Walking the Talk

BVF ben downhill

The Journey and the Struggle

18 months ago I wrote about my plan for maximizing menopause preparedness.  As with so many missions, this one has experienced both successes and failures.  Since January 2016, I have grooved my exercise routine in the most awesome way.  I am all over the TRX, doing Spiderman push-ups, incline presses, pistols and more.  I get my cardio intervals and I’m foam rolling.  I feel stronger now than at any time since high school, and I’m proud of this accomplishment.

*sigh*

The eating, on the other hand, continues to be a challenge.  Earlier this year a patient looked at me without expression, and stated bluntly that I had gained 8.7 pounds since the last time he saw me.  Right after that’s kind of inappropriate, I thought, well, he’s right, I have been gaining weight.  Last March I wrote about weight loss strategy, thinking mainly about my exercise habit formation.  Sadly, my own weight has gone opposite to the desired direction, despite an honest attempt at adherence to my own advice.  Evidence suggests that weight loss really is about 80% diet and 20% exercise.  But sometimes you can only focus on one thing at a time.

Back in 2008, when I finished nursing, I thought, I can get my body back!  I knew I was not going to exercise, and I had no energy to police my food choices.  But I also knew I was eating too much, so I decided to just cut my portions in half.  It felt easy, decisive, and empowering.  I lost 25 pounds in 9 months, and got down to my wedding weight.  But eventually I acknowledged that though I was thin, I was squishy.  So I connected with my trainer in 2014, the primary goal being to get moving without injuring myself.  Right now I’m up 17# since my nadir in 2009, though I’m much more fit than the last time I lived at this weight.

Talking the Walk

I’ve always had a love-love relationship with food, and it shows in my weight/habitus.  I notice also that my own state of mind and body has influenced the advice I offer to patients.  Before I exercised regularly I spoke to patients a lot more about diet; now it’s more balanced.  One patient brought it up recently.  He asked, “What about the doctors who smoke, or the obese ones, how can they advise anybody about healthy habits?”  I’ve thought a lot about it, so I was ready to answer.  To me, there are three main options, all of which I have tried.

Disclaim.  We doctors can rely on our authority to tell people what to do to get healthier.  They notice our fat rolls, or smell cigarette smoke on us.  They see the dark circles under our eyes and surmise that we don’t sleep enough.  Maybe they can tell we don’t exercise.  But we admonish them to eat less and move more.  We say (subconsciously) to ourselves, “Do what I say, not what I do.”

Avoid.  Rather than give lifestyle advice at all, we can focus on prescriptions and referrals.  We feel we have no place instructing patients to eat more leaves, go to the gym, or quit smoking, when we don’t even do so ourselves.  So we don’t even bother, feeling like hypocrites.

I think both of these responses are rooted in shame and perfectionism.  And I think we should not fault physicians for choosing them—that would be meta-shaming–never helpful.  These are normal, human responses to our professional training and expectations.  Physicians have long held positions of authority and expertise.  Until very recently, our relationships with patients were mostly paternalistic.  But with burgeoning access to information, a culture evolving (rightly) toward patient autonomy, and physicians experiencing historically high levels of burnout and suicide, we cannot afford to burden ourselves with the illusion that we must be perfect in order to be credible.

Connect.  I think the healthiest response, for both patients and physicians, is for us doctors to acknowledge our own struggles; to empathize with the difficulty, the conflict, and the utter disappointment of not being able to control our actions and choices as we would like.  I think patients don’t expect us to be perfect.  But they do want us to be human and relatable.  I often find myself saying, “I know that feeling,” or, “Yep, that’s my weakness, too,” or, “Oh, and what about x-y-z?  That’s my problem!”  Only once has a patient said to me, “Shame on you!”  He was a perfectionist himself; I didn’t take it personally.

