Oh Baby, I'm so tired

Right now I am still working locum tenens and traveling most of the time. The past few months, I have been traveling four days a week about 3 hours from home. My hotel does not have a kitchenette, just a tiny fridge and microwave.  I have not yet mastered the art of eating healthy under these circumstances. I know that I need to plan, and feel guilty as I chide my patients for not planning meals better. I have so many excuses.

Firstly, I usually leave here Tuesday evening and get to hotel sometime between 10 pm and midnight.  I get settled by 1 am at the latest and have to get up at 530 to start whining about going to work. I arrive at my customary time-10 to 15 minutes late. I promise myself that I will stop at Costco on the way back to the hotel and get fruit and healthy snacks. Sometimes, I actually do this, but mostly I get off work 10 hours later, emotionally and physically exhausted and promise to order something healthy from a fast food place. But lack of sleep and being emotionally drained does not lead to healthy choices. I choose a burger and fries. I don't even like fries. Oh, and I diet Coke because we all know that the diet Coke cancels out all the fat, sodium and calories from the other food.

I feel guilty while eating and don't enjoy even one bite. I know I am hurting myself. I am not practicing what I preach. I have plenty of time to feel guilted out because the caffeine from the diet Coke will keep me awake until midnight again.  I fall asleep resolved to exercise in the morning in the hotel gym even if I am tired, but the fraking update on my phone has silenced my alarm and I wake up too late to eat the hotel breakfast, pick up a healthy lunch and head off to work arriving late again. Community clinics are always stressful and at least for me, emotionally draining.  Fast food for lunch, but subway this time...a little better, no?  I stop at Costco, pick up fruit, yummy spinach salad and Brita water bottles. 

Again, I stay awake too late trying to answer email, work on business plan research, facebookking.  I know that lack of sleep leads to poor food choices, but I have not figured it out yet. I know I need to exercise to have energy but the constant traveling leaves me always feeling tired and unsettled. I know it hard for my patients who have very little education regarding this health stuff. But I have no excuse. Really.  I know what to do and I know how to do it.  I just don't make the time to plan ahead. I don't have a reasonable bed time. I know that I need a long time to wind down after work.

So, this week? Same plans.  This week, I will shop BEFORE I travel and fill my cooler with good things and remember to ask for a ground floor room because the hotel does not have elevators. This week, I will exercise even when I am tired. Really.....It could happen.

Physican Burnout? Put down the matches, Doctor!

Today I was reading yet another article on physician burnout  keep wondering why they do this to themselves? They have been slowly making in roads in stopping the insane hours of residency  They are barely starting to figure out that NO one thinks clearly or learns well when sleep deprived. All those hours does not make for a better physician. They KNOW that.  But seem determined to continue with this sort of extended hazing process.

The physicians themselves limit the number of medical school spots available and then strangely complain about the shortage or primary care providers that they are purposefully creating. ( BTW, thank you for making it easier for me). Now, they are working themselves into the ground, burning out and creating a depersonalized health care system that we all agree is not working. But who is creating scheduling themselves for 30-40 patients a day? They are.

I sometimes wonder what came first the burn out and resulting depersonalization of healthcare or the 10 minute visit that led to the burnout? They have the power to change this. They do.  I wonder if they are depressed? You know how depressed folks just get "stuck"? They know it is crazy. They know it is scary as hell to go home hoping to whatever God you pray to that you didn't miss something important. But they do it.

They really do have the power to change it over night if they wanted to. They could all just linkedin, fb, tweat, or g+ each other to say NO. No, I won't see more than x patients today or any other day. It is dangerous. It is wrong.  It doesn't work.  They could do this. They write their own rules. There are laws against the corporate practice of medicine. No one can force them., except themselves.

I am honestly wondering about the secondary gain.  They say that they want to be with their families. Do they? They could be. They each have the power to hang out a shingle just Marcus Welby and make their own hours.  They could stop taking insurance and start practicing medicine and healing again.  I promise you that they are NOT forced into this situation.  This is the life that they are choosing for themselves. 

Isn't there a pill for that?

Isn't there a pill for that? This is one of the most common things that I am asked by my patients when I start talking about nutrition, exercise, weight loss, pain management and graceful aging.  They ask me for pills to sleep and are initially upset when they find out that I can but will not write a prescription for Ambien.  I tell them that I don't believe in Ambien ( or Vicodin) deficiency.  They are often frustrated when I begin talking about sleep hygiene because they have already tried "everything". 

Everything does not include cutting out coffee, soda, energy drinks, and other forms of caffeine. Notice I don't mention chocolate: I am not cruel.  Everything does not include any form of exercise or a regular bedtime. Everything does not include getting away from screens and lights a few hours before sleep. Everything does not include any of the many things we all need to do in order to have restful sleep.

