Rally

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NaBloPoMo 2018:  What I’m Learning

In my first practice it was common for whole families to be my patients.  Grandparents, parents, children, grandchildren, cousins, and other webbed relations.  My fondest memories of those years revolve around witnessing the love, tension, and ultimate cohesion of these complex units of humanity.

One day Grandma came for a routine follow up visit.  We reviewed her blood pressure, glucose, and cholesterol numbers.  She wanted to lose some weight.  Everything was stable, but something seemed off.  I could not put my finger on it, and when I asked if everything was okay she said yes.  This scenario repeated maybe once or twice more over some months, and slowly we agreed she was depressed, though I’m not sure if I ever used that word.  There was no trigger, no event.  She had not had a history of depression.  She was just down, she did not know why, and she could not make it go away.

Grandma came from a culture and a generation that did not feel comfortable doing talk therapy.  She was also reticent to take prescription anti-depressants, even if they might help her feel better.  But she was happy to see me more regularly, just so I could keep track of her medical problems and make sure she was okay.  We reviewed the same list each time: fatigue, low mood, anhedonia.  No suicidality, biometrics stable.

Sometimes I would also see Son, Daughter-in-law, or Granddaughter.  I would ask them how Grandma was doing.  They never used the word ‘depressed,’ but they described how she was ‘kind of down,’ ‘sad,’ ‘going through a hard time.’  And then they would tell me what they were doing about it.  Someone would always be at Grandma’s house, keeping her company.  Sister would invite her out to lunch.  Granddaughter would take her out shopping.  Everybody attended to her just a little more, rallying around her, and nobody ever talked about why.

Grandma herself rallied, and her depression lifted over time.  In Chinese the expression for this is equivalent to having ‘walked out’ of it, like depression is a long tunnel in the mountain.  What a privilege to bear witness to this phenomenon—the family saw Grandma walking in a dark place, and they moved in a little closer, each with their own candle, lamp, or torch.  They helped light her way, and they all walked out with her together.

I had a shit day today, mostly of my own making.  Cramming in too many things, all scheduled too close together, trying to do too much, falling down on multiple levels, and adversely affecting multiple people around me.  I almost bailed on a chance to be with an amazing group of people tonight, out of exhaustion and self-loathing.  But these were my friends and I had not seen many of them in several months.  I felt quite listless at the beginning of dinner, not unlike I imagine Grandma felt.  But as I communed with my tribe, reconnected, and met a new friend, I started to feel better.  The yummy duck helped, too.  They could intuit a shadow on me.  And with gentleness and respect for boundaries, my friends rallied around me.  It was not pity or sympathy.  It was genuine empathy and wishes for my well-being.  So I rallied, too.

Things feel overwhelming more often now than before.  The anger, bickering, blaming, and self-righteousness I see, hear, and feel all around (and within) me really gets under my skin—ha, literally, I guess.  I know this will never be a permanent state; I will feel better tomorrow.  It’s also an interesting opportunity to observe how I’m walking the self-care talk—including the self-compassion part.  Fascinating.

Well friends, that’s what’s on my mind tonight.  My patients save me by teaching me.

I’m going to bed.  So I can rally some more tomorrow, and maybe help someone else do the same.

Relationship Revolution

 

“In my lifetime I want to see the culture of medicine driven more by relationship than by revenue.”

–me

 

Nice to be back, friends!

This post is a bit different from my usual format and style.  It’s maybe more raw and blunt.

Please bear with me and keep an open mind?

I know posting this may be risky.  It started out as just jotting down ideas for a longer, more detailed future post.  I had to get the ideas and thoughts out so I could focus on work.  And then the ‘jotting’ somehow evolved into what I imagine a poetry slam might look like.  So I decided to post as is.

My long term objective is to stimulate generous thought and respectful discussion between patients and physicians.  I wish to prod us out of our default complaint modes and reorient all of us to the idea that we are all on the same team, but our connections are under siege by outside forces.  The system harms and oppresses us, physicians and patients, the end users, and the ones with the real power.  Together, we are the sleeping (sedated?) giant that must rise up and reclaim the system for ourselves.  This post is an attempt to spark the flame that draws us together, by pointing directly to the spikes that drive us apart.

Disclaimer: What follows is my own expression and does not represent or reflect the opinion or position of any colleague, institution, or professional society with whom I associate or to which I belong.

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I hear my colleagues say: Get rid of the patient portal!

