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.

New on HTC: The Bit Post; Choices

Captured from Facebook

Friends, every once in a while I have moments of relative wisdom and avid connection. Often it comes while responding to patient questions, sometimes on the phone, sometimes on email or portal messaging, and very often over text. So many posts on this blog started as these little, ‘bit’ insights. I marinate them, stir them around, turn them like a Rubik’s cube, until they’re so convoluted that it takes another, longer period to unravel them again to be ‘worthy’ to post.

So tonight I’m trying something new: the Bit Post. When moved, after brief and thoughtful enough consideration, I give myself permission to post these small notes, as is and with just enough background, just to share, in case they resonate with anyone. I feel an urge to engage here on the blog more frequently and lightheartedly, with less perfectionism and self-doubt. So we will see how this goes!

I sent the message below after a dear patient apologized for some behaviors that appear to have led to suboptimal blood test results. They made a self-judgmental comment about their life. I could feel their guilt and maybe some shame. So I replied honestly, as I wrestle with many of the same challenges. The example I give happened just last night.

So we go together, my patients and I. We are all here doing our best!!

Onward, my friends—ODOMOBaaT!

“Your life is what it is. Your choices are what they are, influenced by many circumstantial factors that vary day to day, moment to moment. No need to apologize to me—I’m not you!
“I have a rapidly evolving perspective recently on how I counsel people on habit and behavior change anymore.
“I’m here to inform and advise, not to judge. All of our choices are trade offs made in real time. I overeat tonight because I’m with friends and enjoying the food and that is more important to me in this moment than losing weight. I may regret it later and I’m not consistent at slowing down and asking myself when the weight later becomes equally important to me as dessert now. You see?
“We just have to own both our choices and their consequences.
“My goal is to have the fewest possible regrets when I die. I wish that for you too, but only you can know what choices will get you there.
“Makes sense?”

The Prosperous Heartbeat Bank

Okay friends, this is a fun post with some lighthearted existential philosophy. It also talks about sex, so consider yourself warned.

I really do wish everybody peace, love, and health (usually joy, also). People who receive emails, texts, and snail mail from me will all tell you. I also love a cheeky, irreverent expression sometimes, and this one showed up before the New Year:

From The Fuckit List page on Facebook

I shared it immediately with all my friends who would appreciate it, including a brilliant and pragmatic cardiologist. I added ‘etOH [ethanol] and weed in moderation, and the rest–yeah!’

The ensuing email thread between us:

Friend: 😂😆 no orgasms in moderation?!?!

Me: Some things you just cannot get too much of.  No risk.  😉😆

Friend: i’ve never heard a physician say “no risk” – only “low” “moderate” “high” risk. so i’m happy to go with no risk!!!!

Me: Teeheehee / It just occurred to me—YOU are the cardiologist!! IS there a risk?? 😱 / I cannot lead people astray here… / I suppose MI [myocardial infarction–heart attack] during sex does occur, right? / So shit, there is a risk! 😣

Friend: i suppose as a cardiologist, it’s always a risk-benefit ratio. risk is very very low. benefit is likely there every time. plus there’s the added cardiac benefit of ischemic pre-conditioning [training the heart with exercise] in those with significant CAD [coronary artery disesae] wherein you can develop angiogenesis [growth of new blood vessels] and collateral formation [bypass blood flow around blocked arteries] in the context of regular sexual/exercise activity. so it’s a big yes to orgasms!!!!

Me: Omg YYYAAAAAAAYYYYY!!! 💃🏻🎉🥳❤️ / And ENDORPHINS, yes? 😄

Friend: ah, yes, sympathetics. you know there is a hypothesis (totally unproven) that you are born with a certain # of heartbeats and once you use them, your life is over. if that is the case, endorphins, sympathetics and (eek) orgasms are probably no good for us. but again, that hypothesis is totally unproven and the more “exercise” you do, the slower the resting heart rate and the longer (observationally) the life. so probably, all in all, better to stick with the orgasms than to avoid them!!!

Me: Ooooo, fascinating!!  I bet there is some vague, partial and flexible truth to that theory?  Like yes, any given heart has a finite number of future beats left at any given time.  

AND, there are likely many things we can do throughout our lives that give it more or fewer remaining beats—like a bank account that we deposit to and withdraw from… 😜 OH I just LOVE this idea!!

Deposits:

Diet: fiber, healthy fats, lean protein, moderate naturally occurring sugars (Food Rules by Michael Pollan: Eat food, not too much, mostly plants)

Movement: full body, cardio/strength/mobility

SLEEEEEEP OMG 

Stress: wise mind, radical acceptance, inner peace; and FUN!!

Relationships (I would bet anything this is proportionally the DENSEST, highest value heartbeat reserve elevator): love, meaning, connection… 

Of course withdrawls are the opposites of these… I wonder whether bad sleep or toxic relationships are the greatest heartbeat extinguishers?  My money’s on relationships—maybe not even toxic ones—rather the lack of them altogether.  It makes total and complete sense to me that loneliness is a better predictor of mortality than smoking (I think it’s actually phrased that it’s a bigger mortality risk than smoking but I bet it’s a better predictor, too—if you look at the data a certain way?)…

OMG this totally aligns with my framework of the 5 reciprocal domains of health!! 😄 ❤️ ❤️

Ok so my mom told me that her dad told her that we are each born with a finite amount of prosperity in life.  So the idea is to be frugal with spending, consumption, partying etc in your youth, so you have enough to spread out over a longer lifetime.  I do like that idea.  It feels akin to humility and generosity to me…  So I wonder if there can be a pooling effect among one’s tribe—that we all spend/consume/share over a lifetime and extend/improve all of our lives?? 

OH thank you for telling me about this, I will think more (and possibly write) on it!! 😄 xo …And maybe my gong-gong’s theory is also flexible like a bank account, too. 

I think we get to invent it, since it’s all made up to help us feel better about how we choose to live life anyway! 😄

THANK YOU for stimulating such fun thinking tonight! 😄

Ok more soon, big hugs!!! xo

//

All of these thoughts and ideas poured out between us from 4:44 to 7:22pm on 12/28/2022. I’m not sure more writing is required at this point? I thought about doing the math–for each episode of exercise, how many more beats, and does it even out with a resulting lower resting heart rate over a lifetime…? Nah. It was a fun and thought-provoking conversation between two friends which, for me at least, tightened connection and elevated joy. I am definitely heart-healthier for it.

Hope 2023 is off to a peaceful, loving, and healthy start for you all, my friends, if not a moderately buzzed and high, frequently orgasmic, and suddenly wealthy one. 😉