To Train Or Not To Train

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My sister and brother-in-law run marathons.  No, wait, they are elite marathon-running machines.  By next weekend, they will have run 150 marathons between them in just a few years, including Ironmans and ultramarathons, in 39 states and at least 7 countries.  They lead training groups for Team to End AIDS and enjoy a loyal following of running enthusiasts and friends.  So you can imagine my honor when they recently told me, “You could totally run a marathon, Cathy.  You’re already more fit than a lot people who start training.”

For a moment I actually considered it, because wouldn’t that be so cool, to enter that elite circle?  Then I quickly remembered: I. Hate. Running.  …For now.  But it got me thinking recently–talking politics may be like marathon training.  Some people really like it and do it well (by ‘well’ I mean they are informed, articulate, respectful, and engaging with people from all points of view—their discourse is elevated).  They resemble my sister and brother-in-law: athletes who consistently perform at the top of their training, with few or no injuries, leading others to follow in similar aspirations.

Other people, however, would sooner feed themselves through a wood chipper than strap on a pair of running shoes, or engage in political discussions.

Most of us are somewhere in the middle, I suspect.  I can run a few miles with my trainer if she makes me–the conversation and scenery distract me and the time goes by faster.  And I know I can slow down or take a rest if I have to–it’s safe.  But I have many other preferred exercise activities.  Could we consider talking politics as the elite marathoning of communication?  It is so hard to do well!

When I think of long distance running my mouth goes dry.  I get short of breath and my knees hurt already.  I feel the incredible slog, one heavy step after another–not at all like what I imagine my family feels, bounding weightlessly like antelopes toward their next PR.  I experience a version of the fight-or-flight response, a visceral sensation of threat: I’ll have blisters everywhere, I’ll never make it to the end, they’ll have to carry me, I’ll have a heart attack and die!

Maybe some people have a similar reaction to politics?  I don’t know enough, it’s too complicated.  It’s overwhelming, I’ll look ignorant, people will judge and shame me before I can even finish a thought.  It’s all so emotional, I can’t handle that, it will only escalate into conflict, my relationships will all be at risk, I’ll lose all my friends!

As you may have read, I have been trying to get some conservative friends to engage face to face.  I am genuinely curious about their points of view; I want to understand.  I want to practice my skills—curiosity, openness, empathy, identifying shared interests, withholding judgment.  Two invitations were initially met with a non-response.  After a follow up call or two, I am scheduled to meet one set of friends for dinner this week, and the other said he was too busy.  I feel like I’m dragging them out running when they would much rather play golf or go bowling.

I have realized: we don’t all have to keep up with every day’s new political freak shows.  We don’t all need to be the debate champions of our particular ideology.  Not everybody has to be a marathoner.

HOWEVER:

We all need exercise.  The body is built to move.  Regular physical activity, as we all know, reduces our risks of obesity, diabetes, and heart disease.  Did you also know it can decrease depression, dementia, and even cancer?  So pick your sport—just do some kind of movement every day!

Similarly, even if we don’t all talk politics, we all need effective communication skills, especially in the arenas of conflict resolution, negotiation, parenting (which encompasses them all), and the like.  We are social beings—we only survive by cooperating and living well within our tribes, and by tribes living well among one another.  That can only happen if we practice getting along.

So if you’re not a runner/marathoner, what do you do?  What is your thing, how often do you engage, and what keeps you coming back?  If you hate talking politics, how else are you already a great communicator?

Maybe you’re a natural at getting your toddler/tween/teen to see the wisdom of the rules and getting their buy-in to follow them.

Maybe you can always help your boss and coworker iron out their differences because you can understand both sides (are you in HR?).

Maybe you like to debate the merits of the Marvel Comic Universe vs. DC—and you could argue both sides because it’s just more interesting that way.

We all have areas where we shine, where we contribute to the tribe through words and actions.

I have picked up some tips along the way:

  1. Validate people’s feelings, even if you don’t agree with their position or behavior.
  2. Stay open to the 2% truth of an opposing philosophy or idea.
  3. Withhold judgment on the whole person even though they espouse an ideology you despise, at least until you know from multiple encounters that they have no shred of kindness or humanity in them.
  4. Look for what you have in common with people, and choose to focus there more than on how you differ.

