Music Effects on Cognitive Function of the Elderly

Whether the music is orchestral, rock, country, or jazz, most seniors like to listen to some kind of music. Music can soothe or energize, make us happy or sad, but the kind we like to hear does something that can be positively reinforcing or otherwise we would not listen to it. As my 80-year-old jazz trumpeter friend, Richard Phelps, recently said at his birthday party, "Where there is life there is music. Where there is music, there is life."

Relatively little research has been done on the effects of music on brain function in older people. But one study recently reported the effects in older adults of background music on brain processing speed and two kinds of memory (episodic and semantic). The subjects were not musicians and had an average age of 69 years.

The music test conditions were: 1) no music control, 2) white noise control, 3) a Mozart recording, and 4) a Mahler recording. All 65 subjects were tested in counter-balanced order in all four categories. The music was played at modest volume as background before and during performance of the cognitive tasks, a mental processing speed task and the two memory tasks. The episodic memory task involved trying to recall a list of 15 words immediately after a two-minute study period. The semantic memory task involved word fluency in which subjects wrote as many words as they could think of beginning with three letters of the alphabet.

Processing speed performance was faster while listening to Mozart than with the Mahler or white noise conditions. No improvement in the Mahler condition was seen over white noise or no music.

Episodic memory performance was better when listening to either type of music thatn while hearing white noise or no music. No difference was noted between the two types of music.

Semantic memory was better for both kinds of music than with white noise and better with Mozart that with no music.

Recognizing that emotions could be a relevant factor, the experimenters analyzed a mood questionnaire comparing the two music conditions with white noise. Mozart generated higher happiness indicators than did Mahler or white noise. Mahler was rated more sad than Mozart and comparable to white noise.

Thus, happy, but not sad, music correlated with increased processing speed. The researchers speculated that happy subjects were more around and alert.

Surprisingly, both happy and sad music enhanced both kinds of memory over the white noise or silence condition. But it is not clear if this observation is generally applicable. The authors did mention without emphasis that the both kinds of music were instrumental and lacked loudness or lyrics that could have been distracting and thus impair memory. I think this point is substantial. When lyrics are present, the brain is dragged into trying to hear the words and thinking about their meaning. These thought processes would surely interfere with trying to memorize new information or recall previous learned material.

A point not considered at all is personal preference for a certain types of music. There are people who don't like classical music, and the data in this study could have been made "noisy" if enough of the 65 people disliked classical music and were actually distracted by it. In other words, the effects noted in this study might have been magnified if the subjects were allowed to hear their preferred music.

My take-home lesson was actually formed over five decades ago when I listed to jazz records while plowing my way through memorizing a veterinary medical curriculum. Then, I thought that the benefit was stress reduction (veterinary school IS stressful and happy jazz certainly reduces stress). Now perhaps I see that frequent listening to music that was pleasurable for me might have actually helped my memory capability. If you still have doubts you might want to check my latest blog post, "Happy thoughts can make you more competent" (http://thankyoubrain.blogspot.com/2015/01/happy-thoughts-can-make-you-more.html).

Anyway, now that I am in the elderly category, I see there is still reason to listen to the music I like. Music can be therapy for old age.

“People haven't always been there for me but music always has.”

    —Taylor Swift

"Memory Medic's" latest book is "Improve Your Memory for a Healthy Brain. Memory Is the Canary in Your Brain's Coal Mine." It is available in inexpensive e-book form at Amazon or in all formats at Smashwords.com.

Bottiroli, Sara et al. (2014). The cognitive effects of listening to background music on older adults: processing speed improves with upbeat music, while memory seems to benefit from both upbeat and downbeat music. Frontiers in Aging Neuroscience. Oct. 15. doi: 10.3389/fnagi.2014.00284.

How does the brain work?

We have no idea. We are still in the very beginning stages of understanding most of the basics. From a researcher's perspective, it's a very exciting time to be a scientist, because you get to rummage around on the ground floor. But from an overall perspective, most of it is spooky.  

Let me give you some examples of how little we know about how the brain works. We know that you use the left-side of your brain for speech. Under normal circumstances, if you get a stroke on the left side of your brain, your speech can be greatly affected. Depending upon where you got the stroke, it could affect your ability to speak language or your ability to understand language.

There is a little six year old who suffered from something Sturge-Weber syndrome, a catastrophic brain disease. Because he had this disorder, the little guy had to have his entire left hemisphere removed. No left hemisphere, no language. That should have completely destroyed his language ability. Right?

Wrong!

Within two years, the little guy had regained his language abilities entirely. The right side of his brain seemed to have noticed there was a deficit and simply rewired itself to take over talking. Do we understand this?

We do not.

We do not understand how you learn a language of any kind. We don't know how you know how to walk. We don't know how you know how to read. You have a complete map of your body in your head. Actually, you have several maps of your body in your head. Some of them tell you where you are, some of them tell you how to move. One even tells you how to see. We don't know how they coordinate their information. We don't know how it knows its you - and what, if anything, YOU are. Consciousness remains a slippery fish as ever.

So you ask me how the brain works. I am happy to repeat my answer. We have no idea.

Visit brainrules.net to learn about the 12 things we know about how the brain works. These are the Brain Rules

.

Mental practice & Mental rehearsal

Mental practice

In 1972, Corbin defined mental practice as the repetition of a task, without observable movement with the specific intent of learning’. It is to enhance performance in the absence of a physical activity.

