Group Therapy

Group therapy is a powerful tool. Effective group therapy provides psycho-education, gives members permission to talk about their fears, and to receive feedback and support from others who are in the same boat, so to speak!  As early as 1895, the French social psychologist, Gustav LeBon referred to the “group mind.” At about the time, William MacDougall, an Englishman, also saw that groups can affect individual behavior.

Effective group therapy takes place when an environment of trust has been established, which facilitates group members’ ability to share issues of concern in the here-and-now, and to be supported. That is, to allow people who are struggling with the same or a similar issue talk about how they manage symptoms on a day-to-day basis, about the tools they find effective in coping with such feelings (anger, guilt, helplessness, hopelessness, or other issues), and that help to improve their quality of life. The role of the therapist is to facilitate the process and to encourage members to apply lessons learned in group to everyday living.

As with any organism, the group goes through a developmental process:      

1) Form, at the beginning                                                                                

2) Storm, when members vie for power and control                                          

3) Norm, when members develop group rules or norms, leadership becomes shared by group participants, and the facilitator can assume more of a peripheral and less active role.                                                                       

4) Perform, when differentiation of members is respected, open feedback is expressed and shared, and members work together.                                      

5) Adjourn, when the group terminates.

As a prerequisite, group members are required to sign an Informed Consent for Group Therapy. While confidentiality cannot be guaranteed, it is understood that whatever happens in the group stays in the group so that participants will feel safe enough to talk about what they perceive as their most uncomfortable issues, and to respectfully challenge any therapeutic intervention that does not resonate with them. In the same way, the therapist does not take personally members’ disagreements, but welcomes questions and perspectives as valuable resources for promoting group cohesiveness and social learning.

 Seven qualities of successful group therapy have been identified (Yalom, I & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York: Basic Books):

1) Installation of hope – if group members expect help, a positive therapy outcome is more likely.

2) Universality – hearing others’ stories and sharing their own promotes group members’ understanding that they are part of a community with the same or similar issues, so that members don’t feel so alone.

3) Imparting information – the therapist gives factual information on issues of concern, and members share advice in an environment of mutual support and respect.

4) Altruism – a “must have” component: giving and receiving help is intrinsic to the healing process: people need to feel they are needed.

5) Corrective Recapitulation of Primary Family Group – the therapist and group members help participants become unstuck from early traumas, and assist them to reframe early family conflicts correctively. For example, the member is helped to process, from an adult perspective, childhood or other trauma that disrupted the developmental process, and to adaptively realign the process.

6) Development of Socializing Techniques – group members learn basic social skills, and gain an understanding of the vast difference between their intentions and their actual impact on others.

7) Imitative Behavior – group members imitate and learn from each other, identify with more senior members of the group or with the therapist, find out what they are not, and also what they are.

Participating in group therapy can appear intimidating, but the group can be a wonderful support network as well as resource for ideas for dealing with a particular life situation or challenge.

Group therapy is, indeed, a powerful healing tool which all participants can access, and influence, and in which all participants are equal stakeholders!


Written by Pansy Lindo-Moulds, LMHC

Screening for colorectal cancer

Colorectal cancer is the third most common type of cancer in the U.S. It is the second leading cause of cancer related deaths within the U.S and the world.

Colon cancer is rare before age 40 and 90% of cases occur after age 50, which is why we start recommending screening for all adults at age 50. Your doctor may recommend earlier screening if you have significant risk factors, so always review your medical and family history with your doctor.

Risks for developing colon cancer include a family history, prior colon cancer, prior colon polyps, inflammatory bowel disease (not irritable bowel disease), high fat and low fiber diet, lack of physical activity, smoking, diabetes, radiation exposure, certain genetic syndromes.

Now that you’ve been appropriately warned or perhaps worried, let’s talk about ways of detecting colorectal cancer early, when it is easiest to treat.