So even if you’re not an elite running machine like my sister and brother-in-law, or you’re not your community’s foremost political pundit, know that your other training matters.

I may complete a marathon someday…  Never say never.  For now I’m happy to stick with my TRX, kettle bells, 7 minute and Betty Rocker workouts (once again, I have no financial interests in any of these businesses).  I appreciate my family’s invitation to run, and I respectfully decline at this time.  Similarly, I will try to be more mindful about inadvertently pressuring people to talk politics.  It’s never meant to be adversarial, only a bid for connection—I’m looking for training buddies!

I don’t need everybody to talk politics.  But I do need everybody to practice excellent communication, especially in political discourse.

We all need that.

Getting Past ‘You Suck’ as Dialogue

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Hello again friends, and Happy New Year!  It feels good to be back.  Diving right in with long form again…

This recent article from Wired got me thinking (again), there are so many layers and moving parts to healthcare reform, that no one player stands to lose all or benefit all from any changes.  And yet so much of what we read and hear has an, ‘it’s so simple, they just don’t care about you, but I do’ tone.  The piece describes why insurance companies, who may have advocated most fervently against implementing ACA regulations, actually have a stake in maintaining its current status.  Nothing in our healthcare system is black or white, all good or all bad.

So when I see politicians (and friends) speaking and writing in oversimplified sound bites, and vilifying a whole group (all liberals, all Republicans) over one aspect of their point of view, it really frustrates me. That is exactly the opposite of productive dialogue.  It just makes people stop listening, because they don’t feel heard or understood.  So they have no incentive to hear or understand you.

Many use the car insurance analogy to explain health insurance.  It’s not exactly parallel, but it makes some sense.  The law requires every car to be insured.  (Drivers of) cars that don’t violate traffic law get lower premiums, the longer they stay ‘safe.’  The more traffic law violations, the higher the risk, the higher the premium.  I have an actuary friend, who works for a health insurance company, who advocates, in part, for higher premiums for those who ‘use’ the healthcare system more—like the higher risk cars (drivers).  I understand this logic.  But this idea of making older and sicker people, and women pay more, just because they ‘use’ the system more (and thus financially speaking cost more), does not sit well with me.  People are not cars.  Not everybody maintains their cars well.  But poorly maintained cars do not necessarily lead to increased accidents and traffic law violations.  Poorly maintained health often leads to a human body’s multi-car highway pile-up equivalents.

My friend advocates for insurance coverage for catastrophic care (also aligned with the car insurance model), but not necessarily for preventive or primary care.  There are different ways of ‘using’ the system. If you get preventive care, like recommended cancer screening and annual exams, it may cost more at the time. If you seek help for your back pain early, from your PCP, chiropractor, and physical therapy, that costs money.  But if these early interventions prevent future, more catastrophic and costly outcomes, should we really penalize those who make them?  Illness and infirmity come with age.  So, often, do fixed incomes.  Is it right to make our elderly pay more for their care?

There are costs and benefits to care other than money, which is where health insurance and car insurance diverge sharply, in my view.  I know they are harder to quantify and assign, but they matter.  That secure feeling that I can get care when/if I need it, that my children and I have access to professionals dedicated to my health and well-being, a sense that in our society, I matter just as much as the next person, regardless of my net worth—these things all matter.  Each individual’s health or illness contributes synergistically to the health or illness of a society.  A mother’s depression, untreated and uncontrolled because her health plan does not cover mental health services, can negatively affect every aspect of her and her children’s lives, emotionally, physically, financially, and socially.  We cannot only look at healthcare on dollar spreadsheets of ‘use.’

Maybe it’s about priorities and philosophy—ideology?  Do we feel all people have an equal right to equal care, or do we differentiate what people deserve based on particular group memberships or other characteristics?  Do we feel we should only be responsible for ourselves, or are we called to look out for one another?  I personally believe in equal access to care and ‘look out for others as yourself.’

