- On a scale of 0-10, 10 being physically, mentally, emotionally, spiritually, and relationally ideal, how to you rate your overall sense of health and well-being right now?
- How satisfied are you with how you feel in this regard?
- If you’re not that satisfied enough, what would make it better?
- How can my team and I help?
I asked these questions recently on my patient’s executive physical summary. It was a more direct, concrete, and global query than I usually make, and better, I think.
When I think about the ultimate collective goal of medicine, maybe it’s preventing death–at least the premature, preventable kind? Just think of the time, energy and resources we Americans spend on anti-aging this, longevity that, etc. About a quarter of Medicare spending occurs in patients’ last year of life. We spend more money on healthcare, for much worse outcomes across multiple health metrics (including life expectancy), compared to other developed countries.
But isn’t death/longevity the ultimate lagging indicator? If my current patients live to be 80 or older, I will not know most of them at the ends of their lives–I’ll be long retired. How will I know if I helped them live longer or better? What metrics can I use in the meantime to know if I’m making a difference (of note, medical care of any kind appears to contribute only about 10-20% to overall health outcomes in the United States–the rest being determined by genetics, behaviors, and socioeconomic and environmental factors)?
We measure all kinds of things in the clinic: Weight/BMI, blood pressure, cholesterol, and blood sugar, among others. But other than weight, none of these metrics are sense-able in real time, unless they are extreme. They are markers of risk–correlates–and important to monitor. Taken together, they can indicate an individual’s risk for illness or even mortality. But they can never predict any given person’s ultimate health outcomes. They are incomplete markers. Other correlates such as loneliness and stress are just as important, and much harder to measure, so we generally leave them out of the overt risk assessment.
Too often, the metrics become the goals themselves. Look no further than the myriad wearable devices available today to track sleep. With little to no evidence as to accuracy, precision, or relevance of the ‘data’ collected, consumers fixate, spending precious psychological capital, on colorful graphs and numbers of their nightly sleep metrics. They compare results at the gym, evaluating and judging, thinking and worrying, even catastrophizing, about dementia or other decline because their sleep scores are less than ideal. Is this really better than simply attuning to one’s own body and mind? I think we can all estimate with adequate accuracy the overall quality and quantity of our sleep, and what affects it.
So what better metrics can we use to assess health and well-being in real time? Ideally, these would be sense-able markers, unique to each person, and also actionable in real time. I think we do this in many ways already–we attune, sense, and respond to body cues, and many patterns become routine, often mindlessly: We feel fatigued so we caffeinate. We feel anxious so we imbibe. We feel stressed so we eat, withdraw, or lash out.
Real time and sense-able markers of health and well-being include hunger, satiety, mobility, ease of motion, strength, pain, endurance, energy, joy, tension, curiosity, mood, confidence, ability to accomplish goals, and feelings of connection. But how often do we actually stop and sense these aspects of body, mind, and community? How might my advice about blood pressure, cholesterol, and glucose management change, if I asked you more relevant questions about how you feel in your body, mind, and spirit, at various times of day, and in various environments and contexts? How might this modify your openness to, engagement with, and ability to execute said advice?
My job as primary care physician is to help you be as informed and intentional as possible about relationships between your senses, health metrics, their risk correlates, and potential outcomes. It’s up to you to decide, in any given moment, what’s worth attending to, trading off and not, for which values and goals you prioritize. What are your ultimate health goals? What, if you have a moment to reflect at the end of your life, will give you peace? How can you attune and act today and hereafter, to make that scenario more likely?
I wrote to another patient recently, who expressed disgust at himself for regaining weight he had lost during the height of the pandemic, feeling alarmed at watching his ‘numbers go in the wrong direction’:
“My highest goals for you this year are to redirect your focus away from numbers (cholesterol, weight) and more toward tuning in to your body and mind. I would love for you to come back next year and tell us about your unique signs of hunger, satiety, loneliness, sleep deprivation, and relationship rupture, and how you discovered to address them! I think I want this for myself, too!”
When reporters ask healthy old folks how they stay well, they never talk about blood pressure, cholesterol, or blood sugar. They talk about finding fun ways to move their bodies, enjoying and moderating food, learning new hobbies, and staying connected to their loved ones. Medical metrics have their place; I think it’s in the back of the health awareness and action bus.
And no matter the length of your life, I want to help you make it the highest quality, every day you get to live it.
Cathy, somehow I missed this post in my inbox when you first posted it. I’m glad I found it this morning. You gave me lots to think about. I wish I had a doctor who asked these sorts of questions—of herself and of her patients. (Actually, I did, but she retired during the pandemic—I miss her!) Of course, I don’t know what my current doctor ponders when she thinks about her patients or her purpose, but I haven’t yet gotten the impression that she is reflecting on these things or connecting with her patients beyond a surface level. As for the questions you posed at the beginning of the post, I wonder if it might be more revealing if you asked the patient to think about their overall sense of health and well-being over the last week or even month.
Asking “right now” may not be an accurate picture—they may be in an especially good mood because the day has gone well and they were happy with their weight on your scale. Or they may be stressed and grumpy because they couldn’t find a parking space or had an argument with their spouse. So their answer might be weighted to the current moment, and not reflect a true picture of their overall life satisfaction. Rather than ask about one specific moment in time, I’d rather be asked about my predominant ratings in these areas over a recent period of time.
Regardless, I’d love to have a doctor who engaged with me on this level of thought and care.
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Hi Donna! Thank you so much for this thoughtful comment. I will definitely take it into account as I query patients hereafter. Most of the time I think it’s understood that we’re talking about ‘lately’, however patients choose to think of it, or I frame it in the context of recent life or world/contextual events… It’s always good to be as clear as possible, and also to consider in relative terms. How now, in the current decade of life, or in this situation, compared to the college/early career years, before this or that happened, etc.? SO many layers and turns it could all take, I LOVE it!! 😀 Thanks again!!
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