Tag Archives: COVID

Life Is Not a Randomized Controlled Trial

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It’s more like that movie Everything Everywhere All At Once.

When I review biometric and lab results with patients at the end of a Day of Care (our practice’s name for the full day executive physical), results often correlate with what people tell me about their habits and circumstances in the past year, or even the past several days. Sometimes, though, one or more results do not align, and we have to stop and consider why. Occasionally this leads to additional testing and we actually find something that needs to be treated. But most of the time it’s not clinically significant and it’s okay to monitor for relevant signs and symptoms and repeat the test annually as per routine. It’s life.

But we humans fixate. Whether it’s weight, glucose, cholesterol, or some metric on a wearable device, it’s easy to get caught up in ‘the data’ and seek the one central variable (or latest technological solution) that we can address solely and thus yield the result we want. Expert scientists devise studies that control for all variables but one, intervene, collect the data, and make correlations into conclusions. There is definitive value in these experiments, and we should absolutely continue rigorous, evidence-based study and practice of medicine and public health.

And, we healthcare professionals must also step back often and look at whole systems–individual humans (body, mind, and spirit), humans in family and community, and local and global economies–not just snapshot data in vacuums. Weight, glucose, cholesterol, body fat, and cognitive function, among other things, often move in tandem. The good news is that the lifestyle advice we give to optimize all of these is all the same. The general principles are definitely not rocket science, and I think we can safely stop spending time, energy, and precious resources proving ad infinitum that good sleep, physical activity, whole foods, and healthy mindset and relationships are good for us.

That said, if it’s that simple, why are we not all already doing it? Because simple in theory too often becomes complex in practice, and we tolerate complexity less and less in our modern, instant gratification-seeking world. I borrowed a sign from a colleague early in my career: “Move more. Eat less.” Simple–deceptively and delusionally so. Now I see these words and want to reply with a scoff and an expletive–as if it’s just that easy. And yet we get so many messages that everything should be easy; that if it’s not easy then we’re doing it wrong. This supplement, that diet, this other meditation app, and any number of new cutting edge products–online, shipped to your door tomorrow!

If our goal is to elevate health and wellness and prevent disease, it’s not only our individual actions that matter. How do our behaviors intersect with, and how are they driven by, in entropic and synergistic combination with our environment and things we cannot control? In integrative medicine when inflammation is assessed to be high, a trial of elimination is often recommended. My colleagues point first to caffeine, alcohol, added sugar, dairy, and gluten: Eliminate them all for a month or so, and see how you feel. Many people report feeling significantly more energy, relief from digestive symptoms, clearer cognition, and myriad other benefits. One might interpret this as the result of removing ‘toxic’ substances from the body, which may be at least partially true. But I posit that it’s likely also due to elevated attention, intention, and mindfulness around eating, which likely cascades to subtle alterations in other health domains such as sleep and exercise. Nothing in a system happens in a vacuum–everything affects everything, directly or indirectly.

Look no further than COVID lockdown in 2020. The vast majority of corporate executive patients in my practice experienced marked improvements in almost all health metrics by the end of that year. They had eliminated work travel, business dinners, long commutes, and at least some office politics. Earnings projections and all manner of professional expectations were scaled back and down. For this privileged population, life acquired a drastically new balance of better sleep, more consistent movement, more quality time with loved ones, and net fewer calories consumed per week. After an elimination diet, patients are instructed to reintroduce foods one at a time in small quantities, to determine reactions and and thresholds. This makes sense, and can also be misleading because whatever makes us feel badly is often not just one thing. Corporations have varied in their reintroduction of prepandemic practices essentially reverting to prepandemic state. Many of my patients’ 2020 health gains have regressed commensurately.

So in practice, what can any given individual tweak in their daily routine or immediate environment to make healthier behaviors easier and more consistent? How can we change the default systems settings so we don’t have to exert such heroic intentional energy fighting our status quo habitat to be well? I still think we need to take a harder and more honest look at our global institutions, traditons, and default practices, especially those driving corporate culture. This is exceedingly difficult and complex, ‘way beyond the scope of an internal medicine doc’s weekly blog.