I also believe that people need to understand–personally and concretely–that everything does cost money, we all pay for one another’s use (and disuse, and misuse) eventually, and more care is not necessarily better.  So I understand and partially agree with my friend’s argument that people need to have ‘skin in the game’ to control overuse of services for no benefit.  One great example is end of life care.  I like this article from Fobres, which describes the conundrum succinctly:

According to one study (Banarto, McClellan, Kagy and Garber, 2004), 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life.  I know there are other studies out there that say slightly different things, but the reality is simple: we spend an incredible amount of money on that last year and month.

Dr. Susan Dale Block, Chair and Director of Psychosocial Oncology and Palliative Care at the Dana Farber Cancer Institute and Brigham and Women’s Health Care, recently shared some data with her colleagues.  In the Archives of Internal Medicine, a study asked if a better quality of death takes place when per capital cost rise.  In lay terms … the study found that the less money spent in this time period, the better the death experience is for the patient.

 
Cost, longevity, quality of life, quality of care, value, perceptions, public health—these and other aspects of health and medicine are all inextricably enmeshed, though definitely not integrated.  Any decisions about one must be made in the context of all the others, carefully, transparently, and honestly.  Whenever we hear, ‘if we just do this, everything will be better,’ red flags should fly.

I wrote the first draft of the paragraphs above on my Facebook page.  I ended the post with, “So let’s each educate ourselves on the facts, as well as we can, and try to look at the big picture. It’s so messy.  And it’s what we’ve got, so let’s deal with it–with maturity, patience, professionalism, and equanimity.”

Another friend, a fellow liberal, commented, “This has nothing to do with healthcare. It’s about reducing taxes on the wealthy, reducing benefits for the poor, and denying the democrats credit for anything good. If they actually cared about healthcare, they would fix the obvious problems with the ACA. And because the ACA was the republican plan, they will continue to tie themselves up into pretzels to disown it and put something else in place. That being said, I hope the American people continue to demand access to affordable healthcare for all. It’s a right, not a privilege.”

I had to reply: “(My friend,) I understand your point of view, and I share your passion for equality.  But your statement exemplifies exactly the broad brush, ‘you suck’ attitude that I see holding us all back.  I refuse to believe that all Republicans are only motivated by making the rich richer, and that none of them care anything about the poor, as so many of us on the left say.  We must extricate ourselves from this destructive narrative and learn to hold space for everybody’s complex views and experiences.”

My point here is that nothing is as simple as we’d like.  It’s so much easier to blame those who disagree with us for being stubborn, selfish, or evil, than to cope with the discomfort that our system is deeply flawed, there are no easy answers, and our fundamental philosophical differences make it that much harder to agree on the best way forward.  And yet, this is what we are called to do.  It’s up to each and every one of us to change our language.  Each of us has, I believe, the opportunity and the responsibility to create an environment in which open, respectful discussion and debate are the norm, rather than echo chambers and verbal warring.

I am only one person.  I have no designated leadership titles or widely visible platform.  But my words have power.  So do yours.  Please use them wisely.

 

On Journeying Together

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NaBloPoMo 2016, Letters to Patients, Day 30

To Patients Who Journey With Me:

It is my privilege and my honor.

Well here we are, my friends, we made it!  30 posts in 30 days, woooo hoooooooooo!!

I had 30 topics all lined up on Halloween, and I think I used 6 of them.  How fascinating!  Looking back, I’m pretty proud of the content this month.  It all came from places of true feeling and contemplation, and I tried my best to make it relevant to the physician-patient relationship.  I meant to write more cogently about policy and operations, maybe illuminate more of the physician’s experience, to help patients understand our perspectives.  I wonder if that is more appropriate for long form writing, or even not writing at all, more like panel discussion or podcast?

Some of you have followed, liked, and commented all the way through—thank you so much.  After all, what is a blog if nobody reads it?  The feedback has held me up and kept me going.  It’s not so different from my relationships with actual patients.  Some are superficial and short-lived.  But most have a true human connection, and potential for integrative growth over time.  My heart is warmed whenever you inquire about my children with genuine caring.  When you remember my extracurricular projects and congratulate my successes, I feel respected.  Heck when you just notice that my hair is longer, I know you see me!

