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.
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.
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.
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.
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).
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’.
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.
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
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.
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.
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.”
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!
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;
the accreditation requirements for graduate medical education requires
that we document each aspect of our curriculum and our residents’
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
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.
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?”
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.
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.
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. |