It’s too much!

Limiting characters does not work, they just send multiple messages

Charging for messages just makes more work

“They abuse the system”

“We give an inch, they take a mile”

Keep them away!

Us vs. Them mentality.

Antithetical to mission of medicine: To meet patients where they need us, and help them.

WHY?

Because we are too busy.

DOING WHAT?

Every. F*ing. Thing.

Rx prior authorizations

Endless documentation, infinite clicks

Rx refills with no information on follow up or patient status

Filling slots to meet RVU goals

Prescribing more meds to meet “quality” goals

Keeping up with the latest evidence for every disease, test, treatment, guideline, diet fad

Rushing to the next patient so that the patient we’re with does not have time to even think of their questions, must less ask them

Patients walk away from visits with their true needs unmet.

So they use the resources available to them to ask for what they need.

And this ‘adds’ to our work

And we feel busier and more frustrated, exhausted, frayed, irritable

We feel Overwhelmed.

 

Patients also feel it

They feel unseen, unheard, dismissed, discarded

And they don’t understand or relate to where it comes from

They get angry

So they send more messages: to us, about us; criticizing us, lashing out

Making us feel bad about ourselves

Which manifests as defensiveness first, then even more frustration, exhaustion, irritability

But we don’t disengage.

We remember our calling.

We forge on in smoldering resentment, pride, bitterness, duty, guilt, shame, and occasional fulfillment

 

And then abstractions to reconcile the cognitive dissonance

 

Patients suck

All they do is take take take

They don’t understand that I’m Doing My Best to help them

Why don’t they appreciate me

They are so entitled these days

They want everything now now now

They think I’m at their beck and call

Like I’m not working every minute of every day

Like I don’t have a family and a life also

Like I live only to serve them

Patients are the enemy

Really?

 

Oh and it happens on both sides

 

Doctors suck

All they do is type away at that blasted computer

They don’t even look up, see me, or hear me

They don’t understand what I need

They just want to see more patients

Make more money

I’m just a number to them

A cog on a conveyor belt

They’re all in the pockets of Big Pharma and Insurance

They withhold the help I need

They hoard it

They don’t care about me

They Don’t Care About Patients

All they care about is making the next buck

Doctors are the enemy

Really?

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There is no substitute for the Time and Energy

Required to cultivate Healthy, mutually Respectful, mutually Fulfilling, mutually Beneficial relationships

It is always a two-way street

Our relationships kill us or save us.  Always.

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Doctors and patients must find ways to reconnect

Find one another through the thick morass

And Hold Tight

In Solidarity

Learn, Train and Practice Together

Our Communication, Empathy, Compassion, and Collaboration skills

Defend against the forces that drive us apart

Advocate for one another and for our Sacred Contract

So we may once again

Heal Through Connection

 

The Only Diet That Works

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Hello Friends!!  Oh my gosh, it feels so good to be writing again, like sinking into my favorite squishy armchair, at the campus coffeehouse where I have met my friends since college, to sip, gab, bond, and plot to save the world.

New phase of life, woo hooooooo!  And eekgadds.  I have long thought of balance as a dynamic state, like that octopus ride at the amusement park.  I am the ride, spinning around, raising and lowering each aspect of life in controlled coordination, attending to each car so nobody flies out and gets hurt.  With the added responsibility I have taken on at work this year, it feels like I have just agreed to accept a massively overweight rider in that car, and my whole frame now strains to keep everything moving smoothly.  At first everything looks normal.  But the continuous strain of gravity, mass, and cumulative sheer forces create microfractures in my arms over time.  And suddenly one day, something (or everything) may come crashing to the ground.  People get hurt.  The ride is broken, in need of major repairs, possibly never the same again.

 

So better to slow the RPMs now, decrease the amplitude of vertical oscillations.  And, increase frequency and intensity of maintenance: inspection, lubrication, computer upgrade, parts replacement.  All of this is to say that 2018 is my year of graduate study in life-octopus ride maintenance.  Curriculum so far includes a lot of Thomas Rhett songs (“Drink a Little Beer”), communion with close friends, and a resurrection of my spiritual life.  I’ got this. [fist bump emoji]

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Okay so, this is a post I have thought about for weeks and I can finally sit down to write it today/tonight.

