Category Archives: medicine

Why I Take the Scenic Route

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June 23, 2020 somewhere in Colorado

I-70 or 285?

I ask myself every time I leave Centennial, on my way to Silverthorne. If I have time and nobody in the car who will complain, I always choose 285. It takes at least 45 minutes longer, and it’s a much prettier drive. Thanks to dear friend Rachel who took me this way the first time in 2012, I have now stopped at state parks I never knew existed and passed through beautiful valleys and plains that take my breath away. Less traffic also makes for a more relaxing, even contemplative ride, which I appreciate more and more. Fun turns that open up around the bend to expansive landscapes never get old, and depending on time of year or day, and of course weather, I never know what I’m going to get. Every time, I am richly rewarded with yet a new perspective on the path, the journey–this iteration of the way. I get to explore and learn, to savor and revel. I learn what exits lead to which trails, where to get gas, and where to stop for the best views.

I have the sweetest gig any primary care doctor could hope for. With 5% of a typical full time patient panel, I have the greatest luxury in all of medicine: time.

When someone presents with classic signs and symptoms of a well-described and well-understood condition, it’s okay to take the highway of standard testing and conventional treatment. When the story and picture are less clear and straight, we need to slow down, look around, listen harder, wander the side roads. What’s rustling in the bushes? What path was taken to get here, and what roadblock(s) encountered along the way? What equipment do we anticipate needing as we proceed, and will we know how to use it?

Sometimes even the clear and straight path turns icy, muddy, or otherwise unexpectedly obstructed. This is when knowledge of alternate routes really pays off; even better if those routes are familiar. So often I take extra time talking to patients, even when I think I know what’s happening. I ask more questions to flesh out the story fully, to learn more. Have you had this before? What’s same/different about it this time? What was the context? What made you call me about it? How much is this bothering you? What are you worried about? What’s going on in your life now that may have triggered this? What else is happening? What do you think is going on, what story are you telling? Anything else?

I never know what I’ll learn in these meandering exchanges; most of the time I just get to know my patient a little better. That’s worth so much in itself. And eventually, I have learned, all of this accumulated familiarity matters. My ‘impression and plan’ for any given problem can evolve quickly over a history and physical exam, sometimes taking sharp turns. And it’s the best feeling when my patient and I can look at each other and say, “Wait, remember when…?” and it sheds light from the past on what’s happening today.

Today’s objective may be relief of pain and discomfort. Depending on the severity and urgency of the problem, we may race to that end speeding on the freeway. Our journey together as physician and patient, however, is more like a long and winding road trip. We have much to explore, if we travel together long enough. When you’re not in pain and have some time, we can take the scenic route together, get to know each other better. All of the photos, wildflowers, stories, and memories we collect along the way just make the trip, and our connection, that much more beautiful.

Meaningful Metrics

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  • 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 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

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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?”