But I have a plan starting this week: Look for the bright spots. This idea comes from Chip and Dan Heath’s 2010 book Switch: How to Change Things When Change Is Hard. In this post-COVID era of deep psychological and social ambivalence, who’s doing well? Which organizations or teams have figured out an apparently optimal dynamic balance of in person and remote work, productivity and accountability metrics, morale, cost management, and overall integrated systems coordination? Who’s doing allostasis–maintaining stability through change–well? It’s almost never just one thing–it’s everything everywhere all at once but likely in small, cumulative, integrated ways, sometimes at the periphery and sometimes central.

Looking at whole systems can feel so daunting, especially when we get really humble and honest and see just how intricately webbed everything is–how even a small change in one domain can domino and propagate across a whole network. It can freeze us in incertainty and fear. Or it can free us to experiment–in an ‘uncontrolled’ rather than ‘controlled’ way–because too often we have no control and must act anyway. We can experiment mindfully, transparently, humbly, accountably, and flexibly. Small tweaks can establish new standards, which lead organically to subsequent adjustments downstream. A realiable cycle of assessment, action, learning, and application can help prevent getting stuck in rigidity and attachment to status quo well beyond its functional efficacy.

Life is change, an uncontrolled trial of human nature in variable and dynamic context. Everything Everywhere All at Once, all the time. We can breathe through the overwhelm, and look from both ground level and ten thousand feet. Any one thing matters both a lot and not very much in any system of systems–one of my favorite paradoxes!

So let’s get out there and BE and DO what we can! Take responsibility and own our attitudes and actions, respect others, and live in alignment with our values and integrity. What else can we ask of ourselves than that?

Susceptible

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How do you assess risk?

For a long while now I have thought of risk in terms of intrinsic and extrinsic factors. For any given challenge, any individual (or collective) may have certain baseline predispositions for a certain consequence or outcome. The intersection of those innate properties with the external environment and conditions then create the actual outcome(s). This post is about self-awareness and self-regulation in service of mitigating risk in two situations: Infection and severe mental stress.

Infection

When was your last COVID vaccine? There have now been two booster vaccines available after the initial doses back in 2021. In the current endemic state of the virus, repeated vaccination feels less urgent than before. Some will continue to say ‘always’ or ‘never,’ but most of my patients want to discern more thoughtfully. I advise situationally. The following applies not just to COVID, but for any infection we may contract in the wild:

Intrinsic risk: What is your overall state of health? How many risk factors for infection and complication do you have (eg advanced age, respiratory illness, diabetes, other immune compromise)? What are your nutrition, exercise, and sleep habits, generally and now, and do they protect you or make you vulnerable (sleep deprivation and high mental stress increase risk)?

Extrinsic risk: What is your likelihood of exposure, in terms of intensity, duration, and novelty? What is your access to healthcare in case of severe illness? How would infection impact your function, livelihood, and the health and function of those around you (and what are their intrinsic risks, if you were to expose them)?

I did not get my second COVID booster until right before I traveled to Taiwan last month, even though it’s been available since last fall. It was mostly due to inconvenience, though I also did not want to spend a whole day in bed (my reaction to this vaccine), and I assessed my risk of infection and complication to be low. Then Husband got infected at the same time that Friend told me all about her severe and prolonged experience with long COVID, and I learned that cases in Taiwan were still fruequent and severe. I would be traveling alone with Daughter, who has asthma, spending 20+ hours each way and all days in country in crowded airports and public spaces. So while I had no overt intrinsic health risks, I was moved to vaccinate by both subjective and objective extrinsic factors.
I prioritized sleep the week before and all through traveling. I minimized caffeine intake. We wore KN95 masks in all public spaces throughout the trip and washed hands vigilantly. COVID infection during international travel is no joke, and we took no chances. Thankfully, we arrived back home uninfected and healthy.

