Dr. Safiya Debar: Welcome, everybody. Thank you so much for joining us.
Welcome to the Mayo Clinic Health Care webinar. My name is Dr. Safiya Debar. I'm one of the GP's on the executive health team here at Mayo and together with my colleague, Dr. Kapur, we welcome you. Thank you for taking the time to join us. And today we'll be inviting you to take a sneak peek of the world of Mayo and how we approach health and a little bit about our screening. I will be taking you on a whistle stop tour of the neuroscience and stress. We're going to be talking about how we can reframe stress and why it is integral to any health screening that we do, not just for health screening, but for us as individuals. And that by understanding basic stress, we are able to leverage our neuroscience and therefore create health, wellness and thrive. Just a few housekeeping rules. We're going to be taking questions at the end. So if anything comes up, please pop them in the comments and we'll be answering everything at the end. And can I just please remind you to make sure you're muted and that your cameras are off as well? So first, allow me to introduce you to Dr. Kapur and Dr. Sandeep Kapur, trained at Guy's and Thomas's and then underwent internal medicine training at Cleveland, Ohio. He then came back to the UK and has been at Mayo London since it started. He is an incredible physician and incredible colleague to work with and really, I think has been integral to the development of Mayo and what it is today. So it's been a great pleasure and honour to have you.
Dr. Sandeep Kapur: Thank you very much Safiya, for that very kind introduction. So I am going to give a bit of a talk about what the work that we're doing here at Mayo in London and to perhaps give you a bit of an insight into why what we do is slightly different to what else is sort of undertaken around the rest of London and throughout the UK. And so we'll go through that together. So let's begin with just a bit of an outline. So we'll talk a bit about Mayo Clinic. We'll talk about Mayo Clinic in London, we'll talk about who we are, what we do, why we do it, and then we'll take some questions. So the Mayo Clinic actually was founded by William Mayo, who opened his practice in 1864 in Minnesota. Rochester. Interestingly, William Mayo was a Brit who hailed from Salford. And to give you an idea, in 2022, Mayo had annual revenues in excess of 16 billion. It's a not for profit organisation within the US. There are three sites that we have. We have a campus in Minnesota. Rochester is about you alluded to the hospital there actually opened in 1889 and that's our largest campus and about 100 years later Mayo opened two other sites, one in Arizona and one in Florida. Again, just to give you an idea of sizes scale, our Minnesota campus has over 30 MRI scans and 40 CT scans and does approximately 1 million diagnostic images. Imaging procedures per year. And so that over the years, since 1889, as you can well imagine, that's given Mayo a vast knowledge bank of imaging data that we're able to tap into. We're able to have our images uploaded to U.S. and get second opinions from the U.S. So as with lots of other organisations, Mayo is following the needs of the patient whereby patients and or consumers are now requesting that they don't need to travel such large distances to be seen. And so as a result of that, Mayo has felt is developing its global presence and that's through a facility, as we have here in London, an outpatient clinic, but also partnering with hospitals in the Middle East and in China, and also opening regional offices where patients can be referred into the Mayo system. So that's how Mayo's evolving globally. And if we just come back down to the Mayo Clinic in London, the clinic itself opened in September 2019. We are housed in a beautiful building that dates from the late 1760s. We have three consulting floors. We have a fully kitted out diagnostic suite, and we're also fortunate that at the top of our building we have a business lounge where we can where patients can conduct business in between tests. The other point to make is that we are able to provide comprehensive assessments by also tapping into local knowledge here within our building, because the clinic as as we've opened since opening, we've certainly expanded. We've got over 40 consultants, a mixture of part time and full time colleagues that are housed within this building who we can work with in an integrated manner. But also we're fortunate that we can tap into those resources at the Mayo, where we have 4000 colleagues, where we can undertake both synchronous and asynchronous consultations. So let me tell you a bit about what actually goes on in the building with our executive Health programme, what we pride ourselves with is an unhurried consultation which allows us to provide a thoughtful, high quality delivery of patient care. And an example of this would be that when we, for example, think about performing diagnostic tests, we always have a discussion with the patient in terms of thinking about what we're doing, why we're doing it, and what we're going to do with the information, how is it going to change patients management. So in this way, patients are fully informed and fully understand the reasons