Fecal Occult Blood Test (FOBT)
This test requires you to collect 3 separate small poop samples at home and provide them to the lab on a card, which the lab will then test for blood. This test will not be able to see the inside of your colon or detect any polyps unless they are bleeding. Because this test detects a component of blood, you do need to avoid certain foods, such as red meat prior to collecting the samples. This routine screening test is valid for 1 year only and any findings of blood will require a colonoscopy.

A colonoscopy is a medical procedure done by a trained doctor who specializes in the colon. He inserts a colonoscope, which is a long thin tube with a camera on the end, into the rectum and through the colon to visualize the tissue of your colon. Calm down, you get some medication to help you relax for this procedure and you definitely need a chauffeur as a result. Fortunately, during this procedure, if there are any polyps or areas of concern, the gastroenterologist can remove the polyp or take a biopsy immediately. Unfortunately, in order for the gastroenterologist to have a good look around, we need to give you diarrhea the day before the procedure. While it is unlikely, colonoscopy does have the risk of perforation and bleeding (when they remove the polyp).
Interestingly, the biggest complaint I get isn’t about the procedure, or even the diarrhea – it’s that the liquid to induce diarrhea tastes pretty darn icky. Even with today’s technology, the best we can do is watered down Crystal Light apparently. Sorry. For most people, this routine screening test is valid for 10 years.

Flexible Sigmoidoscopy
A flexible sigmoidoscopy is an outpatient procedure similar to a colonoscopy that can be done by a trained doctor who doesn’t have to specialize in gastroenterology, which can increase its availability. You will still need to have bowel prep with diarrhea the day prior to get a good exam. The sigmoidoscopy does not usually use sedation and it doesn’t reach as far within the colon as the colonoscopy, which are the main differences between the two exams. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed.

Here are some possible other methods that may available, depending on your location, medical needs or the timing of your reading of this.

Double Contrast Barium Enema
A barium enema also requires the bowel prep with diarrhea. You are given a dose of barium solution rectally to outline the colon during a radiologic exam. It is less sensitive than a colonoscopy for smaller polyps and cancers. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed. We don’t usually recommend this as a routine screening for colorectal cancer.

CT Colonography
This is a CT scan that visualizes your colon in order to look for abnormal findings. A CT scan also requires the bowel prep with diarrhea, so you still haven’t found a way to avoid that portion of the pain and suffering of maintaining your health. This screening does expose you to radiation, and the accumulation of repeated radiation may increase cancer risk in the future. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed. So far studies haven’t been conclusive on whether this screening reduces the deaths from cancer, so many insurance companies will not pay for the procedure and the USPSTF does not recommend this as a routine screening for colorectal cancer.

Immunochemical-based Fecal Occult Blood Test (iFOBT or FIT)
This newer test is more expensive than the regular FOBT. This routine screening test is valid for 1 year only and any abnormal findings will require a colonoscopy. This test is not considered effective if it is completed one time only. I haven’t known our local insurers to cover this testing, so if you find out differently, let me know.

This is a poop test which can detect both blood and DNA biomarkers that have been linked with cancerous growths. It is more expensive and new to the market so not quite ready for prime time yet. Stay tuned for more information on when this one may be incorporated into the guidelines.

The incidence of colorectal cancer in Hawaii is 43-49/100,000.
This incidence of colorectal cancer death in Hawaii is 11-14/100,000.
(source: CDC)

Let’s lower these numbers!


Fluoride is a naturally occurring mineral that protects the teeth from decay. It stops the demineralization of the good enamel and helps enhance the remineralization of bad enamel on the teeth.

It seems that there is a complex relationship between systemic (body concentration) and topical (on the surface of the teeth) fluoride, as the concentration of fluoride in the enamel does not completely explain how we achieved such a marked reduction in cavities by adding fluoride to water. There seems to be at least some level of topical protection from the systemic fluoride from salivary secretion of fluoride as well. And, who’s to say that some of the topically applied fluoride doesn’t get into our system as we swallow a small amount?