There is some agreement that mental practice frequently has a beneficial effect on other the learning of a new skill or the betterment of performance of an existing skill.

Mental practice has been found to improve both cognitive and psychomotor performance.

The use of mental visualization in sports, mental practice was used in the context of sports psychology as a possible means for improving performance on a wide range of sport related task.

The mental practice most helpful to improve riding skills, is the mental practice of those skills in the midst of being improved or attempted for the first time.

Mental practice is most famous for the gains achieved in terms of muscle memory and the mental organization of sub-skills needed to successfully achieve a new skill.

Mental rehearsal

Mental rehearsal is one aspect of imaginary. It means the mental practice of performing a skill as oppose to actual practice. This is sometimes called mental practice and is a strategy adopted by many sportsmen and women.

It is a strategy for practicing something in mind before actually performing the task.

By mentally rehearsing it form mental image of the skill or event that the people are going to perform. No physical movements are involved in mental rehearsal. Some performers find mental rehearsal easier than other but the ability can be improved with practice. Mental rehearsal appears to be particularly useful in therapy settings with patients who are unable to engage in large amounts of physical practice because they lack endurance.

Mental rehearsal is used either to learn a new skill or to improve existing skills. There are a number of ways in which metal rehearsal is used including skills practice and rehearsal, practicing for events, competition practice, practicing ‘What if….?’, scenarios, replaying performance and performance routines.

Sleep in Your bad attitude, avoid!!

Generally speaking, you cannot learn from sounds of new information while you sleep, though this was a fad several decades ago. But in an earlier post, I discussed a new line of research where sleep learning can occur. The key is to play sound cues that were associated with learning that occurred during the previous wakefulness period. The explanation I posted was that cue-dependent sleep learning can work because a normal function of sleep is to strengthen memories of new information and that presenting relevant cues during sleep increases the retrieval of these memories and makes them accessible for rehearsal and strengthening.

The latest experiment by a different group shows that this cuing during sleep can modify bad attitudes and habits. The test involved counter stereotype-training of certain biased attitudes during wakefulness, and investigators reactivated that counter-training during sleep by playing a sound cue that had been associated with the wakefulness training.

In the experiment, before a 90-minute nap 40 white males and females were trained to counter their existing gender and racial biases by counter-training. A formal surveyed allowed quantification of each person's level of gender or racial bias before and after counter-training. For example, one bias was that females are not good at math. Subjects were conditioned to have a more favorable attitude about women and math with counter-training that repeatedly associated female faces with science-related words. Similarly, racial bias toward blacks was countered by associating black faces with highly positive words. In each training situation, whenever the subject saw a pairing that was incompatible with their existing bias they pressed a "correct" button, which yielded a confirmatory sound tone that was unique for each bias condition. Subjects were immediately tested for their learning by showing a face (female or black) and the counter-training cue, whereupon they were to drag the appropriate bias-free face on to a screen with the positive word. For example, if the first test screen was that of a woman, accompanied by the sound cue, the subject dragged a woman's face onto a second screen that said "good at math." Results revealed that this conditioning worked: both kinds of bias were reduced immediately after counter-conditioning.

Then during the nap, as soon as EEG signs indicated the presence of deep sleep, the appropriate sound cue was played repeatedly to reactivate the prior learning. When subjects re-took the bias survey a week later, the social bias was reduced in the sound-cued group, but not in the control group that was trained without sound cues.

Experimenters noted that the long-term improvement of bias was associated with rapid-eye-movement (REM) (dream) sleep which often followed the deep sleep during early stages of the nap. That is, the beneficial effect was proportional to the amount of nap time spent in both slow-wave sleep and REM sleep, not either alone. It may be that memories are reactivated by cuing during deep (slow-wave) sleep, but that the actual cell-level storage of memory is provided by REM sleep.

Implications of this approach to enhancing learning and memory show a great deal of promise. Can it be used for enhancing learning in school? Can it be used in rehabilitation of addicts or criminals? But there is a dark side. Now might be a good time to re-read Huxley'sBrave New World wherein he actually described conditioning values in young children while they slept. Sleep is a state where people are mentally vulnerable and without conscious control over their thoughts. Malevolent people could impose this kind of conditioning and memory enhancement on others for nefarious purposes.  These techniques may have valid social engineering applications, but they must be guided by ethical considerations.

The importance of mentors in family medicine

Saying that my medical alma mater, NYU School of Medicine, isn't known as a school that produces family physicians is a gross understatement. Actually, it routinely ranks last in the nation in the number of students matching to Family Medicine residency programs. My class of 2001, which sent 4 students to such programs, was a one-time aberration.

So how did I get started in family medicine? I give a great deal of credit to the Reading Hospital and Medical Center, which allowed me to do an elective rotation in their residency program from June through July 2000. But what inspired me to look into family medicine rotations in the first place? I recently came across a 13-year old letter I wrote to my cousin's husband (then a family medicine resident training in Minnesota) that gives part of the answer, and speaks to the vital importance of finding mentors for medical students who are interested in primary care careers.

I hope that life in Minnesota has been treating you well! So far I have been enjoying the second year of medical school at NYU. The classes have been much more interesting than last year’s, and while I still have a long way to go, I’m slowly beginning to believe that I might someday know enough to take care of patients.

Last month we had a speaker come to talk about rotations and residencies in Family Medicine, and that made me wonder how you were doing. Is this the first or second year of residency? How do you like it? How many years are left to go? Where (geographically and what kind of community) do you plan on practicing after it’s over?