I stress eat. I eat when I’m bored.  I eat late at night, and I love sugar, starch, salt, and fat.  The struggle is real, and I know it all too well.  So when I ask you, “What small changes can you commit to in the next month?” believe me, I’m asking myself also.  And if you tell me something that has worked for you, I’ll probably try it.  I still think my ‘4 A’s of goal setting’ apply: Assessable, Actionable, Attainable, and Accountable.  I just haven’t found my 4A formula for eating yet.  But lately I have taken a more lighthearted approach to healthy eating trials.  Nothing is life or death, and I know iterative changes are best.  If one thing doesn’t work, hopefully I can learn something and move on to the next.  No dessert on weekdays.  Vegetarian on days I work.  No eating after 8pm.  No starch at dinner…  Meh, none of it seems to stick yet.  Even my cut-it-in-half strategy doesn’t appeal to me these days.  It’s so frustrating!  And it’s also okay, because I know I’m doing my best, just like my patients are.  We can all just take it a little more lightly, one step at a time.

So by the time menopause actually hits, I’m confident that I will be prepared to meet it, with grace and maybe a little irreverence.  I’m learning to judge myself (and thus others) a little more gently.  I’m learning to love my body, whatever shape it’s in.  After all, it’s the only one I’ll have this time around, and I need to maintain it for the long haul.  Turns out, my patients have been my best companions and consultants on the journey.

 

 

 

 

Inspired

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…by a friend of a friend.

It’s okay to lament the darkness. Grief is normal and healthy.

But then go get a candle and light it.  Then go about lighting other people’s candles with yours.

The best part is, the light just multiplies. Your light shines no less brightly for giving some away.

And pretty soon darkness gives way to all of our light.

Peace and hope, friends. 

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!

On the Golden Positivity Ratio

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Courtesy of Bryan Jorgensen, Las Vegas, NV, 2016

NaBloPoMo 2016, Letters to Patients, Day 25

To Patients Seeking Positivity:

Aim for the Golden Ratio!

As many of you know, I have recently undertaken to re-evaluate my Facebook usage.  Not long after I established my account c.2008, I decided to make my page a monument to positivity.  I realized that after I die, it would be the most visible and accessible legacy I leave, and I have total control over what I post.  I minimized complaining and ranting, and when frustrated I would try to write with an attitude of learning, of moving forward.  Lately I tend to leave off the latter.

Somewhere along the way, I think over the past year, but I’m not sure, pessimism and cynicism snuck in, no doubt related to politics.  The layers of consciousness infiltrated by the negative campaigning this time around extend deeper than any other election cycle in my memory—but maybe I just don’t remember.  I think humans have evolved to forget pain as a survival mechanism.  If women remembered all the pain and anxiety of pregnancy, delivery, and caring for a newborn, we would never do it more than once, are you kidding me?

I used to review my Facebook posts and feel elevated.  Today they often bring me down; it feels terrible.

Thankfully, I have some tools to resist the negativity.  I was reminded recently during my 3 Question Journal Shares with Donna over at A Year of Living Kindly.  I remembered something about healthy relationships maintaining a 3:1 ratio of positive to negative interactions.  Turns out it’s actually 5:1, widely attributed to observations by Dr. John Gottman, renowned marriage and relationship psychologist.  I think the same thing applies in other realms, too, such as self-talk—a reflection of our relationship with ourselves.  It’s not a far leap to see how this idea pertains to news, social media, and any other human interactions.

Business researchers have discovered a 5.6:1 ideal ratio in highly functioning organizations, whereas low-performing teams’ ratio landed close to 0.3:1.

For more information on the science behind the theory (and motivation for practice), I highly recommend Positive Psychology in a Nutshell, by Ilona Boniwell.  For a brief overview, check out this PDF.  The book summarizes the origins of positive psychology as a field, and the research and wisdom of its study and application.  For example, psychologist Barbara Frederickson has described how positive emotions contribute to our personal growth and development (taken from Boniwell’s text):

  1. Positive emotions broaden our thought-action repertoires
  2. Positive emotions undo negative emotions
  3. Positive emotions enhance resilience

So hereafter, I will pay more attention.  I will likely continue to share articles that illuminate my concerns for the future.  But I will aim for the 5:1 positivity ratio.  Holy cow, can you imagine if that’s actually what we saw on the news and social media?  And why not aspire to 5:1 in my personal interactions, too?  That’s taking charge of my own happiness, yes.