
Historically Unprecedented
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What’s responsible for such rapid
change?
Progress
Progress
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Differentiation (proliferation, combination,
invention, discovery)
Progress
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Differentiation

Tree, time, DSM, medical specialties,
pharmaceuticals, mountain, bioethics
DSM, # Conditions
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1952 – 107
1968 – 180
1980 – 226
1994 – 365
Bioethics
Progressive bioethics
 Conservative bioethics
 Global bioethics
 Feminist bioethics
 Islamic bioethics
 Catholic bioethics
 Utilitarian bioethics
 Deontological bioethics
 Dignatarian bioethics
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Progress
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Differentiation (proliferation, combination,
invention, discovery)
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Always results in . . .
more and more
 of everything
 faster and faster
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More of Everything . . .
 >500
baccalaureate degrees
 1,100 movies a month w/ satellite dish
 450 English language versions of Bible
 30,000 different products in grocery store
 55,000 configurations of coffee at Starbucks
 >>500 billion documents Internet
 10 hours of media exposure/day
More of Everything . . .
2,000-4,000 MEDLINE citations added/day
 Read 2 healthcare articles qd → 1,000 yrs behind
 >900 million MEDLINE searches in 2007
 5,020 journals; > 15 million journal references
 110 Medical Specialty Societies
 6,000 ‘rare’ conditions, National Office for Rare Diseases
 >>diseases, lab tests, procedures, billion codes
 743 specialty daily newsletters, MDLinx
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Collision Course
 Everything
within this system is on a
collision course—the more and more of
everything faster and faster colliding with
human limits.
more, faster → → human limits
More of Everything . . .
 Balance
& self-care are moving targets
 Nearly all the forces of modernity are
imbalancing
 The escalation of the norm is followed
by a normalization of the escalation that
then becomes the new normal
Progress axiomatically leads to…
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Stress
Change
Complexity
Speed
Intensity
Imbalance
Overload
Stress
 Stress
definition (among many):
Physiological adaptation to change
 Small, large, good, bad change
 No stress, low stress, hyper-stress
Stress
Productivity
Stress
Productivity
At stake:
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Productivity, Longevity
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Excellence, Efficiency
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Morale, Sustainability
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Innovation, Passion,
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Service, Caring
Change
 There’s
been more change since 1900 than all
of recorded history before 1900.
 There will be more change in the next twenty
years than the previous century. The Futurist
 In the next 100 years there will be 20,000
years of progress.
Ray Kurzweil
Change & Health Care Costs
There will be more and more people living
longer and longer with more and more
chronic diseases taking more and more
medications that are ever more expensive
using more and more technology with
higher and higher expectations in a context
of more and more attorneys.
Complexity
 Progress
flows toward complexity
 20,000 pieces of technology
 In medicine, complexity not recognized
as a specific entity of concern
 PDR: 3500 pages vs. 300 pages (1948)
 Lipids
Speed
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Automatically increasing speed
A speed limit to life?
Hyperliving
89 yr old patient
Intensity
 Torque;
Tightly-wound
 Muscle tone, mental vigilance
 Thesis: Restorative rest requires a relaxation
of muscle tone and psychic vigilance below
a ‘set’ point. Many people are so tightly
wound that they never experience
restorative rest.
Imbalance
 Fast
Company, Balance is Bunk
 Such thinking applied to other areas
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Healthy Lifestyles (Adherence to Healthy Lifestyle
Habits, 1988-2006, AJM, vol. 122, issue 6, June ‘09)
 Balance
is inexorably more difficult
 Conclusion: quite trying?
 Balance in the universal order
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Homeostasis
Overload
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What does it look like?
Overload
A
science/psychology of human limits
All
humans have limits
Subjective vs. objective
Little science devoted to the upper limits
of human performance in the peoplehelping professions
Overload
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Only so many details . . .
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The problem is with over (not load)
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Belgium work horses, sled dogs, camels
Overload
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A state of chronic overage that leads to
dysfunction in at least one important
area where life requires a decent
minimum
Overload
 Short
term overloading is universal
Common Symptoms
Apathy, withdrawal, depression, work dread
 Irritability, anger, hostility
 Frustration, disorganization
 Mistakes, poor judgment, chaos
 Fatigue, exhaustion, burnout
 Moral failure, relational problems
 Risk taking, excessive self-medication
 Abnormal sleeping or eating patterns
 GI & CV symptoms, headaches
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Margin
The space between our load and our
limits; Our reserves
 The opposite of overload
 Power – Load = Margin
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Margin: Examples
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Airline scheduling
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Interstate traffic
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The margins of a book
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Power grids
Margin Is Where We…
 Recharge
our batteries
 Recover our health
 Rest our bodies & spirits
 Nourish our relationships
 Think deeply about priorities
Margin
Margin is never easy.
But it is easier . . .
when at 100 % (maxed out) than
when at 120 % (overloaded) or
when at 140 % (burned out)
Margin
 Is
in favor of:
growth, vision, challenge, ambition, discipline,
work, productivity, efficiency, excellence
 Is
also in favor of:
balance, morale, focus, longevity,
sustainability, creativity, innovation, service,
caring, relationships
Margin, Limits, & Thresholds
 On
the unsaturated side it’s possible to
be open and expansive.
 On
the saturated side it’s impossible to
be open and expansive. The rules
change.
Margin, Limits, & Thresholds
 On
the unsaturated side of limits,
decisions on load & commitment are
much easier.
 On
the saturated side of limits, each
decision requires a new & often difficult
assessment of priorities. At saturation,
it’s a zero sum game
Individual vs. Institutional Responsibility
Three approaches
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Individual-home
Individual-work
Institutional-work
 It’s
not what overload and high work
hours require us to do, it’s what they
prevent us from doing.
 A ‘decent minimum’ is required in
many areas of life
 Not a single-point source problem
Three Scenarios
80% - 100% - 120%