Monday, October 20, 2014

Saying Goodbye to My Yellow Backpack



Ten years ago in high school, my then (and now!) best friend, Susanna, gave me this yellow Northface backpack.


At the time, I needed a new one and couldn't afford the then-trendy Northface packs being sported around school. When she gave it to me, it was practically new. Sue is and has always been there to help me out and keep me organized and on top of everything, even down to having a cool backpack.
The bag supported me and my books throughout high school, college and grad school. While I've never really been attached to stuff, something about that bag connected with me and I carried it for years. When I graduated grad school, I went traveling for 3 years around the world. I packed a traveling bag with clothes and my yellow Northface with the essentials I wanted close by.
Backpacking, for a long period of time shaped me and taught me things about myself that I was desperate to learn. There's a community among backpackers in which only the genuine are accepted, and the genuine are instantly accepted and loved. Lifelong friendships are formed in weeks and it seems that there are no outsiders. You can arrive in a hostel one day, and the next, be surrounded by a group of people you never want to leave. With each good bye, I packed my yellow bag and ventured to new hostels, new countries and met wonderful new friends. Some of those friends lasted as long as my stay, while some recently made the journey across the world to be at my wedding.
Traveling reinforced so many things about my personality that I knew, but were reinforced: adapting to change and new environments, chasing adventure, and working hard (more on that another day). What I didn't expect to learn though was how much stock I put in what other people thought of me at home. And how compelled I felt to measure up to what everyone else had or was doing. Without the pressure to have trendy, new stuff, I carried around my beat up old bag without giving it thought. No one commented on it and I never felt weird carrying it around. To be fair, most backpackers carried beat up old bags, but even still, you might know someone for weeks before they even asked you what you did for work back home. Because only the genuine survived in the backpacking world, anyone trying to be someone they weren't just to fit in, stood out and had a tough time connecting. This environment cultivated a true connection and a real appreciation for who I was. For probably the first time in my life, I was 100% myself all of the time. When you're truly connected with who you are, your inner voice and deeper desires connect with your thought process and have a much louder voice and provide a guidance that you simply can't ignore.

That inner voice was yelling for me to move back home and start the health coaching practice that would become Sweat and Butter.  I had been coaching clients along my travels but felt driven to come home and build a community that would guide and inspire them, as my travels had done for me. With me, I brought my yellow backpack. My first year home, I carried that thing around like a kid with a blanky. I carried it fearlessly to workshops, client sessions and corporate meetings.
Recently, I've become increasingly self conscious about walking into meetings with my beat up yellow bag. I went back and forth between, "It's me they're meeting, not my bag," to "First impressions mean a lot." Trading in my bag for a newer, more professional Michael Kors seemed like a betrayal to the powerful self confidence I gained on my travels. True to my ‘all or nothing’ tendencies, I attributed letting go of my bag to erasing everything I learned on my journey. I felt like moving home and fitting into trends meant that I had to let go of the confidence I carried with my Northface.
As my business grows, it is becoming more and more important to support my clients to stay true to themselves by staying true to myself in my practice. I encourage my clients to "fit out.”  What I've discovered in my struggle to let go of my bag is that you aren't defined by what you own or how you look. I preach it all of the time, and yet, fall prey to it myself from time to time anyway. What I didn't realize is that you can become equally defined by what you choose not to do, if the reason not to do something is out of fear of change and refusal to let go.
So today I ask you to bid my bag farewell with me. Across thousands of miles and over dirty floors, buses and business meetings, my bag has served its purpose.
Sibe on a bus with my bag. Ok, So we weren’t always slumming it.
As the zippers fall open unintentionally, and my belongings fall out on the sidewalk, my bag sending me a message. Move on, keep growing, and find a new bag to carry these changes through the next phase.

And as I move on, and my life continues to grow and change, my needs and my bag will too. Just like your body is always changing and it's important to not get stuck on one way of eating, your life will continue to grow and change and it's important not to get stuck on a belonging or in one way of living. Even if that way of life has served you in many ways, we're spirits born to ever shift and grow.
So share with me, what behaviors or belongings are you holding onto? Why are you holding on and what will change when you let go? 





