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It's Not Compulsive If it's Helpful, Right?

Posted By Randall Reitz, Thursday, April 14, 2011
Updated: Wednesday, May 25, 2011
OK, true confessions. When engaged to marry as an undergrad at Brigham Young University (at BYU you’re either married, engaged, or actively pursuing engagement) I took a course titled "preparation for marriage”. The class content was outstanding, and included a mixture of communication training, family-of-origin orienting, sexuality awareness raising, and expectation lowering.

Despite the bounty of helpful science that was shared, only one off-hand comment remains specifically lodged in my consciousness. The teacher, a slender woman in her 60’s, made the observation that if a person only puts on 1 pound per year after marriage, by mid-life he or she will be overweight, and before dying will be morbidly obese. I did not want to be morbidly obese.

That being said, awareness of a potential problem is rarely sufficient for avoiding said problem, see: overweight doctors, stressed-out therapists, and bankrupt accountants. Ten years (and a divorce, remarriage, and child birth) later I found myself exactly 10 lbs heavier than when I sat in that fateful class.

While the premarital education hadn't had its intended effect, the moment of epiphany did. For the first time in my life I started jogging regularly. I began by running 2 to 3 miles around a local park a few times each week. In the process I found a partner who shared my running cadence and my interest in centrist politics, post-modern Mormonism, and raising children to be nerds. Six a.m. runs became the highlight of my week.

To keep track of my progress I started a simple spreadsheet for recording how often I ran, times in races, and occasionally a weight. Eventually I added graphs to the spreadsheet because I found the downward slopes motivating. Over time the spreadsheets became more sophisticated, including an automatically tallied point system for all forms of exercise, and monthly goals for points (100), days with at least 1 point (90%), and ratio of running vs other forms of exercise (1:1). I was in heaven (see: "raising children to be nerds” above).

Over the first few months I lost the 10 pounds and over the next 5 years my weight was homeostatic. As every first-year systems therapist learns, homeostasis is not stagnancy, but variation within limits. My limits were up or down about 2 pounds. When I moved to Frisco, Colorado my weight dropped another 5 pounds, I believe because of higher metabolism from living at 9,000’.

In the last months of my mountain years my work demands had become so consuming that I discontinued tracking my exercise and weights. Then, I moved back to Grand Junction and started my current job where I have unfettered access to free food in the hospital cafeteria. Within 6 months of stopping the spreadsheet, my weight was back up the 15 pounds that I had lost, and I was back on my way to the dreaded pound per year.

So, I brought back the spreadsheets, and for the first-time, I started weighing myself everyday. I was quickly able to re-gain my sporting lifestyle and re-lose the weight. With this close observation, the weekly average for my weights narrowed to a 1-pound range. Proof positive of the axiomatic, "that which is tracked moves in the desired direction”.

Admittedly, I do more than just track. I’m also 1.5 years into a habit of only drinking water and milk. When my weight gets 2 pounds over my goal weight I don’t eat sweets for the day and remind myself of this deprivation by writing "NST” (no sweets today) on my hand with a marker. This common medical acronym is cause for concern for my colleagues who are unaware of my habit and of laughter and reassurance for the previously initiated.

I had it all figured out.

And then, one day I was in the precepting room of my residency program—consulting with the young doctors regarding the behavioral issues of their parents. I felt a twinge of pain in my lower left flank. I quietly got up, did a lap around the clinic and returned to the precepting room massaging my side and walking with a slight hitch. One of the more brilliant faculty physicians looked up from her computer saw my gait, observed "you have a kidney stone”, and went back to her computing. Within 5 minutes I was writhing on the exam room floor, getting a rushed testicular exam from a colleague (evoking thoughts of how adolescent girls must feel in the back seat) and limping off to get a CAT scan while clutching a vomit-filled garbage can.

My wife still gets upset when women tell her that kidney stones are worse than labor pains.