When I talk about eating healthier foods,  they ask me for supplements. Can't I get a pill for that? I am not against supplements such as fish oil, but they miss the point. We need to eat real food.  I know that many folks don't like water, fish, vegetables or exercise.  Sometimes it is an aquired taste. But I remind them that coffee, cigarettes and alcohol were all nasty the first time we tried them, but we stuck with the gagging, choking and bitterness until we became convinced that we loved those things.  We can do the same with fish and other healthy foods. We can.

Trust me, it is easier for me to write a prescription for that pill. I can be in and out of that visit in five minutes. I could more easily see the 25-42 patients that some clinics want me to see in a day.  It takes time for me to get to know my patients. It takes time to understand what works for them and where they need support. There isn't a pill for that. 

Every Body Lies and why it is our fault

Me:  (seated across from patient with BMI of 48%) So, tell me about your diet. What sort of things do you enjoy eating?
Patient: I don't eat anything really. Water in the morning, sometimes coffee. I have a salad with no dressing for lunch and maybe a carrot for a snack. Dinner is Lean Cuisine, more water. I never eat dessert. I drink water all day.
Me: ( smiling kindly) And tell me about what sort of exercise or activity you like and how often.
Patient: Oh, I walk for an hour every morning and go to the gym 3 days a week.
Me: I am confused here. That is a lot of exercise and not many calories- What do you think is going on with this 18 pound weight gain over the last month?
Patient: I don't know. I do every thing right... I just keep gaining.

Now, we all know that what this patient is saying is not likely true. Some of my colleagues would say that the patient is in denial.  They are not aware of what they are eating and they mistake the intention to exercise with actually exercising. To some extent that may be true, but I think that the answer lies in their experience with their providers.  I think most of the reasons have to do with what they expect to hear. Maybe they don't want to disappoint us. Maybe they don't want to hear from one more person what they already know.  Maybe WE don't make it a safe place for them.

I will share some of the things that ARE working for me and my patients in some future posts, but today-I want to say that the trust and open communication that leads to changes in health behaviors and ,ultimately, outcomes does NOT happen in the 7 minute visit:  It happens when I take the time to listen. It happens in the moments between the M.A. knocking on the door to remind me of my busy schedule and the patient understanding I believe they are important enough for me to listen to them.

Fat Primary Care Providers?

I do remember those ads that told us that 3 out of 4 doctors recommend a certain brand of cigarette. Advertisers use images of the gray haired, white coat wearing physician because it conveyed a sense of trust. Tobacco companies understood that showing those images on billboards and in magazines might help distract smokers from those pesky studies showing the link between cancer and smoking.  Physicians and other trusted health care providers do influence the patient's behavior. Many studies have shown that the physician's recommendationt to stop smoking positively impacts smoking cessation rates. We also know that physicians who smoke are not very likely to make  those recommendations. And even if they did, would the patient listen to a provider who reeks of tobacco?

I think the same principals hold true for fitness. A recent  Australian study showed that overweight physicians are not as likely to counsel their patients on diet and exercise  as are physicians with a normal BMI. This same Australian study showed that physicians with a normal BMI are more likely to document obesity in the patients chart than overweight physicians (93% vs 7%).  If the health care provider doesn't even bring up the issue or offer guidance, then it can not be expected they will positively influence change.  Even if the out of shape provider offers advice, would the patient listen?

I have referred many of my patients to the nutritionists associated with the medical group. I had several patients come back to tell me that they would not return to the programs because the nutritionist weighed about 300 pounds, according  their description. They told me that they couldn't believe anything she said because of her obesity.  I can't imagine how many other patients never tell the providers why they don't attend those nutrition classes.

Like it or not, we are held to a higher standard. Like it or not, we influence our patient's behavior by our own. I am working on my own fitness and with my very hectic life I understand the struggles that my patients are having with adopting a healthier lifestyle. I know that for the most part, I make healthy choices but sometimes, I screw up too. After a crazy busy day in a clinic where I saw 42 patients and felt stressed the whole day by their complexity ( no simple colds or UTIs in the group), I was exhausted and cranky when I picked a drive through place to grab supper ( the hotel does not have a kitchen). I thought about a salad for about 20 seconds and then ordered that huge burger, fries that I don't even like and a Sprite. I wolfed down the burger, a couple of fries and had a few sips of the pop and went downstairs to the vending machines and grabbed some of those little chocolate donuts.  I felt guilty but I ate them ( not all but probably half of the pack). 

How do counsel my patients who do this nearly every day? I tell them that focusing on the bad doesn't help. I will make healthier choices the rest of the week- increase my exercise and make a plan for next time. I will be stressed again. I will be too tired to cook.  I will be too exhausted to exercise.  I don't pretend to be perfect. I don't pretend to have all the answers.  I know that if I am not able to work on my own issues I can't help anyone else work on their issues.