Friday, September 12, 2014

An Expiration Date on Life

**Name of patient was changed to protect their identity.**

She nodded along quietly, her husband's hand lightly palmed on her lap.  Ms. Robbins had been through numerous chemotherapy sessions and two surgeries, the first of which left her without a uterus, Fallopian tubes, or ovaries.  That was nearly three years ago.  The second surgery left her without a large section of her bowel, part of her kidney, and a bunch of other ancillary tissue.  Despite all of our efforts, the cancer had survived.

While the oncologist explaining that her recent PET scan showed progression of her cancer, Ms. Robbins and her husband nodded along.  Her eyes shifted patiently from my preceptor to a glossy diagram of a uterus back to me as we described that we had run out of treatment options. The cycle continued like this for what seemed like an hour, but to my patient time in fact stood still.  Her eyes began to tell a story as she came to understand her prognosis. They were devoid of fear, and sadness had washed away through the years that had passed since her initial diagnosis.  She wasn't angry nor desperate; she and her husband were composed.  When she finally spoke, she calmly asked, "My daughter is getting married in July.  Do you think that my body will...um...hold up until then?"

---

Imagine for a moment that a fortune teller was able to tell you (approximately) when you would die.  How would that change your plans for the year?  How about your plans for tomorrow?  Would it force you to reevaluate your priorities?  During this visit with Ms. Robbins, the story told by her eyes described what it must feel like to have an expiration date placed on your life.

Ms. Robbins probably saw this day coming.  Again and again, a new therapy held the promise of buying her more time, yet surgeries and toxic medicines did little more than to make her nauseated and weak.  She's battled for three years, coping with the idea that an expiration date might soon be laid before her, and that day has finally come.  The oncologist's response was short, "Well...if we try more therapy, then it's possible.  But without any more chemo, I'd say maybe...three months?"  

Three months. 

At that point, the gaze that I saw in the Robbins' eyes spoke not of bikinis, finances, favorite desserts, or dress sizes.  Their eyes said one thing: I want to be with my child on her wedding day.  

---

Every day I counsel patients on lifestyle change.  Part of my success relies on tapping into the deeper reasons that they want to lose weight or improve their diet.  For most people, weight loss is, on the surface, a ticket to feeling sexy in a bikini.  But what happens when you achieve that goal?  Think about it...what about your life improves when you lose weight?  The bikini body might be good motivational start on your journey, but take a step back and consider the big picture.

We don't know enough about cancer to prescribe a lifestyle that will prevent it (entirely), but often times modern diseases such as cardiovascular disease, diabetes, and hypertension present with even shorter timelines.  We are all close to somebody that has died of a heart attack or one of the other complications of metabolic syndrome.  Ms. Robbins' battle with cancer is not meant as a tale to strike fear into your heart.  After all, fear is a poor motivator judging alone from the fact that many heart attack victims don't change their exercise or dietary habits.  Rather, it's simply meant to provide some perspective.  

---

It's hard to imagine being told that you have only three months left to live, yet this is the reality facing so many mothers, fathers, and children today.  A terminal diagnosis leaves no room for fear.  It dissolves the ego and forces a family to focus on the present.  I have experienced this in the gynecology oncology clinic where I work, and I am the son of a father diagnosed with a terminal illness.  Regardless of your involvement, witnessing the re-emergence of that little spirit behind the shadow of our colossal egos draws perspective into the forefront.  

And, from that vantage point, it is a lot harder to swallow.  


Nathan Riley, MD, is a Resident OB/Gyn at Kaiser Permanente in Los Angeles.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at nathan@sweatandbutter.com. You can also connect with him on Google+. 




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Thursday, August 28, 2014

What's the Deal With Gluten?

By Caroline Shannon-Karasik

These days, it’s hard to pick up a newspaper, turn on the television or surf the Web without seeing a mention of two little words: gluten-free.  But the truth is, while there is more information out there than ever, the wealth of knowledge has also caused a bit of misconception about the lifestyle, how it affects certain people and what the difference is between healthy gluten-free food and gluten-free junk food. 

