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.

Progress Notes

Reaching goals isn't always as easy as I imagine. There are always those unexpected roadblocks that need some creative thinking to work around. This once only a dream idea of providing the quality of healthcare that I know is possible is taking shape. It is even much bigger and more beautiful than I had imagined on my own.

Each day brings a new and sometimes surprising development. Today, the architect that will help us with our build out showed us even more wonderful ideas than we had imagined on our own.  During our walk-through today we sadly discovered that some walls that need moving are load bearing. All of the thick walls that we thought were dry wall or lathe and plaster are actually mason walls with drywall on the outside of them, meaning that knocking some of them down may mean that we have to get permits and inspections which could be VERY bad for us.  Then one of the partners came up with a very creative idea for working around everything. The architect was inspired to think more creatively.

So, we have our practitioners, we have our space, we have a mission and we even have some amazing business plan ideas. Now, the hardest work begins as we each individually and collectively form our legal structure. We are all caregivers, health care providers-healers...none of us are skilled at this next phase, but we are excited to learn and grow in this leg of our quest.

I am grounded enough in reality to understand that in a perfect world even though we are promised to be ready for patients by late fall- October, or early November, life can happen.   There are nearly always interesting events along the way.  But we are getting there and I am so very joyful!

Practicing and Preaching

Some days I feel a little guilty encouraging my patients to make healthier choices, when I am not in the best shape. . I mean, I am by no means a super model, but I am not ready for the biggest loser either. I actually relate to the same struggles that my patients complain about- busy schedule, long work hours, lousy weather,  and endless other excuses to drive through for that burger, or skip the exercise.  I was reading a Deepak Chopra tweet about that guilty feeling that we all get when we look in the mirror and realize we are not in the best shape.

I am starting this blog as a place to share my own struggles and successes. A place to talk about things that I am trying or reading.  I hope that a few health care providers and wellness folks join in to share some of their stories as well.