Looking back, I make sense of this occurrence as the defining moment of when healthy, fastidious habits devolved into compulsive behavior. According to the DSM-4, repeated thoughts and behaviors aren't classified as obsessions and compulsions unless they cause distress or disruption in the person’s life. Or, more technically: "The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.”

Sometime in the previous 6 months, I had become so committed to maintaining the weight that I wanted, that I had taken up a bad habit. As my spreadsheet only included the lowest weight for the day, on days when I didn't like my morning weight I would put off eating and drinking in the morning and weigh myself again before lunch. Worse, on weekends my lowest weight was at the end of a long trail run. If I didn't like the weight before the run, I wouldn't drink much water during the run and then wouldn't re-hydrate until I got back on the scale.

In recounting, these steps are embarrassing, but worse, I’m convinced that they contributed to my developing kidney stones. This same family doctor who diagnosed me has helped with my on-going treatment. She informs me that one of the most important steps in preventing new kidney stones is to drink large amounts of water. Ugh!

One year later, I’m still as meticulous about tracking exercise and weights, but I've made an accommodation to ensure that my approach is more healthy. I now weigh myself only 1-time per day—first thing in the morning before breakfast or any exercise. This, then stimulates extra water drinking because I find that it helps fuel my exercise and temper my appetite.

What on earth does this have to do with collaborative care?

Well, as a therapist in an integrated family medicine residency, I’m constantly aware that it is a compulsive milieu:
  • We track all our warm introductions, joint appointments, and inter-disciplinary consults for grants;
  • The EMR and patient registry "tickles” us to pay attention to minute details of patient care;
  • Fear of a bad outcome or a litigious patient prompts extra tests and images;
  • We’re now sigma six and "lean” trained to practice healthcare using the same processes that pilots use to avoid crashes;
  • Meeting the accreditation requirements for graduate medical education requires that we document each aspect of our curriculum and our residents’ evolving competency.
Like my spreadsheets, this attention to detail is helpful. It helps to ensure efficiency, patient safety, and fidelity to our healthcare model. But, at some point the demands pile-up to an extent that one barely has time to look up from the computer screen to collaborate with a colleague or to motivate a behaviorally-challenged patient.

For example, our new EMR is so time-demanding that laptops are now ubiquitous at our resident education days. At last week’s session 19 of the 20 participants were only nominally aware of the presentation because they were "working their boxes”.

Pursuit of best practices can result in worst practices.

A wise man once asked: "If a son shall ask bread of any of you that is a father, will he give him a stone? or if he ask a fish, will he for a fish give him a serpent?”

Obviously, people who choose to practice in primary care, do it to offer our patients bread and fishes: we aren't in it to offer stones or serpents to the unwell. But, neither did I start tracking my weights to give myself a stone.

When we find ourselves with a stone, we need to step back, re-calibrate, and return our focus to the pole-star. As we consider the excitement of each new healthcare innovation (PCBH! PCMH! ACO! EMR!) we do well to remind ourselves that the indelible center of healthcare is the relationship between the patient, the family, the community, and the clinicians who have the privilege of joining them in the pursuit of wellness.

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Randall Reitz , PhD, LMFT is the executive director of CFHA and the behavioral science faculty at St Mary’s Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.

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Kat O'Boyle says...
Posted Monday, July 4, 2011
That's it. It's time for a career change: the new weight loss guru for nerds everywhere. Your book could have detailed descriptions of these spread sheets and percentages, and you could travel the U.S. and speak at conventions (Star Trek conventions????). I have to say, it seemed like it was working so well until the kidney stones, but I suppose that is the point, and I think that lesson applies to almost everything in life. The fact that you had this realization about yourself is impressive, and the most inspiring part of your story.

The tidbit about gaining 1lb. a year is terrifying. I wish I were better at spreadsheets....
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Randall Reitz says...
Posted Monday, July 4, 2011
Kat, embrace your inner-nerd (or inner-Trekkie) and start tracking important life data points. You'll find that they move in the desired direction. I know there is something that you've been counting recently. Perhaps you should begin counting digitally. :)
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