Time, Books, Bread, and Love

What is/are your love language/s?

According to Gary Chapman’s popular book The Five Love Languages, mine are, in order: quality time, words of affirmation, receiving gifts, physical touch, and acts of service. Since learning the framework, I have observed for Husband’s and Kids’ languages, and become more fluent in a few of their respective dialects. Some are easier to pick up than others! It’s humbling to think how friends and family may feel rejected by me when I respond sideways to their bids for love, because I don’t understand their intent. “Rats!” as friend Eileen would say. I can do better!

On the other hand, how wonderful when I can converse in love speech with someone in appreciation and joy? Words are definitely my currency–quality time for me means being together talking, and not just about pop culture and current events. I consider any thoughtful or personal verbal expression a gift, and especially anything via snail mail. I get positively giddy when I open the mailbox and see colored envelopes, interesting stamps, and omg stickers–it all just makes my heart sing.

Friend and fellow writer Nicole recently recommended the book Write For Your Life by Anna Quindlen. It’s a fast, easy, and heartwarming read by the veteran journalist and novelist. It validates my insatiable need to write–for myself and for sharing–and inspires me to do it with ever more abandon and joy. Quindlen reflects on the timeless relevance of Anne Frank’s diary, and our collective delight in finding old letters between lovers from the past. She wishes her parents left more words on paper, in their own hand, now that she can no longer connect with them in a tangible, tactile way. Even if you’ve never thought writing could stimulate, soothe, inspire, or connect you, this short work may convince you otherwise. Spending quality time with yourself and your thoughts, processing through pen on paper, may yield ideas, insights, and epiphanies that come no other way; and those who read them subsequently may benefit and connect to you in ways you cannot yet not imagine. So inspired was I after reading, that I bought multiple copies of WFYL and gifted them to friends. With each volume I selected a specific journal to go along. Pleather- and cloth-bound, blank, lined books invite original composition with artfully embossed covers: windblown trees; “Be the Change”; “ZEN AS F*CK”.

For my friend who took on a big new hairy leadership role, I included 6 additional works: The Art of Possibility, Benjamin and Rozamund Stone Zander; Switch, Chip and Dan Heath; Big Magic, Elizabeth Gilbert; Rising Strong, Brene Brown; Drive, Daniel Pink; and The Infinite Game, Simon Sinek. To the one who stands together with his wife at their respective professional crossroads, I accompanied Quindlen with John O’Donohue’s wisdom in To Bless the Space Between Us. His poems soothe, uplift, warm, and reassure, promoting reflection and also whispering, coaxing our own wisdom to emerge from within. Sharing others’ words, wiser and more eloquent than my own, is another way I love my friends.

When I can get the timing right, of course I also include some sourdough in the gift bag. Sven continues to thrive, leavening my loaves reliably for a over a year now. His heirloom flour descendant, whose products my gluten-intolerant friends can eat without consequence, has finally also developed that fruity aroma that I recognize as my starter. There is something special about giving and receiving gifts we make (or write) by hand, with our time, talent, and treasure. It’s just another level of love, expressed concretely and tangibly.

Nobody questions the value of sharing and expressing love between friends and family.

But what about between colleagues? Leaders and those they lead? Systems and their contingent members? What does it take to learn and attempt to speak anybody’s ‘love’ language? When we do personality tests at the office and find out who’s an introvert or extravert, who thinks versus feels their way to a decision, can we as leaders and coworkers make the effort to communicate–to relate–on another’s terms in addition to our own? I fail at this day after day; rats! I can do better!

In the end it’s about how we each feel seen, heard, understood, accepted and loved–why limit this essential and life-sustaining human reciprocity to ‘loved ones’? Better yet, why not include all with whom we are in any relationship among those we consider ‘loved‘? It may require quite a brave and committed redefinition of and reorientation to ‘love’, no? But how might this inspired shift in perspective, even by only a fraction of one degree, profoundly alter the course of business, healthcare, education, government–everything?

How Business As Usual Is Killing Us

Surf & turf and a side of asparagus, lobster bisque, smashed potatoes, and an unlimited bread basket, with cocktails and wine, and tiramisu if there’s room.

Most people don’t eat like this all the time, but how many restaurants are filled every night with rooms full people eating exactly this? Many of my patients may eat like this (or something very similar) multiple times a week.