Well, guess what? I am a gluten-free gal who has celiac disease, so I say now is as good a time as ever to suss out the details, right?  According to the National Foundation for Celiac Awareness (NFCA), an estimated 1 in 133 Americans has celiac disease, yet 83% remain either undiagnosed or misdiagnosed. And, as you might have guessed, the only treatment is a strict, lifelong gluten-free diet.

Why Is Gluten the Bad Guy?

Here's the short of it: When people with celiac disease eat foods containing wheat, rye, barley, triticale and/or contaminated oats (i.e. gluten!), their immune systems cop an attitude and create a toxic reaction that causes damage to their small intestines, making them feel like crap. Talk abut a host of symptoms that come hand-in-hand with celiac disease –– digestive discomfort, diarrhea and vomiting, chronic fatigue, nutritional deficiencies, migraines, reproductive health issues and anxiety are just a few. 

What’s more, mild to severe symptoms resulting from gluten intolerance and sensitivity are plaguing people left and right. According to the NFCA, research estimates that 18 million Americans have non-celiac gluten sensitivity. That’s six times the number of Americans who have celiac disease. Unlike celiac diseases, non-celiac gluten sensitivity does not result in an autoimmune response, but many of the symptoms, including digestive discomfort, bloating and cramping, migraine headaches, and fatigue, are similar. 

"The prevalence of gluten intolerance and celiac disease diagnosis is certainly remarkable and has clearly caught the attention of the medical community by surprise," says Jennifer Fugo, certified health coach and author of The Savvy Gluten-Free Shopper: How to Eat Healthy Without Breaking the Bank. "They've spent a massive amount of time generally believing that an immune reaction to gluten was of little interest and problem for those of us complaining of various issues that don't quite make sense when viewed separately."

Gluten on the Rise

So, why now? Why the increase in diagnoses? Experts say there are two main reasons pointing to the increased awareness of gluten and the nasty spell it has cast on many: 

Today's "wheat" isn't exactly wheat. Kiss that idyllic vision of farmers harvesting their grains goodbye. The truth is, very little of our grain production is done in a wholesome manner. These days, we're chowing down on refined grains that have been modified to suit the business that agriculture has become.
We like to eat ... a lot. Take the fact that glutenous grains have been hocus-pocused and match it with the fact that the overconsumption of food is an ever-expanding problem, and you've delivered quite the double-whammy to your guts. "What might be an occasional issue in the past for those sensitive has now become a monster storm of inflammation that rolls through the body at every bite, [causing] repeated damage to the body," Fugo said.

Gluten-Free Game Plan

So what are you to do? If you suspect gluten may be a creeper that lurks in your gut, then it’s time to pay a visit to your doctor for testing. And listen up: Don't stop eating gluten before you have a blood test –– it may provide a negative result. If the blood test proves you're a dead ringer for celiac disease or gluten intolerance, then the doctor may order a small bowel biopsy. Don't worry –– after the hell your intestines have been through, a teeny biopsy is a walk in the park.

Left untreated, celiac disease can lead to even more health problems, including Type 1 diabetes, infertility, certain types of intestinal cancer and osteoporosis. So guess what that means? This isn’t something you want to mess around with, mmmk?

Need More Help?

The National Foundation for Celiac Awareness and Celiac Disease Foundation offer loads of information, including a symptoms checklist, recipe ideas, shopping tips and information on the latest research.

Do you have questions about celiac disease or a gluten intolerance? Visit my Website SincerelyCaroline.com for recipes, shopping lists, and more, or send me an email at caroline@sincerelycaroline.com.

_______________________________

Pad Thai Veggie Noodles
gluten-free and vegan

ingredients
  • 4 cups spiralized zucchini and/or yellow squash
  • 1/4 cup gluten-free soy sauce or tamari
  • 2 Tablespoons toasted sesame oil
  • 1/4 cup pure maple syrup
  • 2 Tablespoons natural chunky peanut butter
  • 1 Tablespoon arrowroot or tapioca starch
  • 1-2 garlic cloves, minced
  • juice of 1/2 a lime

directions

(1) Peel zucchini and/or squash. Prepare spiralized pasta using a spiral vegetable slicer, like the Paderno World Cuisine model, and place in a large bowl. Set aside. (No spiralizer? Use your vegetable peeler to make quick “pasta” by simply continuing to peel the zucchini or squash, creating ribbon-like noodles!)