why we are undertaking these diagnostic tests. So if we move on to what is health, So the W.H.O. definition is here, you can see that. But really our approach to health is that it's not necessarily defined by the doctor but by the patient. And the doctor's role is to help the patient with a particular health condition and navigate them along that particular journey. Now, I want to just introduce a concept here. We know that life expectancy is increasing. The recent data puts the global life expectancy at around 73 years, and we know that of that 64 years generally are of good health and the last decade of life tends to be of poorer health. And what with increasing life expectancy, what's happening is that those years of morbidity are becoming greater and greater, which has a cost to the patient, patient's family and a wider socioeconomic cost. And so what we really are wanting to do is want to explore that, expand the health health span so those years of healthy living and compress the morbidity years. And we can do that by thinking about delaying disease onset and reducing disease severity. So let's just explore those a bit bit further. This this graph illustrates in a slightly different way what I've just mentioned. We want to have patients going long or consumers going along the top axis where you can see the health span. Well, let's be continuing along as a straight line as far as possible and then have minimal years of morbidity. And a good example of this would be with the Queen, for example, she passed away, sadly, not too long ago at the age of 96, but two days prior to her passing away, she was actually meeting the 15th UK Prime Minister and that just shows that she was going along that life health span and had very minimal morbidity. And that's what we're trying to really achieve. So if we look at the the big, big components of that contribute to death and morbidity, the main chronic disease that we see of cancer, cerebrovascular disease, diabetes and other chronic respiratory diseases, all the chronic respiratory diseases is the only one of these chronic conditions that are actually in decline, and that's due to the reduction in smoking prevalence rates and is anticipated within the next decade to be overtaken by neurodegenerative diseases such as Alzheimer's and Parkinson's. Diabetes is also on the rise. Over the past five years, deaths from diabetes have increased by over 30% and the biggest modifiable risk factor that we do have globally is hypertension. And that accounts for why cerebrovascular disease is the top of the list. So if we look at these individually, we look at cancer, for example. This just shows a breakdown of the normal of the cancer, new cases of cancer. But if we look at the statistics overall, in 2020, there were over three, 3 million, nearly 3 million new cases of cancer in Europe and 1.3 million deaths from cancer. And this statistic hasn't really changed over the past five years. So if we think about this in terms of the journey that a patient has, we will often see the patient on this journey. Any of these following steps. So, for example, patient will initially notice symptoms and that may be, for example, blood in the sputum, it may be changing bowel habits and those symptoms will then force them to seek medical health help with the health care provider. And we also know that at the moment accessing healthcare is a problem. So we may see patients at this first stage, then If the patient has seen the health care provider it is then incumbent on their health care provider to come up with a diagnostic list of possibilities and send the patient down the correct referral pathway. And we find that in some cases patients aren't getting the correct diagnosis or not being sent down the correct pathway, and we will often step in at that point. And then the third area where we also intervene on the patient's journey is the tissue diagnosis. Tissue diagnoses have become more and more complex. It's no longer just the histopathology, it's often the immunological studies, the genetic studies. And then these are all often combined together to also be discussed. At an MDT meeting where that will further incur some delay for the patient in terms of the data that the patient's actually informed of the diagnosis. And so we will also often get requests for second opinions or tissue diagnoses. And then so for further management patients will often ask for second opinions in terms of are they on the correct treatment plan or are they being managed in the correct manner. So we have the opportunity to help patients with all of these pathways, all of these points of access in the journey. And we know that early diagnosis makes a difference. This is just some data from Cancer Research UK and you can see the big difference that occurs between early and late diagnosis across these three common cancers. I put this other bit of the slide up merely to illustrate that the big centres, the centres that are dealing with large volumes of cancer patients also build up expertise. And Mayo Clinic is no different from from those. Annually It treats over 130,000 patients with cancer. And so from there they've built up a vast knowledge base. But they also drives research. As I saw right at the beginning, Mayo