Since I haven’t even started my clerkships, I don’t really know which field interests me most, but since NYU doesn’t have a Department of Family Medicine, I thought it might be a good idea to gather information from outside sources that I know I can trust. I’ve spent several summers working with children, so the natural choice would seem to be pediatrics, but I would love to hear your perspectives on taking care of families while raising one of your own.

Have a wonderful holiday season, and best wishes to you and the kids.

Is climate change a clinical health issue?

At first glance, the topic of the cover article of American Family Physician's August 1st issue, "Slowing Global Warming: Benefits for Patients and the Planet," might seem out of place in a journal that aims to provide practical clinical guidance for family physicians. Past summer-themed articles have included reviews of heat-related illness, medical advice for commercial air travelers, and even health issues for surfers. By recognizing climate change as a clinical health issue, AFP joins other widely read medical journals such as The Lancet and BMJ in recognizing the essential role that physicians can play in mitigating the negative impacts of environmental stress on patients' health.

After summarizing the serious potential health effects of climate change, Dr. Cindy Parker recommends that primary care clinicians counsel patients regarding two lifestyle changes that are likely to improve personal health as well as slow global warming: reducing meat consumption and increasing "active transportation" (substituting bicycling or walking for short car trips). In addition, physician practices and larger medical organizations can positively affect climate change by "going green":



Medical offices and hospitals can help by recycling; using recycled items and Energy Star certified appliances and computers; minimizing waste and waste transport by replacing single-use items with sterilizable or washable items; purchasing wind-generated electricity; and reducing energy use by turning off appliances, computers, and lights when not in use. In 2008, the U.S. health care sector spent $8.8 billion on energy to meet patient needs, not including the transportation of employees or patients to and from health care facilities, resulting in 8 percent of all U.S. greenhouse gas emissions.

In an accompanying editorial, Dr. Robert Gould reviews several national and international initiatives that encourage hospitals and health systems to reduce greenhouse gas emissions, including the Healthier Hospitals Initiative and Health Care Without Harm.

Optimal Spacing for Study, What's this?

We have all been told by teachers that learning occurs best when we spread it out over time, rather than trying to cram everything into our memory banks at one time. But what is the optimal spacing? There is no general consensus.

However we do know that immediately after a learning experience the memory of the event is extremely volatile and easily lost. It's like looking up a number in the phone book: if you think about something else at the same time you may have to look the number up again before you can dial it. School settings commonly create this problem. One learning object may be immediately followed by another, and the succession of such new information tends to erase the memory of the preceding ones.

Memory researchers have known for a long time that repeated retrieval enhances long-term retention. This happens because each time we retrieve a memory, it has to be reconsolidated and each such reconsolidation strengthens the memory. Though optimal spacing intervals have not been identified, research confirms the importance of spaced retrieval. No doubt, the nature of the information, the effectiveness of initial encoding, competing experiences, and individual variability affect the optimal interval for spaced learning.

One study revealed that repeated retrieval of learned information (100 Swahili–English word pairs) with long intervals produced a 200% improvement in long-term retention relative to repeated retrieval with no spacing between tests. Investigators compared different-length intervals of 15, 30, or 90 minute spacing that expanded (for example, 15-30-45 min), stayed the same (30-30-30 min) or contracted (45-30-15 min) revealed that no one relative spacing interval pattern was superior to any other.

Another study has revealed that the optimally efficient gap between study sessions depends on when the information will be tested in the future. A very comprehensive study of this matter in 1,350 individuals involved teaching them a set of facts and then testing them for long-term retention after 3.5 months. A final test was given at a further delay of up to one year. At any test delay, increasing the inter-study gap between the first learning and a study of that material at first increased and then gradually reduced final test performance. Expressed as a ratio, the optimal gap equaled 10-20% of the test delay. That is, for example, a one-day gap was best for a test to be given seven days later, while a 21-day gap was best for a test 70 days later. Few of any teachers or students know this, and their study times are rarely scheduled in any systematic way, typically being driven by test schedules for other subjects, convenience, or even the teacher's whim.

The bottom line: the optimal time to review a newly learned experience is just before you are about to forget it. Obviously, we usually don't know when this occurs, but in general the vast bulk of forgetting occurs within the first day after learning. As a rule of thumb, you can suspect that a few repetitions early on should be helpful in fully encoding the information and initiating a robust consolidation process. So, for example, after each class a student should quickly remind herself what was just learned—then that evening do another quick review. Before the next class on that subject, the student should review again. Teachers help this process by linking the next lesson to the preceding one.

Certain practices will reduce the amount of time needed for study and the degree of long-term memory formation. These include:

• Don't procrastinate. Do it now!

• Organize the information in ways that make sense (outlines, concept maps)

• Identify what needs to be memorized and what does not.

• Focus. Do not multi-task. No music, cell phones, TV or radio, or distractions of any kind.

• Association the new with things you already know.

• Associate words with mental images and link images to locations, or in story chains

• Think hard about the information, in different contexts

• Study small chunks of material, in short intervals. Then take a mental break.

• Say out loud what you are trying to remember.

• Practice soon after learning and frequently thereafter at spaced intervals.

• Explain what you are learning to somebody else. Work with study groups later.

• Self-test. Don't just "look over" the material. Truly engage with it.

• Never, never, ever CRAM!

The vital role of guideline narratives

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of "saved lives." I answered that evidence-based medicine's supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result - and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF's recent prostate cancer guideline, "Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening" in order to convince physicians and patients that it's okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients' stories, but the story of the guideline developers themselves:

Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force's conclusions.