(2) In a small saucepan, combine soy sauce, sesame oil, maple syrup, peanut butter, arrowroot starch, garlic and lime, whisking consistently over medium-low heat. Continue whisking throughout cooking process, until sauce begins to thicken. Remove from heat and pour over veggie pasta, stirring to combine. Top with desired toppings and serve!


Caroline Shannon-Karasik is the author of The Gluten-Free Revolution, a certified health coach and author of the popular gluten-free blog Sincerely Caroline. Her writing and recipe development have been featured in several publications, including, VegNews, Kiwi, and REDBOOK magazines. She has been a long distance runner for more than 15 years and certified Pilates instructor for more than a decade. Caroline lives with her husband Dan and four adopted cats in Pittsburgh, Pennsylvania. 





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Thursday, August 14, 2014

"You're American, I presume?"


[originally posted at my old tumblr blog in 2011]
I just returned from a short trip to the Dominican Republic.  I initially thought that the DR was an oversized Cancun, but this trip changed my mind.  My sister - who is currently living there - was my tour guide.  The highlight of the trip was Cabarete.
The majority of the non-locals at the beach aren’t travelers from what I could gather.  They were living/working in the small beach town, and I left the DR inspired as a result of the mostly Europeans’ outlook on life.  
I’m currently finishing my second year of med school, so I brought my USMLE Step 1 prep book with me to the island, and I opened it up on my lap as soon as my butt hit the lounge chair.  A Dutch man approached me, took my book from my hands, and closed it at the foot of the chair.  
Him: “You’re studying medicine, correct?”
Me: “Yeah…how did you know?”
Him: “I was just watching you walk from the restaurant to your chair, and your behavior reminded me of a doctor.  You’re American, I presume?”
Me: “Yeah.  Why?”
Him: “Americans work too much.  I suggest you just relax and enjoy your vacation.”
My book remained closed for the rest of the day.  I played frisbee with a kid on the beach. I shared some jokes with my sister.  Admired the dozens of kite surfers.  Tasted the salt water. Got a sun burn.  Spoke with some locals.  Bought a mango from a Haitian lady.  Soaked up the smell of the sand.
We spend so much time worrying about our happiness in the future that we forget all about enjoying the present.  In med school, the majority of our time that isn’t spent sleeping is spent with our heads in the books.  We complain of the misery, madness, and frustration that comes with the demands of our program, yet we trudge on because we crave a future in which we enjoy financial stability, a dream career, and the respect and admiration carried by physicians.  Yet there are far too many variables at play to guarantee that all of this hard work will bring us happiness in the future.  
On the other hand, we have complete control over our present.  The variables are laid out on the table in clear view.  You can dwell on the negative or focus on the positive.  In the future, your career-driven focus will hopefully pay off.  But it’s not a guarantee.  Taking time to visit friends, write letters, kiss your significant other, savor your dessert, indulge a runner’s high, smile like a unicorn while plunging face first into the waves off the North coast of the Dominican Republic: In the present, there are various devices which can guarantee you happiness.  
When you’re on your death bed, you won’t dwell on the test score or the career status that were part of an indeterminable future.  Rather, you’ll reflect on those little guarantees that you indulged in throughout your ever-changing present.
Reform Yourself.  Tomorrow could end today.


Nathan Riley, MD, is [now] a Resident OB/Gyn at Kaiser Permanente in Los Angeles.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at nathan@sweatandbutter.com. You can also connect with him on Google+. 




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Monday, July 7, 2014

Here and Now: The Silver Lining of Your Present

In two weeks, I will be moving to Los Angeles to begin a four-year residency program in obstetrics and gynecology.  To celebrate the move, I have been trying to catch up with as many of my Pittsburgh friends as possible.  Recently, on the way back from dinner with some family friends, I was riding with my mother down the highway, and we hit a patch of traffic.