Here in Hawaii, we do not add fluoride to the water. So, the fluoride needs to come from either your doctor or your dentist. According to the American Academy of Pediatric Dentistry 2014 update, there are three recommended ways to provide fluoride to your child:
1. Oral supplementation – This dose is based on the age (and on the amount of fluoride in your water) and can be combined with a multiple vitamin. I’ve been advised by several experts in the area (taste-testers under the age of 6) that the fluoride only is palatable, but the multiple vitamin combination is quite “icky.”
2. Professionally applied treatments – These are usually done by a dentist in his office every 3-6 months.
3. Fluoridated toothpaste – This is my least favorite of the options as a stand-alone source of fluoride. It is the most cumbersome for parents as it does require ensuring the correct amount of fluoride – in the toothpaste, the amount of toothpaste used, the frequency of the brushing, and avoiding rinsing after brushing. And all of these factors need to change with age.

As with everything, there is always a risk. Excessive fluoride can cause dental fluorosis, which can cause irregular coloration of the teeth. This usually presents as white lacey spots on the surface of the tooth, but a stronger form can appear as an opaque white area. A very severe, very rare form can cause some brownish discoloration or pitting of the teeth. This is why it is important to get the correct dosing; as the severe form usually occurs when the community has water fluoride levels greater than 2 mg/L (current recommendations are 0.7 mg/L).

Babies will get some fluoride via breast milk if mom is drinking fluorinated water. Bottle fed babies will get fluoride from two separate sources – a small amount from the formula and from the water used for preparing a concentrate. Most of the fluoride found in infant formula will come from the water, as the amount in the formula itself is quite small. To avoid giving the baby too much fluoride, a low-fluoride bottled water can be used to mix the formula; these are labeled as purified or demineralized and can be purchased at most stores.

I like my teeth. I like my teeth intact. I have paid extra, even when I was living on noodles and butter in medical school, just to have a cavity filled with tooth-colored filling instead of the silver. My waistline may have paid the ultimate price, but I’d be certain my smile wouldn’t.
We’ve seen more studies linking periodontal disease and systemic diseases (cardiovascular, infection, diabetic, etc). Perhaps we’ll see studies linking fluoride into the picture as our knowledge continues to grow. For now, I’ll continue to request tooth-colored fillings on the rare occasion they are needed. But I’ll do everything in my power to prevent cavities from appearing in the first place, for both me and your child.

Man vs Machine (Online symptom checker)

We as physicians and medical providers have a love-hate relationship with the internet. I do really like my patients being more informed and being able to find information regarding their diagnoses. I do however, struggle with my patients coming in and telling me they’ve been “diagnosed” with this or that ailment, which, upon closer examination, actually is a self-diagnosis, perhaps with some assistance from well-meaning friends, TV commercials or Dr. Google.

Sometimes, it may be the correct diagnosis. But sometimes, an assumption about a diagnosis may lead us as clinicians down an incorrect path as we fail to consider the actual symptoms of you – the flesh and blood patient in front of us. We can get distracted by the facts as presented in what we learn in medical school to call the “past medical history.” I’ve always worried about this as a clinician, but now a study is here to tell me whether I should continue to worry or not.

Some people smarter than I reviewed 23 different online symptom checkers diagnoses for 45 standardized written patient scenarios provided to test medical students. The symptom checkers provided the correct diagnosis in 34% of the cases (interestingly, only 24% for emergent diagnoses only). They faired better when utilizing a top 20 possible diagnosis list, scoring the correct diagnosis within the list 58% of the time.
When the symptom checker’s purpose was to triage the symptoms (advise the patient on whether they needed emergent, non-emergent or self care), they actually did a bit better. When the situation was emergent, the symptom checker was correct with triage advice (remember – not necessarily diagnosis) 80% of the time. But the accuracy dropped off with the non-emergent (55% accuracy) and self-care (33% accuracy) scenarios and some of the programs actually always advised emergent care.