Guideline developers could include as part of their reports the narrative of their internal workings: We started with what we knew, we looked at the evidence, we revisited our hypotheses, we argued about the findings, and ultimately we acted here and now because it was prudent, but there are more data to come, and here is what we plan to do as we learn more. Such stories could increase trust and therefore improve the translation of evidence for individual use and public policies.

I attended both of the Task Force's 2008 meetings when screening mammography was debated, and the difference between them spoke volumes. During the first meeting, the panel deadlocked multiple times over whether to recommend for ("B") or recommend against routinely ("C") mammograms for women in their 40s. Both sides made impassioned arguments in favor of their points of view, and after running hours beyond the time allotted for discussion, they finally admitted that they were unable to reach a consensus. In contrast, at the second meeting when the results of a new decision analysis were presented, there was - to everyone's great relief - near-unanimity that the benefits and harms of screening were closely balanced in this age group. (Incidentally, the Canadian Task Force on Preventive Health Care recently concurred with the USPSTF's 2009 recommendations.)

Given the potential for narratives to humanize guidelines for the public, it was disappointing that the USPSTF's first Report to Congress offered a thoroughly sanitized description of the lengthy and challenging process by which it identified and prioritized research gaps in clinical preventive services. This process, which I participated in as a medical officer, consisted of a series of spirited debates over more than two years about thorny questions such as: 1) Is there an objective, defensible way to prioritize certain preventive services more than others? 2) Is it more important to support research on services with insufficient evidence that are already in widespread practice (e.g., PSA tests), or less commonly provided services with potentially large benefits (e.g., CT scans for lung cancer)? Unfortunately, the Report doesn't even begin to hint at how we grappled with these and other contentious issues, much less the multiple impasses that were reached and eventually overcome.

Consequently, I couldn't agree more with the elegantly stated conclusion of JAMA commentators Drs. Zachary Meisel and Jason Karlawish:

Stories help the public make sense of population-based evidence. Guideline developers and regulatory scientists must recognize, adapt, and deploy narrative to explain the science of guidelines to patients and families, health care professionals, and policy makers to promote their optimal understanding, uptake, and use.

Excuse-making by School Children

My last column on "Blaming the Victim" was a departure from my usual emphasis on improving learning and memory. But it did set the stage for this current post on the crippling effect of allowing children to make excuses for underperformance in school.

Most of us know how common it is for kids to make excuses ("the dog ate my homework" syndrome). When we adults were young, we also probably made excuses, blaming the textbook, the teacher, the school, and whatever else could serve to avoid facing the real causes of the problems.

Why do kids do that? The main reason is their fragile egos. Confronting personal weakness is especially hard for kids when they are embedded in an adult culture that inevitably reminds them that they are relatively powerless kids.

I remember a recent dinner-table conversation with my competitive 6th grade granddaughter, who was complaining about a test in which some of the questions were not aligned well with the instruction, which itself was deemed confusing. I said, "I understand that others did do better than you on the test. Wasn't everybody facing the same handicap?" No answer. Then I added, "It doesn't matter who the teacher is or what instruction you get. If you are not first in the class, it is your fault." Again, no response.

One approach that parents and teachers use is to bolster children's egos by praising them richly and often. Too much of a good thing is a bad thing. Too much praise makes kids narcissistic. Anybody who is not aware of the raging narcissism in today's youngsters must not be around young people very much. The most obvious sign is the compulsive checking of e-mail and texting, all in an effort by a child to be at the center of attention.

I and other professors notice narcissism in college students. In a selective college, most students think they are "A" students, and because of low standards in secondary school and grade inflation they are actually told they are A students. If they don't make As in college, it is somebody else's fault (usually the professor).

Scholars are beginning to address this growing narcissism. Eddie Brummelman at the University of Amsterdam in the Netherlands and his colleagues studied 565 children between the ages of 7 to 12. They picked this age group because most other such studies have been in adults, and they believed that early adolescence is when children develop narcissistic traits such as selfishness, self-centeredness and vanity.

Over 18 months, the children and their parents were given several detailed questionnaires that were designed to measure narcissistic traits and parental behavior. There was a small but significant link at each stage between how much parents praised their children and how narcissistic the children were six months later. Because the effect was only small, it suggests that other things also make people selfish and self-centered. I suspect the effect is larger in the U.S.

Maybe school culture is part of the problem. As in Lake Woebegon, "all kids are above average." For brighter students, the instructional rigor is so low that these kids get a false sense of how smart they are and how easy it is to be an "A" student.

I suspect that another factor is that students are not taught enough about how to be realistically self-aware. They may not even know when they are making excuses unless adults call them on it. Too often, parents side with the student in criticizing a teacher when the real problem is with the child.

Some of the blame shifting comes from biology. It is in human nature to claim ownership of things we do that turn out well, but disown actions that yield negative consequences. Experiments support this conclusion. The most recent experiments had a primary focus on our sense of time in association with voluntary actions. The experimental design was based on prior evidence that the perceived estimate of time lag between when we do something and when we think we did it is an implicit index of our sense of ownership. Investigators asked people to press a key, which was followed a quarter of a second later by negative sounds of fear or disgust, positive sounds of achievement or amusement, or neutral sounds. The subjects were then asked to estimate when they had made the action and when they heard the sound. Timing estimation errors were easily measured by computer. Subjects sensed a longer time lag between their actions and the consequences when the outcome (the sound) was negative than when it was positive.