spends over $1,000,000,000 a year towards research activities. Now I mentioned the concept of the unhurried consultation. What's the value of that allowing patients to talk? I want to just illustrate that with just a little snippet from a study that was done and published in the British Medical Journal a few years ago. So it looks at the concept of the spontaneous talking time. So that's the time that the patient is allowed to talk at the start of a consultation when seeing the consultant or the doctor. And so what they did, they looked at the outpatient clinic in the States and the spontaneous talking time, the time the patient was allowed to talk was 22 seconds before they were interrupted. They then did a follow up where they allowed the doctor not to interrupt the patient and just see how long the patient would actually talk for. And that's what this graph on the right illustrates. And the summary of that is that on average, patients spend just under a minute talking and over 80% of patients have completed what they want to say within 2 minutes. So what's the importance of this? Importance of this is that allows the patients to express the real reasons for attendance, and it allows the doctor to understand what their ideas, concerns and expectations are. And that in itself improves consultation efficiency. And this has been looked at, as I say, improves consultation efficiency, but it leads to greater satisfaction from patients. But it also has a cost implication as well. We know that by spending slightly more time with patients, there's a reduced tendency to prescribe. But also more interestingly, it reduces the rate of referrals as well. So that not only is it a cost saving, but it's also less anxiety provoking to the patient. So multitude of benefits with the advance of allowing the patient to be able to talk in this within this consultation model. Just moving on to the other chronic diseases that we spoke about. So diabetes, we these these figures of we're all familiar with. But probably what's the big, big underlying problem is the undiagnosed diabetics. And we know that estimates say show that 3% of the adult population in the US has pre-diabetes, probably 2.5% in the UK. And so this has a huge cost bearing. As you can see, the cost for an undiagnosed diabetic is in excess of $5,000 a year. So what can we do? We know that optimisation of glycemic control leads to fewer complications and certainly fewer and improves morbidity improves outcomes. And one of the big ways of doing this is with weight reduction. We know that just a one kilogram weight reduction will reduce someone's haemoglobin A1 C by 0.1%, so you can see if someone's had sort of the, the 7% level of HA1 C, a drop of a few kilograms is going to have a big impact on their morbidity and mortality. So how can we help our patients do that? Well, we like to use quite a bit of continuous glucose monitoring and there's good evidence that or rather I should say there's emerging evidence that it's use in pre diabetics does have favourable outcomes. And through all of these various reasons, including, you know, empowering patients have greater knowledge of what their glucose variability is, which in itself can then induce behavioural change. So that's just an example of us using real time data to improve patient outcomes. The other big chronic disease that we spoke about was hypertension. This graph just illustrates a study where civil servants were monitored for a 18 year period and their blood pressure was recorded and the various outcomes were noted. And you can see there's a linear, linear relationship. Once the pressure is above 135, the the risk of coronary or a cerebral vascular event increases in quite a substantial way. So again, addressing the patient's blood pressure is very important. And what we find with executives are that they will often present with masked hypertension. That's where clinic the pressure may be normal and the patient may say to me, well, my blood pressure is normal. Do we necessarily need to do a 24 hour blood pressure monitor? And certainly for a lot of my senior management executives, I will often say that it will be sensible to do a 24 hour blood pressure monitor so that we can truly assess what their blood pressure is during the day, what the blood pressure is at night, and also get an average blood pressure reading, which can certainly be very informative. We also use it not only to make the diagnosis, but we also use it to make sure that our patients, when they are being treated, that we have them at an adequate blood pressure, average blood pressure. And with the treatment that they're on and again, there are big cost savings to undertaking or optimising patient's blood pressure control. So all of these steps that we take are really to reduce that morbidity gap that we know that all of us will experience. And we try and do that by delaying disease onset and reducing disease severity. So I think in summary of sort of hopefully giving you a bit of a flavour as to our approach here at Mayo, we try to combine the arts of medicine where we're interacting with our patients in an unhurried way with some of the science of medicine, which is exemplified by our remote monitoring of observations of patients. Thank you.
