Category Archives: medicine

Breaking Point

Posted on by
8

“Dr. Cheng, I feel dizzy.”

We’ll call him Joe. I miss Joe. I met him in his early 60s, a pleasant, dapper, rotund man with a jovial demeanor and well-groomed mustache. He was always on time to his appointments and came with crisp reports on his subjective state of health. Whenever I saw Joe on my clinic schedule, I knew at least that part of my day would be good.

Joe lived a conscientious lifestyle. He paid attention to food and movement, and cultivated relationships that held him up in life. When I think of Joe, I remember feeling unworried about his habits and longevity. So it bugged me that his blood pressure was never well controlled. On maximum doses of four medications, it was consistently 140/90 (ideal is 120/80 or less), and it just would not come down. Luckily for me, his previous doctor had done all of the appropriate work up, including sleep study, kidney imaging, stress testing, etc. Eventually they decided together that this was as good as it would get, and Joe would just focus on doing the healthiest things he could every day and get on with life. I concurred.

So when I got the call months later that he was dizzy, my heart sank. We agreed he would come in that day and we’d figure out next steps. I was prepared to call the emergency department and my cardiology friends to let them know I was sending him over for a cardiac event. But on arrival he didn’t look ill or unwell, just moved a little more slowly. His mood was great, though, maybe even better than usual. I asked him why, what had changed? “I retired!”

His blood pressure was 90/60. He was still taking all four of his blood pressure medications, like the diligent patient that he was.

Back then, in a typical primary care practice seeing a patient every 15 minutes, I did not consistently ask deep questions about people’s work stress and meaning, like I do now. Turns out, Joe had a lot of mental stress at work. He managed it well, though–never lashed out at people, never let it affect his performance. Colleagues threw him a big party and he retired feeling satisfied, looking forward to his next life chapter. And it wasn’t until later that he realized how much his work had cost him in health. Over the next several days, we learned that he only needed a low dose of one medication to keep his blood pressure in the 110/70s. The dizziness went away. I think he was getting ready to go on a cruise. I left the practice soon thereafter, and I don’t know about Joe now. I hope he’s still happy and well.

I remember this story so clearly because until recently, it stood out as unique–that my patient could correlate such a dramatic improvement in a crucial vital sign and a leading risk factor for heart disease to retiring from a stressful job.

Not so unique anymore, though. This year, no fewer than four of my patients have experienced the same thing, but in the opposite direction. Having never had high blood pressure before, they all called me with new symptoms: headache, fatigue, full body tension, and just feeling off. Before calling, they thought to monitor their blood pressure, and all of them reported consistent home readings well above 150/90. And they all knew exactly when it started, all correlated with severe work stress escalation. Adjuvant factors included increased travel, longer work hours on global calls, less time for exercise, and continued business eating. It’s all a downward spiral, for sure, and I submit that the underlying cause, the change that makes four people present suddenly in these six months, is our post-pandemic work environment. While I welcome the increased flexibility and autonomy of a hybrid office model, I’m not sure the net effect is good for us long term. Work-life boundaries have perforated, if they even still exist at all. Given the volume of articles in business periodicals progressing from ‘quiet quitting’ to overt labor force decimation, it’s quite clear to me that we have not invented a kinder, more effective work culture. More and more I hear and feel an ‘us versus them’ gulf growing between workers and leaders–yet another relationship domain affected by polarization. It’s as if the short term, profit driven, make money at any cost prepandemic ethos, suppressed and reassessed (I thought?) during three years of acute obligatory disruption, became an abscess that has now ruptured and resurged–exploding like ‘pus under pressure,’ as we say. Organizations scramble to restore anteCOVID earning and productivity status, still measuring success and achievement with the same metrics as before nature showed us how vulnerable we and all of our systems are. We have learned nothing.

All of these patients are now taking at least one blood pressure medication, pulling hard on their stress management skills, and maybe reassessing whether staying in their current roles is worth the cost to their health and relationships. We connect regularly and I always ask, how much longer can you keep this up? How will you know when enough is enough? What will you do then? I don’t recommend that people quit their jobs–that is not my place. But I ask the important questions, lovingly and bluntly.