As she cursed out the other drivers, it occurred to me how futile her efforts were.  She angrily encouraged the driver – yours truly - to straddle the dotted line so that the other drivers – in an equally frustrating situation – couldn’t creep up in front of us.  She had been at work for ten hours prior to our meal, so she was understandably grumpy about the traffic, but I couldn’t help thinking to myself, “What’s the point?  How does allowing a car or two in front of us change her situation?”  My mother only began to calm down when the traffic started to move, though I tried repeatedly to remind her that chilling out and singing along to the radio with me wasn’t the worst way to cap off our evening.

We have all experienced that feeling of dread that comes with the anticipation of sitting in traffic, especially at ten o’clock at night.  My mother complained that now she wouldn’t “be able to get to bed on time!”  That she had “so many things that she wanted to get done for work before she went to bed!”  But what she hadn’t considered was the silver lining.  This was one of the final evenings that she would be spending with me, her only son, to whom she had reiterated on numerous occasions how sad she had been that I was leaving to the West coast for four years.  Had she just taken a moment to readjust her perspective, she would have seen the silver lining: thirty extra minutes of uninterrupted time with her son. 

Our population always seems so eager to be somewhere.  When we finally arrive to wherever it is that we were so eager to get, we quickly become bored with our surroundings and turn to our smart phones to entertain us until something exciting happens.  When we do achieve excitement, we feel compelled to take a selfie to show how great our lives are for that brief moment.  But after the moment has passed, we are simply waiting for something else to happen.

#awesome
In general, we have forgotten how to live in the present.  Although this concept has become a clichĂ© popularized in Internet memes, maybe there’s something to it?

This concept of being present is rooted in many Eastern philosophies.  For instance, in Buddhism, suffering is attributed to our efforts to control that over which we have no control. Buddhists thus believe that by ridding ourselves of desire – sex, money, power, fame, etc. – we can rid our lives of suffering. After all, you can’t control your past (what’s done is done), and you certainly can’t expect to manipulate your future.  What you do have full control over is your present.  That is, at this moment, you have 100% control over your comfort and happiness, but many individuals are so consumed by what’s on the horizon that they forget to enjoy the present. 

In January, 2010, I set out to complete an Ironman distance triathlon, which consists of a 2.4-mile swim, 112 mile bike ride, and then a full marathon.  After nine months of training, I stood at the finish line with my supporters for only a few minutes before heading to the transition area to gather my things for the ride home.  In hindsight, I can say that it wasn’t as climaticcat as I had hoped it would be, but what exactly had I been expecting?   I was there to become an Ironman, wasn’t I?  In the excitement of finishing the race, I failed to spend just a few extra minutes to look around at my surroundings, to take in the smells, to acknowledge the perfect machine into which I had crafted my body.  All I could think about was getting home for school the next day.  Does this sound familiar? 

Eckhardt Tolle, author of “The Power of Now: A Guide to Spiritual Enlightenment”, refers to the ego in describing this pathology of the mind.  The ego is concerned only with how it came to be (the past) and where it is heading (the future).  In our society, we live by a credo that one must preoccupy themselves with investment for the future, and, in order to accomplish this, we must learn from the past.  But what about the present? 

This illness leads to car accidents due to irresponsible drivers texting or answering emails while speeding down the highway.  It drags a father away to answer a business call the moment before his son gets his first RBI in little league.  It encourages bad habits like eating in front of the TV instead of mindfully enjoying every bite of a freshly tossed salad.  It’s the driving force behind this strange concept that accumulating more material “stuff” like electronics and fancy cars is going to make us happier.  It’s a societal pathology, and it’s likely responsible for the low-grade anxiety that pervades many households and work places.

The good news?  You have all of the tools to fix it.  Extreme athletes experience this on a regular basis.  Rock climbers, for example, are intensely aware of the position of every part of the body at every moment while they are clinging to a wall one-hundred feet in the air. Climbers aren’t thinking about bills, the stock market, financial investments, or other tribulations of life when they are hanging off a rocky cliff side.  As a result, adrenaline junkies experience a “rush” that results from escaping the present, even for a brief moment.