Teaching Kids to Deal with Failure

There is a common denominator to most self-limiting styles of living. It is a fear of failure. Children express this fear by making excuses, which has the unintended effect of blocking the path to success. Excuses may provide immediate relief of anxiety, but it creates a self-limiting learning style that assures continued underachievement.

Whatever one’s station in life, one axiom is paramount: for things to get better for you, you have to get better. This point is well illustrated in an inspiring rags-to-riches success book by A. J. Williams. He points out that a main reason that people do not make the changes they need to is that they are afraid of failure. But, paradoxically, learning from failure is how many people turn their lives around and become happier. Children, I have noticed, are highly resistant to personal change, maybe more so than adults. I am dismayed at how often I show children how to memorize more effectively and they just can't bring themselves to study in a different way. It is as if they don't believe me enough to even try new approaches. Or maybe they have convinced themselves they are mediocre and need the shield of excuses to keep others from detecting their weaknesses.

Louis Armstrong, the famous trumpeter, told an instructive story about fear when he was a boy. One day when his mother asked him to go down to the levee to fetch a pail of drinking water, he came back home with an empty pail. Upon noticing the empty pail, his mother said, “I told you to bring back a pail of water for us to drink. How come your pail is empty?” Louis replied, “There’s an alligator there, and I was scared to death.” His mother then said, “You shouldn’t be afraid. That gator is as afraid of you as you are of him.” To which Louis answered, “If that’s the case, then that water ain’t fit to drink.”

If there is an alligator keeping you away from what you need to do, have faith you will prevail over your demons. But as long as a child lets fear get in the way, her pail will stay empty.

Other kinds of fear are also self-limiting. Many children fear commitment to learning. Commitment exacts an emotional price requiring dedication, passion, and self-discipline. Children fear confusion and difficulty. They fear disapproval.

Kids need to put their under-performance in perspective. Failure and under-achievement are not permanent. They are not pervasive reflections of inadequacy. Children can acquire learning skills that lead to success. Unfortunately, schools don't teach much about learning skills, being focused on teaching to high-stakes tests.

Kids need to recognize their weakness and strive to fix them. But to bolster their motivation and general attitude about school, they need to recognize what they have done well and strive to do even more of that. Dwelling on under-performance is counter-productive.

The Most Important Thing Kids Need to Learn

Excuse-making prevents a child from developing the attitude that will best serve them throughout life: a sense of personal efficacy, a state of perceived control over one's life. I explain this more thoroughly in my book, "Blame Game, How to Win It." But a summary here will have to suffice.

How children perceive their personal power determines how much effort they will expend to control their lives. If they lack a genuine sense of power, excuse-making applies salve to their wounded egos. Self-efficacy is not the same as self-esteem. Psychologist, Albert Bandura, puts it this way: “Perceived self-efficacy is concerned with judgments of personal capability, whereas self-esteem is concerned with judgments of self-worth.” Both are important for happiness, but it is perceived self-efficacy that drives academic achievement. One practical application where this distinction is apparently not recognized is with school teachers who think the cure for low achievement in school is to foster self-esteem. Teachers should emphasize self-efficacy. Children learn self-efficacy from teachers and parents who enable them to master their environment. Students who are filled with self-doubt do not put much effort into school work. They make excuses. As kids are progressively given the skills to achieve, they develop a sense of confidence in their ability to succeed, which will motivate them to strive for more achievement. When I was a kid, I only became a good student when I discovered, more or less by accident, that I could make good grades. Discovering that I could make good grades if I tried motivated me to do just that. This sense has to be earned. It does not come from excuses.

Physical exercise to improve memory

A great way to improve memory is a physical exercise. It is an exceptional way to increase memory.  Exercises can reverse changes in the brain that cause cognitive decline.

Exercise increases blood flow and oxygen to the brain and stimulates nervous system. This releases endorphins onto the blood stream that creates that overall feeling of well-being.

Exercise can help us to get back our memory where it should be. We can take a walk and free ourself from any frustration that we may be experiencing.

By increasing the supply of oxygen to the brain, exercise helps reducing risk for disease and disorders that eventually lead to memory loss.

According to studies, high levels of physical activity could be more protective against cognitive decline than lower levels (Scarmeas, Luchsinger & Schupf, 2009; Taaffe 2008; Weuve, 2004).

When we’re not exercising, our brain is not receiving much blood. Blood needs to flow to the brain so we can think straight.  We have to move around and not be stagnant. Researchers from the Netherlands’ found that physical fitness could improve memory by boosting blood flow to the rain and increasing brain volume.
Physical exercise to improve memory

Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of American Family Physician, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane systematic review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care.

Counterintuitive answers on quality inducements and persistent satisfaction

They've been repeated so often that many health care quality gurus take them for granted: 1) paying physicians for performance will improve quality of care; 2) increasing patient satisfaction will reduce care costs and improve outcomes.

Not necessarily, two recent studies suggest.

A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of American Family Physician concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes commentator Elizabeth Salisbury-Afshar, MD, MPH, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.

In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:

Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.

How much does it cost to have an appendectomy?

A few years ago, a good friend of mine who holds bachelor's and law degrees from Ivy League schools lost his job and became one of the estimated 50 million medically uninsured persons in the U.S. Over the course of several days, he developed increasingly severe abdominal pain, fever, and vomiting. Though reluctant to seek medical attention, he finally was persuaded to visit his local hospital's emergency department, where he was diagnosed with acute appendicitis. Despite his critical condition and the need for immediate surgery, he refused treatment until the hospital's billing department gave him an estimate of how much an emergency appendectomy would cost. Then, as he was being prepared for the operating room, he somehow managed to bargain with the surgeon to reduce his customary fees.