Believe me, I’m not in this just for the science, or the money, or the prestige, or the teaching.  I’m in this to know you, my patient—and for you to know me.  I know there are some who see me as expendable, exchangeable.  Their interactions with me feel purely transactional.  And that’s okay; everybody needs something different.  But I could not long survive a practice of only such relationships.  No, that would kill my soul for sure.  I live for the connections, I say.  I learn from every one of you, and you make me better.

So thank you for journeying with me.  It’s a long, strange trip, eh?  The path winds, the weather shifts, and times change.  But as long as we go together, I’m all in.

 

On You, Team Captain and Tribal Leader

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NaBloPoMo 2016, Letters to Patients, Day 29

To Patients Who Think What You Do Doesn’t Matter:

Think again.

Yesterday I described You, the Elite Athlete.  All great athletes know they do not succeed alone.  They also appreciate the unique contribution they make to their teams.  What teams do you serve?  How do you lead?  It doesn’t matter whether you have a title or designation.  One of my favorite ideas is that no matter our instrument in the orchestra, according to Ben Zander, we can lead from any chair.

For now, think of yourself as Team Captain, or Tribal Leader.  You have invested in yourself by fueling and training, resting and recovering, managing your stress, and cultivating excellent relationships.  Now you can take the returns and reinvest in those around you:

Appraise:  Prioritize self-care

  • Like on an airplane: “Put your own mask on first.” Tribal leaders know that to effectively care for others long term, they first need to be healthy themselves.
  • Practice awareness and management of your emotions, and prevent emotional hijacking, so as to be emotionally available to our teammates and tribe members.

Empathize:  Speak the team’s language(s)

  • Think of your favorite teachers and coaches—they were able to relate to learners at all stages of development and team morale—and lovingly lift us all up.
  • “People don’t care how much you know until they know how much you care.” –T. Roosevelt

Inspire:  Lead by example

  • Effective leaders reject victim mentality, take responsibility for our actions, and model accountability for fellow tribe members.
  • When we captains can take our own mistakes in stride, as learning opportunities rather than shameful horrors, we make it safe for our teammates to do the same.
  • Everybody is then free to take more risks, voice more ideas, offer more of their authentic selves as a contribution to the whole,
  • Because they see us, their leaders, the ones who set the tone for the group, doing it, too.
  • Key here also is leading out loud—excellent captains articulate and coach the methods of self-awareness and self-management that help us all succeed.
  • By inspiring individuals to pursue personal excellence, leaders create a supportive milieu for collaboration and collective achievement.

Motivate:  Empower team members

  • Effective captains (coaches, leaders) recognize team members’ strengths and potential, as well as areas for improvement.
  • Rather than shaming teammates for mistakes or deficiencies, good tribal leaders provide feedback and encouragement, and more opportunities for practice and development.
  • They take into account each team member’s personal goals, and help to align them with those of the collective—excellent captains connect individuals to the whole.

If your actions cause others to

Dream more, learn more,

Do more and become more,

You are a leader.

–John Quincy Adams

What would happen if you treated yourself like a true leader?

On You, the Elite Athlete

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NaBloPoMo 2016, Letters to Patients, Day 28

To All Patients:

What would happen if you thought of yourself as an elite athlete?

I present tonight the first phase of the presentations I have given this fall to physicians, corporate executives, and tomorrow, a corporate design team.  See how it applies to you:

***

What makes you exactly the same as Pat Summit, Martina Navratilova, Michael Jordan, Dana Torres, Peyton Manning, Serena Williams, Wayne Gretzky, and Walter Payton?  You are an elite athlete.  You have a specific skill set which you spent years training and honing.  You continue, through practice and discipline, to refine it.  It’s an upward striving, just like an Olympian—Higher, Faster, Stronger!  And, you’re part of a team.

So how should you take care of yourself—your very valuable, elite athlete self?

Fuel & Train

  • “Regular people diet and exercise. Athletes fuel and train.” –Melissa Orth-Fray
  • Our bodies are our vehicles. Elite athletes’ vehicles require premium fuel and meticulous maintenance.
  • We all struggle with the same challenges—time, motivation, discipline.
  • Each day we have an opportunity to walk the talk, and practice what we preach. Every good lifestyle choice, no matter how small (apple instead of candy, stand rather than sit), is a step of intention toward health.