I read this interesting pledge that 2015 class of  medical students at Hopkins University developed with their faculty advisors:

• I will engage in regular physical activity.
• I will consume a balanced and nutritious diet.
• I will refrain from the use of harmful substances.
• I will diminish personal stressors and look after my mental well-being.
• I will encourage my patient to adopt these healthy lifestyle behaviors. 
• I will work alongside my patient as a partner in this journey.
• I will identify and guard myself from potential prejudices against my patient based on unhealthy behaviors, recognizing the often complex origins of these habits.
• I will respect and seek to understand the beliefs and traditions of my patient that affect his or her health.
• I will do my part to promote healthy lifestyle behaviors within my community.

I am so on board with this! 

The Inns and Outs of the Center

We share the vision of restoring this historic Inn to its former beauty. Our building has wonderful bones and the plans are being drawn up to make it into our Integrative Health Center. My heart races sometimes when I think of all that is involved in starting this project, but I have so many wise advisers and amazing supporters in this venture. 

Each time I walk through the spider webs in the hall, I am better able to visualize our finished space with natural light and polished floors. I imagine our patients walking in and being greeted by one of us. I imagine bringing them to the exam area and making the time to actually listen to them and working together to reach their health goals. I imagine watching outdoor cooking demonstrations. I walk by our movement space we are creating for yoga, Pilates and dance. I love looking out the windows to surrounding mountains through the desert landscape.

And then, there are the meetings with the architect and the reality of moving block walls in a building constructed in 1948. Creating ADA compliant hallways around huge weight bearing pillars. Finding out our beautiful sliding Shoji wall will mean massive demolition of block walls we had just assumed were drywall. 
A commitment to staying as "green" as possible is met by questioning looks by the powers that be.  The perfect layout with our long hallways circling the 4,000 square feet, suddenly being modified to accommodate OUTDOOR hallways. Endless weeks of studying the ideal patient flow and exam rooms are overturned by the constraints of current architecture. 

A younger me would have pitched a fit over the changes, but I have learned to believe that this will all work out for an even better design than we could have imagined. It will become a wonderful place for the transforming the health of our community. It will be the place our patients will be heard and respected. 

Staying on Track

Today, during those quiet moments at work between patient's I found an interesting link on Twitter about  fitness trackers. I was tempted to order one of those shiny, expensive  trackers and was nearly convinced that if I bought one, I would suddenly exercise more, eat healthier and stay on track with all my health goals  That may be true for a few weeks, but eventually it would end up in a drawer keeping my resistance bands,  pedometers and tape measure company.  Technology isn't the answer for me. Jaime Escalante was right- What I need is ganas.

Pretty pleased with my first attempt on Tabata workout. I am not sure I did it right, but tomorrow is another day.  I tried it with just a body weight squat, but I know it wasn't my full intensity at fist.  Glad to be making the effort to be back on track

Today was a day booked with sports physicals, well child checks and back to school exams.  One child was not over weight. ONE.  That is right, ONE. I listened to an overweight mother express frustration with her 14 year old daughter whose BMI was 43%.  I asked the mother who bought the food and prepared it. She told me that the rest of the family was trying to eat healthier and she was fixing two separate meals because the overweight child would not eat vegetables and only wanted pizza and hamburgers.  How the hell is this happening? All day, every day- parents are telling me that their child won't eat anything but junk.  The junk that the parents buy and serve up.

The Road To Hell

Trying to concentrate on the good things that I am doing takes more effort that self criticism.  My plan was to get up early and hit the gym here in the hotel.  Today's excuse is that I got in to the hotel late and didn't get to sleep until well after midnight and then woke up at 630-too late to work out before working from 8am to 7pm.  I fully recognize that is just another in a long line of excuses.  I wonder how I am going to motivate and help my patients move forward when I am not making fitness a priority.  I am not sure how folks who work long and crazy hours make fitness fit in their daily schedule.

I can be less than patient with folks who aren't employed when they tell me that they don't have time to work out or walk etc.  But some of us are mad, crazy busy working long, long hours ( This week I am working 10 hour shifts in one the busiest clinics I have ever worked)  Tonight's plan is to get to bed much earlier, so I will have at least 30 minutes of time for a physical work out.

On the positive side- I kept the Daily Challenge.  I made healthy food choices all day. I actually drank nearly enough water even though the walk in schedule was very busy in the clinic.  I listened to a third 3rd book this week.   The first two on marketing and now the Audible version of How to Win Friends and Influence People- Dale Carnegie. I am planning on using some of the positive talk to see if I can get my M.A. to do something. 

Waiting not so patiently to hear the news about the clinic build out.  I am trying to trust that it will not be as expensive as I fear.  They are going to have to be seriously creative not knock out those block walls.