Sharing this harrowing story weeks later, my friend, until then a strong believer in the power of the market to control rising health care costs, was justifiably proud that his negotiating skills had prevented the hospital bill from completely depleting his savings. On the other hand, he recognized the insanity inherent in trying to practice "consumer driven health care" during a medical emergency, especially given the lack of information about the pricing of health care services. I've written before about how difficult it was for my wife and I to estimate how much it would cost to have a baby (our son, incidentally, is now two months old and doing well). It turns out that variations in pricing for the diagnosis and treatment of acute appendicitis are even larger and less explicable.

A study published yesterday in the Archives of Internal Medicine reported that the hospital charges for patients hospitalized in California for acute uncomplicated appendicitis ranged from $1529 to $182,955, with a median charge of $33,611. Patient age, insurance type, and geographical location explained only about 2/3rds of the observed variations. My friend's experience in a different state confirmed what the authors of this study observed:

A patient with severe abdominal pain is in a poor position to determine whether his or her physician is ordering the appropriate blood work, imaging, or surgical procedure. Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made. In our study, even if patients did have the luxury of time and clinical knowledge to "shop around," we found that California hospitals charge patients inconsistently for what should be similar services as defined by our relatively strict definition of uncomplicated appendicitis.

Given better transparency about pricing, perhaps there is a role for comparison shopping for predictable health care expenses, such as elective surgery or labor and delivery. But huge variations in pricing for emergency care illustrate how badly the consumer health care model fails. There are many flaws in the Affordable Care Act that Congress passed in 2010, but extending insurance to millions of currently uninsured Americans is not one of them. As this example shows, it is our country's broken health system, not the health law, that requires urgent repeal and replacement.

How much does it cost to have a baby?

When my wife delivered our second child in 2008, the hospital sent our health insurance company a bill for $8569. The insurance company then wrote off $4117 of that bill, paid $4352, asked us for a copayment of $100. When we found out last year that we were expecting again, we noted that my wife's new insurance plan requires us to pay 20% coinsurance for all non-preventive care. That would have amounted to several hundred dollars of our 2008 bill, and knowing the rapid rate of health care inflation, we thought it would be good to find out how much it would cost this time around. So we went back to the same hospital, where we expect our third child to be born in a few weeks, and asked if they could give us an estimate of the charges. It seemed like a reasonable enough request, especially since the pre-admission consent form we signed specifically said that patients had a right to know what the hospital charged for its services.

We're just looking for a ballpark number for our flexible savings account, we said. The charge for an uneventful labor, vaginal delivery and single overnight stay. We understand that unexpected things can happen in childbirth, and we won't hold you to it.

The hospital representative we spoke with clearly wanted to be helpful. She called the billing office, the labor and delivery floor, every place in the hospital she could think of that might have that information. But in the end, no one could give us an answer to a seemingly simple question: how much does it cost to have a baby at your hospital?

And the truth is, even if they had, we would have had no way of knowing how much our insurance company would have actually paid. Hospitals routinely inflate their listed charges, knowing full well that insurers will want to negotiate deep discounts. The only people who actually pay the listed hospital charges - analogous to the sticker price on a new car - are uninsured patients who aren't poor enough to qualify for free or discounted care.

The whole idea of "consumer directed health care" is that patients who anticipate medical expenses in advance  can shop around to get the best prices. We had nearly nine months to get ready for having a baby, and that should have been plenty of time. But consumer directed health care doesn't work when no one can tell you the price. A federal report issued last October confirmed what most doctors have known all along: most medical practices and hospitals either can't, or won't, provide estimates about the costs of commonly provided services such as diabetes screenings and knee replacements. Several years ago, health economist and Princeton professor Uwe Reinhardt called the pricing of hospital services in the U.S. "chaos behind a veil of secrecy," and things haven't gotten any better since the passage of health reform.

In the end, my wife and I were forced to make an educated guess about how much money to put away for her labor and delivery. We're both family doctors, by the way, and between the two of us have personally delivered hundreds of babies. And if we can't figure out how much it costs to have a baby, good luck to all of the other women who will be giving birth in the U.S. this year.

Decision making :one of multiple category options

In the previous post, Decision-making learning from one’s mistakes., I provided evidence that selective attention to items that were retrieved into working memory were a major factor in making good decisions. This has generally unrecognized educational significance. Rarely is instructional material packaged with foreknowledge of how it can be optimized in terms of reducing the working memory cognitive load. New research from a cognitive neuroscience group in the U.K. is demonstrating the particular importance this has for learning how to correctly categorize new learning material. They show that learning is more effective when the instruction is optimized ("idealized" in their terminology).

Decisions often require categorizing novel stimuli, such as normal/abnormal, friend/foe, helpful/harmful, right/wrong or even assignment to one of multiple category options. Teaching students how to make correct category assignments is typically based on showing them examples for each category. Categorization issues routinely arise when learning is tested. For example, the common multiple-choice testing in schools requires that a decision be made on each potential answer as right or wrong.

In reviewing the literature on optimizing training, these investigators found reports that one approach that works is to present training in a specific order. For example, in teaching students how to classify by category, people perform better when a number of examples from one category are presented together followed by a number of contrasting examples from the other category. Other ordering manipulations are learned better if simple, unambiguous cases in either category are presented together early in training, while the harder, more confusing cases are presented afterwards. Such training strengthens the contrast between the two categories.