Rest & Recover

  • Chronic sleep debt increases risks for diabetes, obesity, impaired immune function: GET MORE SLEEP.
  • Rest and recovery are integral for sustaining long term performance and injury prevention—ie burnout. This applies for both physical and mental exertion.
  • Take your allotted vacations and really disconnect.  The world will still function (temporarily) without you.
  • Broaden your methods: 15 minute walk, 10 minute meditation, 5 minutes of journaling—unwind, unload.

Manage your stress

  • How do you know when you are ‘stressed?’ How/where does stress manifest in your body?
  • What are your existing resilience practices? How quickly do you abandon them when things get busy?
  • Exercise mindfulness: Live in the moment; breathe deeply; speak and act intentionally, not incidentally.
  • We are no different from toddlers—easily emotionally hijacked when tired, hungry, over-extended.
  • Elite athletes use the disciplines above to manage their emotions and stay focused.

Cultivate positive relationships

  • Coaches, teammates, trainers, psychologists, equipment managers—no athlete succeeds alone.
  • We thrive when we feel seen, heard, understood, accepted, loved, and safe.
  • It is only when our relationships are strong and we feel connected, that we can truly care for ourselves and our teams.
  • Who is your support network, and how do they hold you up?
  • Who do you support, and why/how does this fulfill you?

 

What is your sport?  Who is your team?  How does caring for yourself benefit those around you?  And finally, what can you do today, tomorrow, next week, next month, and in the next year, that will elevate your own health and well-being, and that of your team?  Please share your ideas in the comments!

On the Full Body CT Scan: Don’t Do It.

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NaBloPoMo 2016, Letters to Patients, Day 27

To Patients Considering Full Body CT Scans:

Please reconsider.

Forgive me for putting on my preachy doctor hat for this post.  I will also break my NaBloPoMo 500 word limit for this one.

As we approach the end of the calendar year, many of you may have met your health insurance deductibles.  Maybe now would be a good time to get in some tests to ‘check under the hood,’ as some of you have said.  I share below some of my screening  recommendations, along with rationale.

Keep in mind that for this article, I define ‘screening’ as looking for a disease in a person with a) average risk for developing the disease and b) no symptoms.

Please also know that the opinions I express here are my own only and do not necessarily represent those of my colleagues, employer, or professional societies.

 

  1. Full body CT scan: This is not recommended by any clinical guideline or medical professional society as a screening test for anything.  As I will describe below, specific screening tests are recommended for specific diseases, and the best ones obtain actual cells or tissue, rather than imaging alone.  In addition, a full body CT exposes you to significant radiation, the long term consequences of which are still not fully understood.  Lastly, CT scans inevitably detect incidental abnormalities that have no clinical consequences, but that often lead to invasive tests that can cause real harm, such as bleeding, pain, infection, and anxiety.  This article from the FDA and this one by a radiologist at Harvard explain pretty clearly how the risks of this test far outweigh the benefits.
  2. Colonoscopy (colon cancer): This is the one test that nobody argues.  It is both diagnostic (can see signs of early disease) and therapeutic (can take it out).  Start at age 50, and repeat every 10 years if normal, barring new symptoms.  Read the full guideline from the US Preventive Services Task Force (USPSTF) here.  I know the prep is a pain, and I know you have to take a day off of work to have it.  But on the whole, the returns here are well worth the investment.
  3. PSA and digital rectal exam (prostate cancer): This is perhaps the most personal decision of all cancer screening. Population-wise, we have yet to show mortality benefit from screening of any kind, such that the USPSTF now recommends against screening until better tests become available.  But it’s not really that simple, because prostate cancer affects so many men, and is the second leading cause of cancer deaths in men in the US.  The most important thing here is to decide which risks you are more comfortable with: potential serious harm from screening and unnecessary treatment, or finding cancer at a later, potentially more high-risk stage.  This article from the New York Times may help, and this one from the National Cancer Institute.cancer-cases-and-death-2016
  4. Mammogram (breast cancer): It’s hard to walk back from more screening to less; people fear loss of security. When I started my training over 20 years ago, the recommendation was to screen every woman every year, starting at age 40.  Since then epidemiologists have kept track, and similar to prostate cancer screening, the mortality rate from breast cancer has not decreased proportionally to the amount of screening done.  Diagnosis has increased dramatically, due to early detection.  Again, screening increases the risk of certain harms:  anxiety (so much, for so many), pain, deformity, infection (from invasive biopsies), and then commitment to repeated testing (a vicious potential cycle of imaging, needling, more imaging, and more needling), while likely not saving your life.  Here is the USPSTF guideline, and a helpful infographic .  Like prostate cancer screening, this is one you have to decide for yourself, with the help of your doctor.mammo-infographic
  5. Pap smear (cervical cancer): Again, former guidelines called for annual screening. Today, if your test is repeatedly normal and your sex habits are low risk, the interval can be lengthened to 3 to 5 years, and can start later in life (over 21).  Cervical cancer is highly correlated to exposure to human papilloma virus, or HPV, which is sexually transmitted.  Positive pap results, which range from mild to severe, occur far more often in younger women, and of those, many will revert to normal without progression to cancer in a woman’s lifetime.  The main risk of over-screening, again, is unnecessary procedures when true disease not present.