What does it cost us indeed, as a society, to be killing our workers this way? When will we recognize that sacrificing people in the short term actually wrecks collective success in the long term? When will our culture value people over profit? I hold leaders accountable for their relational output at work, and I also recognize that they–as we all–are simultaneously agents and victims of our complex adaptive systems. Culture does not change easily.

If I have any hand in it, however, more of us will move closer to challenging and changing the most toxic aspects of business culture, one organization, one team, one person, one interaction at a time.

Three Years Ago Today

Posted on by
7

Where were you on February 25, 2020? What was happening around you? What were you doing, planning, looking forward to, worried about?

What day did COVID change your life?

On New Year’s Eve, 2019, my niece declared that everybody was overreacting to the infection sweeping across Wuhan, China. It won’t be a big deal, she said. I specialize neither in infectious disease nor public health, but I knew then that what was coming would be a big. fucking. deal.

This morning, stepping out into the bright sun and crisp air at the end of another unusually mild Chicago winter, Daughter and I recalled 3 years ago. We had just spent a long weekend in Seattle, just for fun. Son had said then that he could see himself living there ‘after school,’ and lo, he ended up there for school. Little did we know then that COVID had already landed, right there, where we were.

Within weeks, whole organizations and governments mobilized and immobilized; life mutated irrevocably around us everywhere. COVID hit me in the face by cracking one of my friendships early on. The week of March 9, I begged off of a gathering, and my friend was angry. I respected and admired her, and loved her family–still do. She subsequently railed at the prospect of lockdown and social distancing, citing economic fallout, apparently dismissing my alarm at the risk to our healthcare system, and my own colleagues, if we deferred such drastic measures. It took me by surprise, floored me, and I was hurt. I wanted to talk more about it, talk through it. But these three years, every time we approach our differences here, she respectfully declines to continue. I respectfully agree. We hit a boundary in our friendship then, which I accept. I can engage with difference elsewhere; there is no shortage of opportunities. Over this time I believe I have both sharpened and softened my communication skills around disagreement and dissent, and I’m still grateful for every chance to practice, learn, and improve.

Facebook showed me what I posted three years ago today. I don’t know which leader moved me to profess my appreciation on social media, but I bet it was one of two, so I emailed them both today with the screen snip of the post. “…recalling 3 years ago, watching and waiting for the pandemic wave to hit us, standing in a state of novel awe and uncertainty.  I also remember feeling confident, though; I understood the medical and public implications and trusted my immediate professional and personal circles to think and act rationally and thoughtfully… Our organization has its challenges, both intrinsic and extrinsic.  Each day, though, I’m still convinced and proud that everybody’s doing their best for the greater good. So Happy Saturday, and thank you for you leadership. 🙂” Having led a small practice through the first 14 months of the COVID morass, I suspect any sincere expression of acknowledgement and appreciation, at anytime, even now, boosts any leader’s spirits. We are all still going through it, and we still need to hold one another up.

This is the 42nd post that appears on a “COVID” search of this blog. I process by writing. Reading back, I apparently felt more fear and anxiety at the outset than I may remember. Memory is complex! Today I recall vividly the acutely discordant and uncomfortable conversations with my friend, while minimizing the overall stress of the time and circumstances? How fascinating. We would all do well to ‘remember’ this paradox of recollection as we continue to navigate, negotiate, and collaborate hereafter.

“We write to taste life twice, in the moment and in retrospect.” Anna Quindlen includes this quote by Anais Nin in her book, Write For Your Life. Have you anything to review from three years ago–emails, letters, photos with captions, blog posts? What does any of it show you about your feelings, thoughts, actions, and relationships back then? How has your life evolved and transformed in the short and profound time since? How have your relationships moved? I’m gratified to take some time today to recall and reflect, and to have concrete evidence of myself to do it with.

Write on, my friends.

How Business As Usual Is Killing Us

Posted on by
14

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.