The British group has focused on the role of working memory in learning. Their idea is that ambiguity during learning is a problem. In real-world situations that require correct category identification, naturally occurring ambiguities make correct decisions difficult. Think of these ambiguities as cognitive "noise" that interferes with the training that is recalled into working memory. This noise clutters the encoding during learning and clutters the thinking process and impairs the rigorous thought processes that may be needed to make a correct distinction. In the real world of youngsters in school, other major cognitive noise sources are the task-irrelevant stimuli that come from multi-tasking habits so common in today's students.

The theory is that when performing a learned task, the student recalls what has been taught into working memory. Working memory has very limited capacity, so any "noise" associated with the initial learning may be incompletely encoded and the remembered noise may also complicate the thinking required to perform correctly. Thus, simplifying learning material should reduce remembered ambiguities, lower the working memory load, and enable better reasoning and test performance.

One example of optimizing learning is the study by Hornsby and Love (2014) who applied the concept to training people with no prior medical training to decide whether a given mammogram was normal or cancerous. They hypothesized that learning would be more efficient if students were trained on mammograms that were easily identified as normal or cancerous, and did not include examples where the distinction was not so obvious. The underlying premise is that decision-making involves recalling past remembered examples into working memory and accumulating the evidence for the appropriate category.  If the remembered items are noisy (i.e. ambiguous) the noise also accumulates and makes the decision more difficult. Thus, learners will have more difficulty if they are trained on examples across the whole range of possibilities from clearly evident to obscure than if they were separately trained on examples that were clearly evident as belong into one category or another.

Initially a group of learners was trained on a full-range mixture of mammograms so the images could be classified by diagnostic difficulty as easy or hard or in between. On each trial, three mammograms were shown: the left image was normal, the right was cancerous, and the middle was the test item requiring a diagnosis of whether it was normal or cancerous.

In the actual experiment, one student group was trained to classify a representative set of easy, medium, and hard images, while the other group was trained only on easy samples. During training trials, learners looked at the three mammograms, stated their diagnosis for the middle image, and were then given feedback as to whether they were right or wrong. After completing all 324 training trials, participants completed 18 test trials, which consisted of three previously unseen easy, medium and hard items from each category displayed in a random order. Test trials followed the same procedure as training trials.

When both groups were tested on samples across the range in both conditions, the optimized group was better able to distinguish normal from cancerous mammograms in both the easy and medium images. Note that the optimized group was not trained on medium images. However, no advantage was found in the case of hard test items; both groups made many errors on the hard cases, and optimized training yielded poorer results than regular training. 

We need to explain why this strategy does not seem to work on hard cases. I suspect that in easy and medium cases, not much understanding is required. It is just a matter of pattern recognition, made easier because the training was more straightforward and less ambiguous. The learner is just making casual visual associations. For hard cases, a learner must know and understand the criteria needed to make distinctions. The subtle differences go unrealized if diagnostic criteria are not made explicit in the training. In actual medical practice, many mammograms actually cannot be distinguished by visual inspection—they really are hard. Other diagnostic tests are needed.

The basic premise of such research is that learning objects or task should be pared down to the basics, eliminating extraneous and ambiguous information, which constitute “noise” that confounds the ability to make correct categorizations.

In common learning situations, a major source of noise is extraneous information, such as marginally relevant detail. Reducing this noise is achieved by focus on the underlying principle. Actually I stumbled on this basic premise of simplification over 50 years ago when I was a student trying to optimize my own learning. What I realized was the importance of homing in on the basic principle of what I was trying to learn from instructional material. If I understood a principle, I could use that understanding to think through to many of the implications and applications.

In other words, the principle is: "don't memorize any more than you have to." Use the principles as a way to figure out what was not memorized. Once core principles are understood, much of the basic information can be deduced or easily learned. This is akin to the standard practice of moving from the general to the specific. Even so, general ideas should emphasize principles.

Textbooks are sometimes quite poor in this regard. Too many texts have so much ancillary information in them that they should be thought of as reference books. That is why I have found a good market for my college-level neuroscience electronic textbook, “Core Ideas in Neuroscience,” in which each 2-3 page chapter is based entirely on each of the 75 core principles that cover the broad span of membrane biochemistry to human cognition.. A typical neuroscience textbook by other authors can run up to 1,500 pages.

Guest Post: PSA screening: does it or doesn't it?

Marya Zilberberg, MD, MPH is an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is also a Professor of Epidemiology at the University of Massachusetts, Amherst. The following post was first published on her blog, Healthcare, etc.

**

A study in the NEJM reports that after 11 years of follow up in a very large cohort of men randomized either to PSA screening every 4 years (~73,000 subjects) or to no screening (~89,000 subjects) there was both a reduction in death and no mortality advantage. How confusing can things get? Here is a screenshot of the headlines about it from Google News:

How can the same test cut prostate cancer deaths and at the same time not save lives? This is counter-intuitive. Yet I hope that a regular reader of this blog is not surprised at all. For the rest of you, here is a clue to the answer: competing risks.

What's competing risks? It is a mental model of life and death that states that there are multiple causes competing to claim your life. If you are an obese smoker, you may die of a heart attack or diabetes complications or a cancer, or something altogether different. So, if I put you on a statin and get you to lose weight, but you continue to smoke, I may save you from dying from a heart attack, but not from cancer. One major feature of the competing risks model that confounds the public and students of epidemiology alike is that these risks can actually add up to over 100% for an individual. How is this possible? Well, the person I describe may have (and I am pulling these numbers out of thin air) a 50% risk of dying from a heart attack, 30% from lung cancer, 20% from head and neck cancer, and 30% from complications of diabetes. This adds up to 130%; how can this be? In an imaginary world of risk prediction anything is possible. The point is that he will likely die of one thing, and that is his 100% cause of death.

Before I get to translating this to the PSA data, I want to say that I find the second paragraph in the Results section quite problematic. It tells me how many of the PSA tests were positive, how many screenings on average each man underwent, what percentage of those with a positive test underwent a biopsy, and how many of those biopsies turned up cancer. What I cannot tell from this is precisely how many of the men had a false positive test and still had to undergo a biopsy -- the denominators in this paragraph shape-shift from tests to men. The best I can do is estimate: 136,689 screening tests, of which 16.6% (15,856) were positive. Dividing this by 2.27 average tests per subject yields 6,985 men with a positive PSA screen, of whom 6,963 had a biopsy-proven prostate cancer. And here is what's most unsettling: at the cut-off for PSA level of 4.0 or higher, the specificity of this test for cancer is only 60-70%. What this means is that at this cut-off value, a positive PSA would be a false positive (positive test in the absence of disease) 30-40% of the time. But if my calculations are anywhere in the ballpark of correct, the false positive rate in this trial was only 0.3%. This makes me think that either I am reading this paragraph incorrectly, or there is some mistake. I am especially concerned since the PSA cut-off used in the current study was 3.0, which would result in a rise in the sensitivity with a concurrent decrease in specificity and therefore even more false positives. So this is indeed bothersome, but I am willing to write it off to poor reporting of the data.

Let's get to mortality. The authors state that the death rates from prostate cancer were 0.39 in the screening group and 0.50 in the control group per 1,000 patient-years. Recall from my meat post that patient-years are roughly a product of the number of subjects observed by the number of years of observation. So, again, to put the numbers in perspective, the absolute risk reduction here for an individual over 10 years is from 0.5% to 0.39%, again microscopic. Nevertheless, the relative risk reduction was a significant 21%. But of course we are only talking about deaths from prostate cancer, not from all other competitors. And this is the crux of the matter: a man in the screening group was just as likely to die as a similar man in the non-screening group, only causes other than prostate cancer were more likely to claim his life.

The authors go through the motions of calculating the number needed to invite for screening (NNI) in order to avoid a single prostate cancer death, and it turns out to be 1,055. But really this number is only meaningful if we decide to get into death design in a something like "I don't want to die of this, but that other cause is OK" kind of a choice. And although I don't doubt that there may be takers for such a plan, I am pretty sure that my tax dollars should not pay for it. And thus I cast my vote for "doesn't."

Job Posting: Primary Care Health Policy Fellow

The Department of Family Medicine at Georgetown University School of Medicine is currently seeking qualified applicants for its one-year fellowship in Primary Care Health Policy. This is a unique, full-time program that combines experiences in scholarly research, faculty development, and clinical practice. Fellows have the opportunity to interact with local and federal policymakers in Washington, D.C. and pursue original research projects with experienced mentors at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. They will join a dynamic group of faculty (including me) at one of the flagship departments for urban family medicine on the East Coast. Past Health Policy Fellows have gone on to hold leadership positions in federal health agencies, community health organizations, and academia. Applicants should be graduates of an accredited residency program in family medicine or expect to graduate in 2012. Please e-mail me at KWL4@georgetown.edu for additional information.

5 quick ways to lose weight 5 pounds in 2 weeks

Excess weight is indeed requires every woman to go on a diet. Who doesn't like her body svelte and beautiful commended? But running a diet isn't as easy as spoken, you need a strong commitment to lose weight.

If you want to successfully run the diet soon and want to lose weight, then the diet tips are excerpted from this lolwot.com might be able to try right now.

1. Never eat junk food

The kind of food that enters the category of junk food such as all fried foods like fried foods, fried chicken, French fries and more. Avoid junk food also is low or even no nutrients such as crackers, chips and other processed fresh bread or biscuits. Replace your meals with a fresh as a salad and steamed or boiled foods only.

2. Drink lots of water

The most powerful diet way to lose weight fast is to drink plenty of water. Make it a habit to drink water before and after eating, before going to bed and to wherever you go. Drinking water will keep the stomach full, preventing dehydration, makes the brain more focus, helping the body's metabolism and burn calories better.

3. Burn more calories

Pay attention to your calorie intake each day. Do not let you eat more calories than the calories can you burn per day. To limit your calorie intake, reduce portions to eat and replace with a vegetable or fruit alone as well as to avoid dinner. To burn more calories, balance with sports such as cycling, running, swimming or aerobics every day for approximately 1 hour.

4. Replace a carbohydrate with protein and fiber

Don't eat too many carbohydrates like rice and bread. If you want to eat the bread, substitute with whole wheat bread, if you want to eat rice, replace white rice with brown rice. But it would be better if reducing your intake of carbs and eating more protein and vegetables, such as fruit, eggs, fish and meat without fat.

5. Sleep

Pay attention to Your night's rest time. Sleep will make you lose weight faster. Be sure to sleep 8 hours per day as this will help the body process the calories and the body's metabolism is better.

Follow the 5 points only, and apply every day. If you can stand the live fifth points above, diet no longer a hard thing to do.