Dr. Safiya Debar: Thank you Sandeep. I love the concept of healthspan versus lifespan. Yeah, and I think yeah, that that rang true for me. Okay. So thank you. Right. So onwards again, if you have any questions, just pop them in the in the comments and we'll come to them.
So I will be talking to you about stress management and we all know about stress. We talk about stress. I'm stressed. You know, I think you can't really engage in a conversation without the words stress or overwhelm being in it. But I guess I wanted to use this time to really be able to reframe stress and why it is so important here. Okay. So we know that a huge amount of us have felt overwhelmed or unable to cope at some at some point. Study after study and surveys continually show the massive impact that stress has sickness, absence costing the UK economy 21 million per year and poor mental health costing employee among employees costing UK employers. If you're an employer 42 billion to 45 billion each year. Okay, so just remember and these figures may be quite abstract for many of us, but it's really now bringing it into our day to day because we know that chronic stress will contribute to absolutely every system. So anxiety, depression, digestive issues, I mean, every organ system is affected. And with a lot of these things, it's important to take this abstract concept. It's like, you know, we know about cancer and we've heard from Sandeep talking about these chronic diseases, but it's only until you have personal experience or a loved one that it becomes very real for you. So looking at stress and its impact, it's it's quite an important exercise to start to look at the downstream effects of it. There's obviously and you can see it from an employer and employee and just us generally. So there's loss of income If you're an employer, there's the operational challenges that come excess administration and the most important dissatisfaction. And so here we just kind of looked at, you know, if you were to take a consultant for example, a consultant being off sick for a day, you're looking at the salary, you're looking at the operational costs, you're looking at the patient dissatisfaction with having appointments moved. So this, you know, unexpected sickness, absence for a week would be at least 10,000 in in salary alone. Plus, you have to add on these costs if you're in HR, If you're a medical director thinking about what is the actual true impact. And we're not even thinking about the extra, you know, the the frustration and the and just the disruption that that can bring and not forgetting the individual that is at the core of this who is going through this. So it's really to look at what does leadership absence mean for me as an employer, as a leader, as a member of a team, whether you are in admin or in any any operational elements or role. So we will be talking about stress. However, what is stress and I invite you for just 30 seconds. To think about what is your definition for stress? What is stress to you? The definition I use and that I find is quite non objective is that stress is a non-specific response. Non-specific because once that trigger goes, there is a beautifully orchestrated cascade that ensues. So it's non-specific. You press the button, stress happens and it's a response to a demand. The demands can be anything, stress can be happy, stress can be good for us, you stress. So this is a sense of well-being. But it can it can it can provoke a stress response or distress. And someone said, look, you stress can be getting married. You know, happy distress can also be getting married. So it's about the perception of that stress and how your body is actually handling it. And I love this this kind of diagram because this is to show us what normal I don't know if you can see my pointer, but if you can anyway what normal looks like. So if you follow a physiological response and time on the x axis, a stressor happens. So ideally we are at baseline. Okay, We're just chilling a stressor happens, we go up, we mount a stress response, so we go up in stress, it reaches its peak and then it comes back down and is meant to hit baseline again. If we complete that cycle, we go up in stress, we come back down. Then we have completed our cycle. There is no what we call allostatic load. So there is no wear and tear, there is no damage. And in fact it's probably good for us because it leads to greater resilience. It's like if you've ever failed in life and you were able to work through that cycle, then the next thing, the next similar experience, you kind of have that, Oh no, but I can do it. So this is a healthy, completed cycle. So if you can if you're not driving, hopefully you're not. But I will invite you to close your eyes because I just want to quickly talk you through your stress response. So close your eyes and imagine a threat. Okay. So I've put a picture of a tiger, but say you're chilling and this guy walks in. What happens? Well, as I said before, a non-specific cascade then