Tag Archives: medicine

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.

Tribal Pride and Tribalism

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NaBloPoMo 2017: Field Notes from a Life in Medicine

What tribes do you belong to?  How do they serve you, and you them?  How not?

I think of this today as I have traveled out of state to speak to a Department of Surgery on physician well-being.  I wonder how often they have internists present at their Grand Rounds?  What a tremendous honor, I’m so excited to be here!  I hope my talk will be useful and memorable, as I represent my field and my institution, in addition to myself.  In the talk I describe the central tenets of Tribal Leadership and culture, and how to elevate ours in medicine.

So I’m thinking tonight about tribal pride and tribalism—the benefits and risks of belonging.

We all need our tribes.  Belonging is an essential human need. To fit in, feel understood and accepted, secure—these are necessary for whole person health.  And when our tribes have purpose beyond survival, provide meaning greater than simple self-preservation, our membership feels that much more valuable to us.  But what happens when tribes pit themselves against one another?  How are we all harmed when we veer from “We’re great!” toward “They suck”?

Of course I’m thinking now of intra-professional tribalism:  Surgery vs. Medicine vs. Anesthesia vs. OB/gyne vs. Psychiatry.  Each specialty has its culture and priorities, strengths and focus.  Ask any of us in public and we will extol each other’s virtues and profess how we are all needed and equally valuable.  Behind closed doors, though, internists will call orthopods dumb carpenters; surgeons describe internists’ stethoscopes as flea collars, and the list of pejoratives goes on.  Maybe I’m too cynical?  My interactions with colleagues in other fields are usually very professional and friendly—until they are not.  I have experienced condescension and outright hostility before.  But can I attribute it to tribalism—that general, abstracted “I’m better than you because of what I do” attitude—or to individual assholery?  Or maybe those docs are just burned out?  As with most things, it’s probably a combination.  Based on what my medical students tell me, negative energy between specialties definitely thrives in some corners of our profession.  Third year medical students are like foster children rotating between dysfunctional homes of the same extended family—hearing from each why all the others suck.

So what can we do about this?  Should we actively police people’s thoughts and words in their private moments?  I mean part of feeling “We’re Great!” kind of involves comparing ourselves with others and feeling better than, right?  Isn’t some level of competition good for driving innovation and excellence?  Should we even embrace this aspect of tribal pride?  It certainly does not appear to be diminishing, and I have a feeling it’s just human nature, so probably futile to fight it.

I wonder why we have this need to feel better than.  Is it fear?  A sense of scarcity?  As if there is not enough recognition to go around?  Like the pie of appreciation is finite, and if you get more I necessarily get less?  Intellectually we recognize that we are all needed, we all contribute.  But emotionally somehow we still feel this need to put down, have power over, stand in front.  And it’s not just in medicine.  I see it in men vs. women, doctors vs. nurses, liberals vs. conservatives, and between racial and ethnic groups.  It makes me tired.

But maybe we can manage it better.  Maybe we can be more open and honest about our tribal tensions, bring them into the light.  Yes, I think surgeons can be arrogant.  And that’s okay to a certain extent—it takes a certain level of egotism to cut into people, and when things start going wrong in the OR, I think that trait can help make surgeons decisive and appropriately commanding when necessary.  I imagine surgeons get impatient with all the talking we internists engage in.  So many words, so little action, they might think.  And yet they understand that words are how we communicate with patients, how we foster understanding and trust.  Maybe we can all do a better job of acknowledging one another’s strengths and contributions out loud and in front of our peers (and learners).  The more we say and hear such things, the more we internalize the ideals.

Tomorrow I get to spend a morning with surgical attendings and residents.  I hope to contribute to their learning during my hour long presentation, but I really look forward to my own learning, to expanding my understanding and exposure to parts of my profession that I don’t normally see.  I’m humbled at the opportunity, and I will look for more chances to bring together colleagues from divergent fields.  If we commit, we can connect our tribes and form a more cohesive profession.  That is my dream for future generations of doctors—to be freed from infighting and empowered to collaborate at the highest levels, for the benefit of us all.

 

I’m the Doctor, You’re the Doctor

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NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.