It feels good to live in the moment, but you don’t need an extreme sport to enjoy the present.  Think back to a time when you were focused on the present.  When did you last find yourself thinking, “Wow…life is wonderful”?  This used to be our normal state back in childhood, before our egos had fully formed.  As a child, our minds and senses were wide open, but somewhere along the line, in the hustle and bustle of adult life, we forgot altogether how wonderful it is to be present.

This past weekend, my fiancĂ©e and I went on a hike in Ohiopyle, PA.  There’s an outlook there that has always dazzled my senses.  Dangling your legs over the ledge, you can see for miles.  You can hear nothing but the sound of the rapids on the river far below.  Stare at the dirt around your feet, and you’ll see hundreds of organisms shuffling around in the dust.  The sunlight at four o’clock was still bright overhead, illuminating the leaves that created a natural canopy overhead.  I had left my iPhone back at the car, so there were no distractions from the feel of my lady’s hand in mine.  Laying back with my head rested on my hands, I had one of those rare moments.  I thought to myself, “This is why I work so hard; this is what life is all about.  This moment is perfect.”

If you are cognizant of the way that you allow anxiety and impatience to rise up within you, it’s possible to spend more of your time in the present, but this is entirely dependent on you.  Are you willing to forego your busy mind once in a while?  The stuff of the past may have been grand.  Likewise, your anticipations for the future might change your life for the better.  But you have no control over those things.  What you can control is this very moment.

Where to start?  The Zen master Rinzai would advise you to ask yourself, “What, at this moment, is lacking?”  Turn off your computer and go hug somebody you love.  Show them that you appreciate them.  Stop and smell the flowers.  Realize that there’s no better time than now to make happiness a reality, because you never know what the future holds.


Nathan Riley, MD, is a Resident OB/Gyn at Kaiser Permanente in Los Angeles.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at nathan@sweatandbutter.com. You can also connect with him on Google+. 



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Tuesday, June 10, 2014

The Biggest, Baddest Disease Facing Medicine Today? Human Behavior

Two college students walk into a bar.  It is about five o'clock in the afternoon and one says to the other, I bet I can drink more beer than you.

The second student smiles and says, Why dont we see who can drink the most before midnight, and the loser pays for both tabs?

The first student exclaims, Oh! Im definitely going to win! They each open their tabs and order a beer.  The first student eagerly gulps his drink and immediately orders another.  The second student slowly sips his drink, enjoying its taste and refreshing coolness.  Before long, two hours have passed and the first student slurs to his friend, “Mmm already drank five annnn I bet-ya din’t even finish yur seggond!"  The second student smiles and again sips his beer.

As the night approaches midnight, the second student decides to locate his friend whos been lost to the growing crowd at the bar.  He finds him alone, slumped in a booth near the back of the bar.  He tries to rouse him, but his friend is hopelessly unconscious and snoring. He throws his friends arm over his shoulder, makes his way to the bar, and discovers that, overall, he had more to drink than his slumbering friend.  In fact, the last beer on his friends tab was only at 8PM!  He generously pays both of their tabs before helping his friend home.

Despite being a somewhat silly anecdote, an analogy can be drawn between this series of events and societal perspectives on health.  We bite off more than we can chew, we misunderstand how our bodies operate, and we often limit our own foresight of consequence. The same attribute that limited the first student’s ability to win his prospective contest can be easily seen in modern medicine.  In fact, as a budding Emergency Medicine physician, I was once asked, “What is the most difficult disease to treat?”  After having finished only a few months in various Emergency Departments, I contemplated the immense array of disease and illness that plagues humanity before realizing an appropriate answer: human behavior.