Currently, medical providers’ diagnostic accuracy rate appears to be 85-90% (hey, we’re all human!). An interesting comparison would have been to have some real life medical providers review the symptoms to see how we held up. I like to think I’m better than a computer, but can I objectively prove that I can make a diagnosis equally as well?
Also, would we humans be any better without being able to lay hands on our patient and do an actual physical exam? We humans have information the computers do not – medical history, medications, qualifying factors, and the very important physical exam. This makes a difference. As does our role in medicine – I suspect an ER physician vs a primary care physician might have similar capabilities regarding triage (I hope I know when I situation is emergent!), but different results regarding correct diagnosis depending on the nature of the ailment. We have different roles in the medical field and therefore different skill sets regarding diagnosis of common day to day maladies. Please don’t expect the ER doctor to use their brain space to know how to treat run of the mill urinary incontinence, but I would absolutely anticipate he could quickly distinguish between non urgent causes and life threatening ones (spinal compression, severe infection, seizure, etc). And if you have an acute heart attack or stroke, you definitely want their skills at hand as they will be the difference between whether you hug your kids at their next birthday.

All in all, the online symptom checkers appear to be able to give you a top 20 list of possible diagnoses when you input your symptomology. If you are willing to go through the treatment for each of those possible diagnoses in succession, not worry about missed diagnosis and want to save the copay, then the symptom checkers are worthwhile.
For me, I prefer to utilize my time with patients making sure we don’t miss something severe, then focus on the most likely cause of their symptoms. After a thorough history and physical exam, as needed. Take that, Computer!

Study Source: “Evaluation of symptom checkers for self diagnosis and triage: audit study,” BMJ, June 2015

Screening for breast cancer

Breast cancer is the second most common cancer in women and the leading cause of cancer death in women in the U.S. Those are scary statistics. But you can do something about it. Breast cancer can be caught early and early detection gives you the best opportunity to have treatment that is less invasive and more effective.

Screening for breast cancer is important and you may have heard some mixed messages about it recently. It can get pretty confusing when there are differing opinions.

What we all agree on:
Mammograms save lives. A mammogram is an X-ray of your breasts and is the best way to detect breast cancer in the early stages, when it is easily treatable. These can often be found before you can feel a lump or have any other symptoms.
Getting my boobs squished sucks. Yep, no argument there. If it is severely painful, some women may benefit from topical lidocaine prior to the procedure to make it more tolerable.
Mammograms sometimes detect false positives. Sometimes, in our concern to avoid missing any potential cancerous lesion, we (meaning the computer programs and radiologist) will look at the mammogram and see an area that will look concerning on the first pass. This will result in you returning for further mammogram or ultrasound images and possibly even a biopsy to see if the area is cancerous in nature. Fortunately, often these will be totally normal tests. Unfortunately, these will result in more tests and extra worry on your part until the results come in.

What we still can’t agree on:
When to start mammograms and how often to complete them. Depending on which governing body you ask (USPSTF, NCI, ACOG, AMA, AAFP, ACS, ACR, etc), it can get overwhelmingly confusing to try to figure out when you are supposed to get a mammogram! Some say you should start at age 40, some say age 50, some say stop at age 70, some say age 75. Then they all differ on how often you should get that stressful mashing of the breasts – every year, every 2, every 3 years – what’s a woman to do!
Please talk to your doctor. He may have updated information, will be able to review your personal health risks (see some of them below), and will review the risks and benefits of completing mammography in the different time frames. You don’t have to make the decision alone.

There are some factors that increase your risk for breast cancer. A first degree relative with breast cancer and the age at which that relative was diagnosed can increase your risk, particularly if that relative had a gene that you could have inherited as well (BRCA). While only 5-6% of breast cancers are associated with this genetic mutation, BRCA testing is available if you have a relative who tested positive for this mutation. Even if your relative didn’t have a BRCA gene, it is important to let your doctor know who in your family had breast cancer and at what age.
You may also have a small increased risk of breast cancer through exposure to estrogen. This can be from birth control pills, never having been pregnant, or having your first child after age 30.