If you want to drastically increase your risks for gout, acid reflux, severe sleep disruption, brain fog, stress intolerance, high cholesterol, high blood pressure, weight gain, and diabetes, there could hardly be a better recipe than the typical business dinner. Here’s the physiology: 1. Red meat, shellfish, alcohol and asparagus are high purine foods that elevate uric acid levels in the blood, increasing the risk of gout, a painful inflammation of joints, especially the first joint of the big toe. 2. High volume, high fat, and alcohol: All of these delay gastric (stomach) emptying, and may loosen the lower esophageal sphincter, making it easier for stomach acid to escape upward, causing heartburn, chest pain, even shortness of breath. 3. Late and prolonged eating: with an already sluggish stomach, finishing a meal within two hours of going to bed makes it even more likely that the stomach will still be relatively full when lying down, sloshing acidic stomach contents right up against that loosened sphincter in the horizontal position, causing painful night time waking, disrupting sleep and negatively affecting mood. 4. Alcohol itself causes neurologic changes that interfere with sleep, even though it may feel initially sedating. It also increases nocturia (getting up at night to pee), can worsen sleep apnea, and is a mood depressant in itself. Taken together, the compounding consequences of the business dinner make it a formidable enemy of health for many executives.

Now add frequent and often international travel with chaotic jetlag, the stress of high pressure, high stakes business transactions, responsibility for whole workforces of people, and disconnection from family, plus emails, voicemails, text messages, and all manner of 24/7 media demanding attention, energy, and time, all finite and precious human resources. It’s a wonder I don’t witness more heart and panic attacks than I do.

Despite these risks and challenges, though, many of my patients actually do and feel fine. They report high meaning in their work, enjoyment from connecting with colleagues (though nobody tells me they love those dinners). They find time to exercise on the road and at home, manage healthy eating, and get good enough sleep in other ways.

Or so we all thought, until the pandemic hit.

My practice closed along with the rest of the country for about 2.5 months in spring of 2020, and the rest of the year and beyond, most of my patients worked from home. Not surprisingly, and also a little shockingly, many of them showed marked improvements in standard objective biometrics when they came for their annual exams that year. BMI, body fat, blood pressure, and cholesterol fell, often precipitously. All of a sudden healthy behaviors that required heroic effort became almost as easy as rolling out of bed. With their long daily commutes eliminated, people could now make–had–time to exercise…and they wanted to because they weren’t mentally exhausted all the time. They could pace about their home office while on Zoom, maintaining energy and engagement. No more international travel, no more business dinners. Their environment and circumstances suddenly and significantly eliminated all kinds of friction on the path to healthy habits. And more importantly, they felt so much better, because they were sleeping more and better, rushing less, and spending more quality time with people they loved. It’s not rocket science–they had their lives back. [Note: I understand that I’m writing about an extremely privileged population. Please know that this awareness is not lost on either my patients or me, and we talk about it candidly.]

Today, frequency and distance of business travel approaches prepandemic levels. Typical work practices are resuming, with some consideration as to their net benefit, but maybe not a lot of action to experiment with or create new, more optimal models of workflow and interaction. In my office, I see patients’ stress levels rising again, weight coming back on, and an overall sense of bewilderment and resignation at it all.

As I write this, I feel a dense tangle of frustration, exasperation, empathy, impatience, protectiveness, and an urge to throw or slam something. Really I feel kind of rageful, actually. Existing disparites of access to resources, autonomy, security, and overall health and well-being widened and intensified dramatically through the pandemic. It makes me ashamed of humanity. How is it that my patients and I–people with agency, autonomy, knowledge, and power–can feel, and actually be, so powerless to change the systems that make us all, privileged and not, so f*ing unhealthy??

I have no concrete or actionable suggestions for how to make things better.

Sometimes I fantasize about going to these business dinners with my patients, like a chaperone. But rather than policing their choices, the point would be to make it safe for everybody to admit that they don’t necessarily want to be there, doing this conventional thing that social norms dictate. Based on years of conversations in the privacy and intimacy of the physician-patient interview, I feel peer pressure operating at the same intensity, and with just as high social consequences, as when we were all adolescents. It’s fascinating and depressing, like a black cloud that everybody feels, nobody acknowledges, and everybody suffers from in collective isolation.

What would it take for these deeply rooted cultural norms, ones that harm us all, to shift even a little? It’s a question I ask myself every day, in multiple domains. I get agitated and hyperventilate at the glacial pace of change. And then, usually, I can take a deep breath. I call on wiser voices than mine to get through.

I know there are people out there bucking the norm, challenging the status quo. I look for that spark in my patients, and I try to fan it, ignite it further. That’s the little good I can do, I guess. Maybe our little fires will one day light the way to bigger change.

Meaningful Metrics

  • 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.