Since December, two people have told me, essentially, “Medicine has failed at nutrition.”  One person was a good friend, the other a new acquaintance.  Both were athletes, well-educated professionals, and thoughtful men.  I respect both of them and was intrigued by their assertions (and, honestly, just a little defensive).  They pointed to the myriad books, fads, products, news articles, and programs around the country in the last decade or so, all claiming to have the one method for lifelong healthy eating.

Their expressions went something like this:  “What’s the deal with gluten?  I’ve read Wheat Belly and Grain Brain and now I feel conflicted every time I want to have some bread, even though I feel fine, and I like bread.  …Is saturated fat bad or good?  On Atkins I can have as much steak and liver as I want, and my cholesterol is supposed to get better.  And Bulletproof says I should be drinking butter and coconut oil in my coffee.  But my doctors all tell me to minimize red meat and oil in general.  …The Inuit people live off of whale blubber, and they have a fraction of the heart disease we have.  I used to think I knew how to eat healthy and now I’m not so sure.  I’m so confused.”

I was taken aback somewhat by both of these conversations, as I don’t feel confused at all about nutrition and eating.  I feel personally tempted, frustrated, vacillating, under-motivated, and/or fat, depending on the day.  But professionally I feel informed, confident, and reassured that I can counsel my patients solidly toward optimal health.  So wherein lies the disconnect?

In my practice, our approach to nutrition starts with the patient interview.  What is your current eating pattern?  How does weekend or travel eating differ from regular workdays?  How does this pattern either promote or hinder your health and well-being?  What are you doing that’s already healthy and where is there room for improvement?  What needs to happen in order for you to make small, sustainable behavior changes for optimal health?  How important is it to you to do so?  The conversations focus on my patients’ own physical, mental, and emotional experiences around food.  They have a chance to relate their eating habits to personal and professional goals, and a vision for their best selves.

I have learned that my advice needs to be concrete, specific, and relevant at a granular level.  I can roll with Paleo, Atkins, Whole 30, gluten-free, vegetarian, ovo-lacto, oil-less vegan, pescatarian, Mediterranean*, or other diets.  There is some good evidence for all of them.  But is any one of them the sole antidote to all of our eating poisons?  My left brow rises every time I hear someone make this claim.  Here’s the key:  None of these diets tell us to eat pizza, burgers, chips, cheesy fries, dinner rolls, diet soda, craft beer, loaded nachos, fettucine alfredo, cookies, cake, ice cream, and candy the way most of us do.  So what are the underlying origins of my night-time corn chip-cream cheese binges?  What strategies can we brainstorm to cut back on my birthday cake consumption between birthdays?  Questions like these and the conversations that follow serve my patients far better than my recommending the blood type diet (which I do not).

Furthermore, leading proponents of each of these diets also emphasize the importance of concurrent self-care in the other realms of health: Exercise, Sleep, Stress Management, and Relationships.  Diet and nutrition are vitally important for health, but they do not occur in a vacuum.  All of our health behaviors need to be assessed in their combined context, and recommendations are best made with circumstances, preferences, logistics, and access in mind.

If you’re an elite athlete whose diet is already 99% cleaner than the rest of us, yes, maybe there is a subtle difference between medical diets that will affect your performance and sports longevity.  Then again, maybe not.  And you are also likely attending to your needs for training, rest, recovery, and stress management.  So you’re probably good either way.

For us regular people, the only diet that works is the one we can stick to, that doesn’t cost us inordinate amounts of psychic energy to maintain, and that actually makes us healthier.  How can we tell we’re healthier?  We may feel: lighter on our feet, increased energy, more regular bowel movements, clearer skin.  When we see our doctors (as we all should, ahem) they may find we have lower blood pressure, lower body fat, smaller waist circumference, lower fasting and overall glucose, lower LDL and triglycerides, and an overall brighter aura and vibe.

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So maybe keep Michael Pollan’s words in mind as a general guideline: “Eat food.  Not too much.  Mostly plants.”  I would add:  Eat foods as close to how they occur in nature as possible.  If you can tell what leaf/seed/grain it is by looking at it, it’s probably better than if you cannot.  Harvest/kill it, cook it (or not), eat it.  The fewer steps the better.  Eat often and slowly with people you love.  Help each other moderate the junk.  Enjoy your food.  Life is short.  Strive for an eating life that adds joy and delight to your whole being, both immediately and in the long term.

Onward, my friends.

 

*I have no financial, philosophical, or other interests in any of these or other diet programs, products, centers, providers, etc.