Breast thermography
Breast thermal imaging maps the surface heat of the breast using a heat sensitive camera. Unfortunately, breast thermography has not been shown to be an effective screening tool for breast cancer and should not replace mammography. Thermal imaging was first suggested as an alternative based on the observations that breast cancer patients had elevated skin temperatures over their cancers. In the original investigations, thermography was found to have a false negative rate of greater than 60% and a 2012 review showed that it missed 75% of the cancers seen on mammogram. Although the U.S. FDA did approve infrared imaging technology (based on safety data, not efficacy), it did issue a safety communication stating “the FDS is unaware of any valid scientific evidence showing that thermography, when used alone, is effective in screening for breast cancer.” The American Cancer Society recommends “thermography should not be used as a substitute for mammograms.”

Breast cancer is detectable early and treatable early. Please contact your doctor and arrange for a mammogram!

Family Medicine vs Internal Medicine

Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.
AAFP. “Family Medicine, Definition of.”

First, let’s start with what it takes to become a doctor. After completing an undergraduate degree (usually 4 years), one must go through the 4 fun years of medical school. While each school operates differently, the fundamentals are the same – learn book stuff, learn clinical stuff, see patients.

After medical school is residency (the first year of which is called internship) and this is where the training starts to really differ. Pediatrics residents focus on babies and children, surgical residents focus on surgery, ophthalmology residents focus on eyes, internal medicine residents focus on adults.

Family medicine residents focus on…everything. Family medicine residents learn adult medicine (including ICU), pediatric medicine, gynecology, obstetrics (although many if not most don’t continue to practice after residency) and psychiatric care. There is time devoted to most specialties (cardiology, dermatology, orthopedics, gastroenterology, etc) and more time is spent in an area of interest to that particular resident.

Internal medicine residents also get time devoted to specialties, but don’t have the pediatric or obstetric training that the family medicine residency requires. Internal medicine offers more options to specialize after residency – cardiology, rheumatology, pulmonology, etc. Family medicine is more limited in this manner – geriatrics, sports medicine, obstetrics.

Both family physicians and internists can provide high quality primary care. Importantly, you want a physician who will look at you as a whole person, not a disease or ailment. Remember, your goal is a long term commitment and working relationship. When you’re seeking a medical spouse, a one night stand just won’t do.

Written by M. Mitchell, M.D.

What is primary care?

Simply put, primary care is your entry into medical care. More importantly, primary care is your long term partner in maintaining your optimal health, for better or for worse, in sickness and in health, from this day forward until death do us part – indeed your medical spouse.

Primary care is care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, as well as diagnosis and treatment of acute and chronic illnesses.
Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient’s medical and health care needs – not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.

Source: American Academy of Family Physicians
Primary Care

Primary care physicians (PCPs) are here to help you in many ways. PCPs help you maintain your preventative care so that you can prevent illness or catch it early. PCPs are trained to diagnose – is that cough really something to worry about? PCPs are trained to treat illness, both long term issues like diabetes and acute issues like the flu. PCPs help you navigate the health care system if the medical care you need is beyond primary care capabilities. PCPs coordinate the care you receive from multiple providers if your condition warrants it.

And, if the system works like it should, and you have a primary care provider who knows you and sees you on a regular basis, primary care physicians have many less well-defined job descriptions. Primary care physicians can help you recognize interrelated symptoms that you wouldn’t have felt were connected. PCPs know you, your families, celebrate your successes and mourn your losses. PCPs know your history and health and can recognize more subtle changes than might have otherwise been unapparent.

Finding the right primary care physician can be as difficult as finding the right spouse (why is it so hard to find someone who cooks, cleans, does windows and is independently wealthy?), but equally as important. The right fit could be a life saver.

Written by M. Mitchell, M.D.