When thinking about any infectious disease, I consider goals and trade offs. How important is it to avoid this illness, in general and right now? What are we willing to do and not do to prevent infection? What are the real costs of prevention and potential costs of illness? How can I minimize my susceptibility in a realistic, pragmatic, and balanced way? As a physician, I must consider infection impact not just on an individual’s health, but on public health as well.

Severe Mental Stress

In recent years, I have added a slide on distress tolerance to my wellness presentations. Practices like cold water to the face, paced breathing, and progressive muscle relaxation can help de-escalate us in the throes of acute emotional hijack, helping us get back from fight or flight to thinking clearly and acting reasonably. We have all encountered situations when we feel overwhelmed, out of control, and powerless. We each have our own unique triggers and reaction patterns, whether it’s performance anxiety, phobia, vicarious trauma, or simply rage, sadness, shame, etc.

Intrinsic risks for severe acute mental stress include history of trauma, tendency to avoid uncomfortable feelings, difficulty managing and expressing feelings or thoughts, and baseline anxiety, depression, etc.

Extrinsic risks for emotional hijack include inciting events that trigger past trauma reactions, often subconsciously. This could be anything from seeing someone else experience the harm you endured, to simply entering an environment similar to one in which you felt unsafe before. Certain words or gestures can trigger us–it can literally be anything. We each have a different threshold in any given situation, depending on the intersection of our current state, baseline traits, and real time conditions.

Susceptibility to mental stress, however, goes beyond simply passive innate attributes coming in contact with inciting circumstances. We all have our stress tendencies, many of which we can only partially control, if at all. Here is where our daily patterns, habits, and practices can really save us. Sleep deprivation and dehydration make everything feel exponentially worse, in my observation. Regular physical activity regulates the autonomic nervous system and improves sleep quality. Moderation of caffeine and alcohol help mitigate these substances’ disruptive effects on brain and body. Consistent self-assessment of mood and energy, what affects them, and anticipating challenges and threats on the horizon can increase confidence in our ability to meet them. Practices such as mindfulness, prayer, and communion with loving others also boost resilience–both mental and physical. And we cannot overestimate the profound importance of healthy, strong, and loving relationships to hold us up through anything life may bring.

For mental stress, while intrinsic psychological risks matter, our strong and consistent habits in the 5 reciprocal domains of health can (sleep, exercise, nutrition, stress management, and relationships) combine in synergy to minimize (or at least mitigate) our susceptibility to acute emotional hijack. Mindset, self-talk, communication skills, and attunement to others in daily life can set us up generally to encounter adversity feeling grounded and solid or vulnerable and insecure.

Thus, in addition to intrinsic and extrinsic risks, intrinsic assets also matter. The more we strengthen them when things are easy, the more easily we can call them forth when things get really hard.

I remind myself that though dividing risk into intrinsic and extrinsic is clear and helpful, it is also an oversimplification. History of trauma is not innate to me as a person, but the experience is integrated into my nervous system. Repeated subjective experiences accumulate and integrate further. I have, one could argue, adapted to it all in a way that protects me from recurrent harm in the future by alarming my system, mind and body, to similar threats, perceived and real. And while I practice my centering, grounding, inner peace methods, it also behooves me to honor and embrace my natural, un-peaceful tendencies. My best outcomes occur when I hold these all in dynamic balance, with nonjudgmental awareness and self-regulation. Anticipation, preparedness, and seeking support from trusted others also help mitigate my susceptibility to adverse outcomes and suffering.

In the end, I wish for all of us to live more peaceful, self-aware, self-efficacious lives. I want us all to move through good fortune with joy, and through adversity with fortitude and confidence, even while we allow ourselves to fully feel fear and distress. As an advanced practice in this domain, the better we understand our own intrinsic vulnerabilities and the conditions which expose them, and manage them effectively, the more likely we may recognize the unique struggles of others. We may all suffer less when these skills help us see, hear, and understand one another more empathically, compassionately, intimately, and lovingly.
We can, if we choose, help minimize one another’s susceptibility to pain and suffering.