We are complex beings, products of not only our personal environments and experiences, but also the experimental result of millions of years of evolutionary trial and error.  Our genetic constructs, though, being 99% similar to each other (and 50% similar to bananas), still create the enormous level of diversity we see in our species.  It is unfortunate that this same genetic construct can incur the wrath of nature: cancer, diabetes, nearsightedness, baldness, and so worth.  It is with this sentiment that individuals identifying genetics or molecular biologys role in human illness stand to carry a sense of truth.  However, it is with this same sentiment that these individuals begin to unknowingly accept certain defeat.Human behavior is as diverse as our individual genetic constructs, but, strangely enough, just as homogenous as well.  We often overlook the simple aspects of our behaviors that are strikingly similar in favor of identifying our unique traits, but I ask you this: When you are hungry, what is your first instinct?  When you are tired, what do you want to do?  Time and time again, “repeat business” presents to emergency rooms, doomed to a seemingly endless cycle of disease relapse and medical treatment, all the while ignoring the role of behavior in the cycle’s perpetuation.  These patients would gladly like to break the cycle, for, as it currently proceeds, they self-identify feelings of misery, pain, guilt, and hopelessness on a daily basis. Yet, after being discharged from the hospital, their illness having been “tuned-up”, they relapse right back into the same cycle!  It is not difficult to see that both themselves and the healthcare system have failed them, for while patients of certain disease types are often victims of themselves, they are victims nonetheless.

What makes breaking this cycle so difficult?  What prevents people from identifying perpetuators in their lives and striving to amend them?  In many cases, lack of knowledge may play a role.  Simply overhearing conversations at the supermarket underscores this hypothesis, No, dont buy those cookies, theyre unhealthy, but make sure you grab a box of Count Chocula because it has a ton of vitamins.  Some people simply do not know the difference between healthy and unhealthy.  How could they?  It is entirely unreasonable to assume that every person has a basic level of understanding of health, whether it be diet, exercise, or disease management.

Another commonly observed barrier is the amount of effort needed to enact change. Improvements do not come easy, nor do they occupy a single facet of lifestyle.  Changing only a single aspect of an afflicted patient’s life is much like changing only one tire on your car.  While an isolated improvement has been made, the overall function of the car has not been drastically improved.  Unfortunately, it is difficult to sustain prolonged improvements in patients suffering from a disease cycle, since, cumulatively, it may take more effort than that person has ever had to expend.  Four tires cost far more than just one, do they not?

Just as importantly, patients may not understand or identify potential improvements and abandon their efforts with feelings that the changes are simply not worth it.  Imagine if I asked you to walk into your basement every morning to ensure that a light bulb in a far-off corner was turned off.  I tell you that it would save you money on your electric bill while also giving you a tiny bit of exercise each morning.  After a few days, you may abandon the task, deeming the idea to be unworthy of the necessary effort.  However, if everyone with a basement were to do this, the energy demand of society as a whole could drastically decrease.  Patients often view the effort it would take to change their lifestyle from the perspective of the person walking up and down the stairs every morning: an unfamiliar and potentially irritating task that offers minimally observable rewards.  

A physician's view of a patient's efforts, on the other hand, reflects the comprehensive advantage that society would experience as a whole: a very simple and relatively easy task with enormous benefits.  The human body is that society, your own society, a gross aggregate of varying cells, tissues, and organs, each dedicated to a specific function while working together towards a common goal.  Through this lens, it is now much easier to see how comprehensive care can suffer from even the smallest infractions.  You see, sins of omission stand to cause just as much damage as the sins we actively commit.

There are an innumerable number of additional barriers that preserve the cycle of disease in patients lives.  Perhaps the person has already admitted defeat and is relegated to the bare minimum until (morbidly) they die.  Or maybe they are financially limited from enacting positive change.  In fact, resource availability could serve as its own dissertation for disease cycles.   Above all, though, the most pervasive attribute of all of these barriers is the role human behavior plays in perpetuating them.  We all have unique life experiences, environments, and perspectives, yet we are all governed by the same inescapable biological laws that mandate the best way we should live our lives so as to maximize life.  I certainly do not claim to know how to begin to improve this system, but I am compelled to recognize the importance of individual considerations in disease perpetuations.

My last analogy takes place in the kitchen sink. The only way a sink remains empty is if the drain can move water faster than the faucet can provide it.  It is your goal to keep the water flowing down the drain as quickly as possible.  All we need is for it to drain just 51% faster than the faucet can provide water, and the sink will never overflow. To bring this full circle, at patient's behavior is at least half of the battle against human disease.  If you do 51% of the work, you can get off of this endless disease cycle that I see so often in the ER.


Vedant Desai, MD, is a resident ER physician at Allegheny General Hospital in Pittsburgh, PA. You can reach him at vedant.g.desai@gmail.com.





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