In summary, these are the most common conversations I have with patients about screening.  You may rightly infer that my personal bias is minimalist:  Primum non nocere.  Unfortunately, we have no good screening tests for some diseases, such as pancreatic cancer, ovarian cancer, and liver cancer, and the screening guidelines in other countries (eg Taiwan screens adults regularly for liver cancer) do not apply here because prevalence rates differ so widely.

This is why I think it’s important to establish care with a primary care physician and get regular check-ups.  That fatigue you feel is likely just life and chronic sleep deprivation.  You’re probably constipated because you eat too few stems/stalks/leaves and don’t move enough.  You and your doctor can review your general health together, and if there is suspicion for some underlying health risk, it can be addressed personally and specifically.

To look up USPSTF guidelines yourself, I recommend searching Google for “USPSTF (disease) guidelines” and look for the hit that starts with “Final Recommendation Statement…”  I have no financial or professional interests in Google or the USPSTF.  Other respected sources for screening recommendations include the National Cancer Institute, the American Cancer Society, and the American Medical Association.  As an internist, I recommend the American College of Physicians.

I hope this piece has helped illuminate the complex decision-making behind screening and diagnostic testing.  I have only scratched the surface; the links contain the data and full rationale.  Please take the time to read through them and discuss them with your doctor.

On Happy Movies

 

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NaBloPoMo 2016, Letters to Patients, Day 26

To Patients Getting Into the Spirit:

What movies do you recommend?

26 days and… writer’s block.  So duh, the obvious solution was to take a shower!  According to Shelley Carson, PhD, the defocused mindstate of showering allows for creativity and innovation.  I noticed the sullenness that envelopes me so often lately.  I wished for a mental uplift, and the gods obliged—they reminded me of “The Internship.”  Vince Vaughn and Owen Wilson play a couple of recently unemployed Gen-X salesmen who land coveted internships at Google.  They lead a dejected team of Millennial misfits who, of course, overcome all odds to win in the end.  It’s admittedly full of cheese.  But the endearing characters and uber-nerdiness get me every time.

Post-shower, I came down to movie night in progress:  “Music and Lyrics,” starring Hugh Grant and Drew Barrymore.  Grant, an 80s pop ‘has-been,’ falls in love with his substitute plant waterer and incidental lyrcist, played by Barrymore.  Once again, current-event melancholy yielded to drippy-sweet romantic comedy.  You just can’t sustain a sour mood in the face of all that adorableness.

Other movies that come to mind, and that I plan to watch in the coming days:

Love, Actually

The Holiday

White Christmas

You’ve Got Mail

While You Were Sleeping

It would really be nice to get fully into the spirit again this year.  Why not aim for joy, after all?  Vacation days, family gatherings, gift exchanges and excuses to shop with abandon…  It could all be good, and I can exercise more control over my mood than I have until now.

So, the feel-good, holiday-mood-elevation movie marathon begins tomorrow, yay!  Please feel free to make your suggestions!