"Your research career should be a series of 30° turns." This is the advice that Steve Reis, MD, associate vice chancellor for clinical research and director of the Clinical and Translational Science Institute at Pitt, gave to Hilary Tindle, MD, MPH, an assistant professor in the division of General Internal Medicine and a former KL2 scholar. The advice was well received.

Dr. Tindle's two main research interests stem from her initial impetus for embarking on a research career: the desire to provoke behavior change. As a primary care physician with Kaiser Permanente in the state of Washington, Dr. Tindle worked in a high-volume clinic. Seeing so many patients every day over several years afforded her a perspective to which she had not been privy during medical training. As the same patients came into her office month after month, it became obvious that the overarching need for most of them was behavior change. Yet she found that the 20-minute appointment times were often inadequate to address this need. Intent on acquiring research skills and knowledge to design new ways of effecting behavior change broadly, Dr. Tindle entered fellowship training at Harvard and obtained an MPH. Although interested in helping people improve their health in many ways, for the purposes of her training she focused on one of the most important aspects of behavior change, tobacco cessation. After completing her fellowship, she moved to Pittsburgh to assume a faculty position and pursue this line of research.

Initially, and for her KL2 award, Dr. Tindle studied tobacco cessation using the technique of mindfulness, the practice of quiet reflection that has been shown to alleviate symptoms of many chronic health conditions. Eventually, her conceptualization of how mindfulness could alleviate cigarette craving was grander in scope than a typical intervention trial could address. She wanted to understand the physiologic mechanisms of addiction as well as the implications of tobacco cessation guidance in clinical practice. This holistic view led her in two directions: first, into functional magnetic resonance imaging (fMRI) studies with colleagues from the Center for the Neural Basis of Cognition and Carnegie Mellon University (CMU) and, second, into the health care domain where, with the support of UPMC, she developed the Tobacco Treatment Service, to help inpatient smokers at UPMC Montefiore and Presbyterian quit or cut down on smoking and control their withdrawal symptoms.

Curious and a "big picture" thinker by nature, Dr. Tindle did not stop there. As she investigated the concept of mindfulness (described in more detail at http://www.umassmed.edu/cfm/home/index.aspx), she became increasingly interested in emotions and their interplay with and effect on physical health. Around the same time, she was fortunate to have been given access to data from the Women's Health Initiative, a long-standing study funded by the National Institutes of Health and involving 160,000 postmenopausal women at 40 sites in the United States. Initially planning to study the tobacco-related variables, Dr. Tindle decided also to explore the psychological variables within the dataset as her interest in this area burgeoned. Focusing on optimism (positive future expectations), pessimism (negative future expectations), and cynical hostility (negative attitudes toward other people), she and her colleagues found that these psychological attitudes independently predicted heart disease and mortality. The findings in such a large cohort of women opened up a second, parallel, field of research that led Dr. Tindle to write a general-audience book that is entitled Up: How Positive Outlook Can Transform Our Health and Aging and will be published by Penguin in May 2013. She views this work as a novel tool of translational medicine, because it aims to encourage everyday people to "live the science" in the service of their own health and healthy aging.

Dr. Tindle's research in this area has pulled together a plethora of studies on psychological attitudes that are considered to be character or personality traits and on the impact that these traits have on health outcomes. The traits, which Dr. Tindle describes as bundled patterns of thinking, feeling, and behaving, are both inborn and developed through life experience. For the purposes of a general audience, she used the term "outlook" to describe them. "Over the course of our lives, our outlook influences key decisions about our health behaviors and relationships, and it precedes and predicts the very health risk factors that often cause our early demise and death." Many of the traits, such as hostility and anger tendencies, are visible in young children, and their presence predicts substance use and antisocial behaviors during the school years and beyond. In addition to influencing health behaviors early on, the "negative" traits are associated with worse cardiovascular health, such as the development of hypertension or metabolic syndrome in early adulthood. These associations remain even when researchers control for other factors, such as diet, exercise, and alcohol and tobacco use. Dr. Tindle's book, which includes interviews with several renowned faculty from Pitt and CMU, as well as other world experts, pieces together literature from psychology, psychiatry, epidemiology, sociology, and medicine to make the case that our outlook is integral to our optimal health and healthy aging. The extent to which people can change their outlook is a major question that requires more research—a task that Dr. Tindle says she is eager to pursue with her esteemed colleagues. Drawing on existing research and rooted in her experiences in clinical medicine, she takes the position that we have some control over our outlook, and she devotes several chapters to providing strategies for feasible outlook change, inviting readers to maximize their outlook in the service of their own health.

Managing these two streams of research, both of which are proving fruitful and attracting interest from a wide variety of parties, can be challenging. Fortunately, however, both streams have obvious next steps. Dr. Tindle is currently pursuing grant funding to implement the tobacco cessation service on UPMC's HealthTrak so that the several hundred thousand smoking patients in the UPMC system can seek and receive medical advice and support for tobacco cessation via an eVisit. If implemented and successful, this scheme has the potential to reduce the number of smokers by tens of thousands, providing significant health improvement in our communities. Her research on positive outlook and health outcomes would, ideally, be tested in a clinical trial. However, obtaining funding for this work will be challenging, as there are few examples of such trials. Ultimately, Dr. Tindle's goal is to produce robust data to help support national guidelines for clinicians on something akin to "outlook care"—providing them with a roadmap to help their patients start off with healthy attitudes in childhood and maintain these attitudes well into late life.

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