ensues. Part of your brain throws like a threat. A threat signalling centre is activated your sympathetic nervous system as well as cortisol production is activated. So what happens? And we can go from top down, but our thinking has to become more negative. We need to be catastrophizing. Oh my God, I'm going to die to pay attention. We tend to start to narrow in focus. We become more judgemental, more negative, more hyper focussed and aware of what is happening. Our heart is getting ready to fight or flight, so we have an increased cardiac output, increased heart rate, increased blood pressure. We need to be we need to deliver more oxygen to the cells. So increased respiratory rate, shallow breathing, our gut, we don't need it. So it's downregulated reproductive system downregulated increase in muscular tension, our immune system. What happens to that? Well, it's got no time to fight viruses or cancer cells or anything else. It goes into an inflammation, inflammatory mode. So I like to think like our that our blood becomes stickier. We have increasing clotting factors, increase in inflammatory cytokines because if this tiger wants to take a bite, I don't want to taste very good. So all of this is happening automatically because of a threat signal. Okay. Because of a perception of of, of, of threat or real threat. Now, turns out he's a vegan so we can celebrate no threat. Now, what happens in our relaxation response if we are able to recognise that the threat has gone and if we are able to recognise our safety signals, then we enter a parasympathetic state, we enter rest, repair, feed and breathe states. So all of that cortisol, Adrenaline, noradrenaline, they all get mopped up. Our parasympathetic led by our vagus nerve gets activated so our breathing slows down, our heart rate slows down, our blood pressure normalises, we start to take bigger, more expansive breaths. We start to then connect with others. We start to go into storytelling, perhaps. Oh, my God, you know what happened to me? We became less judgemental and more open, more curious, more creative. Our digestive system starts to starts to regulate reproductive system, muscular tension goes down. So all of these things start to normalise our immune system. What happens to our immune system? Well, it now has time to clean up, to repair those inflammatory cytokines are then mopped up. So we we enter an anti inflammatory state so everything starts to normalise as we start to move our way back to that baseline. Now if we come back to this and if we're thinking about leadership teams in particular, we may be very highly functioning, but under the surface it may be a different story. So if you look at the top, that's normal. Go up and stress come down. And just remember this we are the only mammalian species that can throw off that whole stress response, that whole stress cascade with thoughts alone. So it doesn't have to be real life or death situation. So if we go to this this graph here where it says repeated hits, so you're in a highly functioning executive team or just life and you get repeated hits. So these are repeated stressors that hit if you're able to go up, down, up, down, then no problem. You're hitting your baseline. But what happens when you're just coming down from something happening at work and then you get called in and there's a disciplinary so your stress goes back up and then your pet is sick, so then your stress goes back up. Can you see where it says lack of adaptation on this? On this one that slowly, slowly, your ability to regulate and hit your baseline starts to wane. And this can result in one of two things. You can either go up in stress and then stay there. So this is where we have a prolonged response. So this is when we're hypervigilant, we're wired but tired. We're anxious. So very kind of active states or life has thrown at you so many stressors that you go into an inadequate response. This is like if someone is slapping me in the face, I will respond. I will respond. But after a while, you may just numb out. You may just show no response. And a few of my patients are like, Well, Safia, this is great. I just want to have no response when it comes to stress. It may look like that, but internally, the adrenaline is still there, the cortisol is still there, the inflammation is still there, the oxidative stress is still there. The effects on your on your blood pressure, as Sandeep says, our hypertension. Blood pressure may be fine in clinic, but it may be when we're in that meeting that our blood pressure is soaring. Right. So all of these effects are hidden. And so when we look at when I when we look at health assessment, for example, at the Mayo, I love this concept of the functional medicine tree. And don't worry about the small print, but it's really just to visually illustrate that we can go organ by organ. Okay? So you can be up there checking your heart, checking your gut, checking your hormones on a very surface level right at the top of the tree. But organ by organ is not going to give you a true picture of your health. And actually, it's starting at the roots at the trunk of the tree, your foundations, which will then lead up into everything else. So at Mayo, we don't look at organ by organ. We look at the whole system and stress is integral. Why? Because depending on where I am operating from, am I operating from a threat state? Right. So this is our limbic system, the amygdala, or am I operating from a relaxed state that will determine my heart rate, my blood pressure, my gut motility, I mean everything. So if if I'm being strategic, I would look at my branch, not my branches, at my roots first, because that will then lead me to a stronger foundation which will then bear fruit as opposed to going upstream and saying, Oh yeah, my blood pressure's high, I need to take pills. But if you're not addressing the root cause, then, then where? Where's the use? So how do we assess? Well, like any other health assessment we have, and I love the concept of the unhurried consultation. We take our time, we take a full history examination. So we do the typical physicals, the differences. I want to know everything. I want to know about the the the roots. I want to know about the trunk. I want to know about everything. So the psychological, the relational. How are you relating? Right. Because you might be high net worth in terms of your job that are you high net worth in terms of your purpose, in terms of your relationships, in terms of your downtime? It's not just about work, spiritual, and this is not necessarily religious, but what is your view of life like. What do you believe? What is your kind of dimension and what I like to call the joie de vivre, like, you know, the the kind of the extra so we have physiological indices that can start to tell us what is happening in stress. So high sensitivities, CRP, some of the cardiac markers, they start to give us, you know, the ambulatory blood pressure. We do lots of other things. We do pharmacologics pharmacogenomics and proactive genetics. So this is to talk to you about the trunk, but really it's about you as a system, right? When we look at our cars, we don't just want a lovely steering wheel or a seatbelt. I want I want a car that moves, that moves well, that is efficient. And if we're thinking about efficiency in your leadership teams, we're thinking about performance. And I'm thinking about a flow state. Because if they're in flow, then everybody else is more likely to be in flow. Extras that I look at is how people are breathing. Because if we have trauma or if we are in a stressed state, then we tend to hold our breath. And so and we are conditioned to suck our tummies in and that can actually affect vagal tone. And it affects your diaphragm, it affects your breath, it affects oxygenation. So how we breathe and I always want to get an idea about mindset as well. So this is all just to say that not all health screens are created equal, so go to the ones that assess you as a system. And I just thought I'd put this slide up just as a kind of peer tension. If you perceive your stress or if your stress feels unremitting and constant. Right, always think of that. Completing of the cycle. If you feel it's uncontrollable. So your locus of control, your ability to control it is not within you, but is outside and it's on you and you're unable to buffer with relaxation. So you cannot relax. Or if you're on autopilot, repeated self-destructive behaviours. If you are having problems with emotional regulation, if you started hiding from life, you know, if you're just kind of ignoring and obviously the most obvious that bring people to doctors, the physical symptoms, okay, they can all be they, they yeah they can all be manifestations and very quickly do not worry about the the small print but this is what for me was a real turning point. And this study looked at three groups of what we call relaxation response practitioners. So these are people who are meditating regularly and adopting stress management techniques. With the eye of faith you have N1 which is here, this one here, and then N2 and N3. So there were three main columns and the bigger in the bigger diagram and long story, regular stress management has significant alterations in cellular metabolism, oxidative stress and is massive and it's so easy to do was simple, simple to do. So it has a massive impact.
So in summary, we all kind of know what's good for us, but now it's about integrating and bringing that knowledge and being able to embody it. So I invite you just to think about one thing that I learned today and just an internal audit of how does my body handle stress currently? How do I how do I handle it emotionally, physically, relationally? What do I do? What do I do, what do I not do? And do you currently have any evidence of wear and tear? If so, like Sandeep said, prevention is better than cure. And so one tiny reframe that we can we can kind of implement. And that is it for my my talk. Thank you so much.