Doctoring Healthy Living Knowledge Nutrition Reflection

Healthy Privilege, Social Fabric, Education — Perspective means a lot.

Perhaps writing about health matters from the perspective of a cardiologist/bike racer is a little like parenting: At times the message seems less than compassionate, even though it’s born out of concern for others, knowledge and a tincture of middle-age experience.

The many excellent comments on my recent telomere/heart-health post stirred me to write a little more–about perspective and mindfulness.

Let’s just get to the comments and I’ll expand. The first one comes from Carolyn Thomas of the HeartSisters blog.

My hunch is that you are speaking from the perspective of a competitive cyclist, meaning that you enjoy what Dr. Ann Becker-Schutte calls “Healthy Privilege”, and for whom the prospect of patients (never mind AHA presidents) being unwilling/unable to embrace Ornish lifestyle makeovers is hard to comprehend.

Perspective is an important consideration. I like to talk about parallax—that is, how the same image can look differently depending on the position of the lens.

The truth needs to be told about my perspective. It is true that I have been gifted good enough health to race bikes competitively (locally at least). It’s also true that I once was overweight, out of shape and hypertensive. In medical school and residency, I weighed well over 200 pounds. I got that way by eating too much and moving too little. One Sunday, after a Jim McKay broadcast of the NY City Marathon, I went for a run. It felt good. The next day I went for another run. Then I bought a running magazine and a couple of books. From then on, healthy choices became the norm.

Do I have a healthy privilege? Yes, but it started with the choices I made at the busiest time of my life. (In those days, residents had no work restrictions.) It is rare to see a patient my age or older who enjoys a healthy privilege without having earned it by stacking together lots of good choices over years. Luck is important as well.

Another truth: I don’t eat a diet anything close to Dr. Ornish’s. Just because one writes about healthy behaviors does not mean one employs them perfectly. I eat better than the average American. My weaknesses are 1) fast-burning carbohydrates and 2) not stopping soon enough once I start eating. So like all doctors, I’m human just like you. During race season (now), I talk to myself everyday about food choices. It’s a struggle keeping the same pant size.

Andy Bailey’s comment really hit me hard.

They say laughter is the best medicine.

When I face a 60-year-old who was fired because of his age, and his wife has serious medical problems, and his daughter is a drug abuser, and he has to raise two small grand children aged 2 and 4, and his house is being foreclosed, well I tell him not to stress out about stuff, go ride his bike, and shop at Whole Foods and Fresh Market. When he stops laughing, he admits that he really does feel a little better.

Ouch. This comment underscores the power of words, and the importance of tone and clarity. One topic that comes up repeatedly when I chat with my imaginary friend is compassion. Concern for others is at the core of doctoring. Everyday, I tell myself to see the suffering in others. In writing about the importance of making time and being motivated, I don’t aim to patronize or minimize the difficulties of others. Rather, what I aiming for is the teach-the-man-to-fish approach to health. The medical behemoth here in the US likes to hand out fish.

Dr. Nieder’s comment highlighted the notion of intent: (Editor’s note: Dr Nieder authors the thoughtful blog — Family Practice 2.0)

When I see the 298 lb guy who works for corporate America, who calls 18 holes of golf three times a week exercise, is looking for his testosterone shots to somehow make his fat magically disappear and swears he doesn’t eat much, I agree with you. But when I see the single mom with two teenage daughters who works customer service for Humana, who barely gets a vacation and if she has to leave work to care for her sick child, she pays for it out of her “Allowed Time Off” (there goes the vacation) I am agreeing with Andy. While we are waiting for corporate culture to change (ROFL) my patients are not looking to extend their telomeres, they are just hoping to survive one more week. That may not be what you intended, but this is what many of my patients would hear.

Yes, of course, it’s not always that simple to be healthy. I get that. This is why I am a student of all things education and social fabric. Somewhere I read that good education and a strong social fabric form the core of a healthy society. And it follows that if society is healthy, then so are its inhabitants. Visiting places like the Netherlands and Germany reinforce that logic.

Some personal perspective on social fabric: Though I am only half-Italian, I was raised in an Italian family. My grandparents gave a parcel of land to my parents. Mom and Dad built a house there, and my grandparents helped raise us four kids. We were blessed with a safety net. My grandparents (and their families) helped my Mom and Dad. We were immersed in love and support. Lots of the kids I grew up with in Windsor Locks, Connecticut had similar deals. And it wasn’t just a family safety net. Most kids I knew attended the same church, played on neighborhood (not traveling) sports teams and went to the one big school in town. There was a real social fabric. I was lucky.

I was also lucky with education: I grew up a little scared of life. Didn’t you? My Dad convinced me that learning algebra was a metric for success in life; my guidance counselor assured me I wasn’t smart enough to be a doctor; staying on sports teams proved awfully damn hard and low-paying jobs at a young age were tough. One summer during college I worked third shift in a union-controlled frozen foods warehouse. That was educational. Again, I was lucky.

Of course it is right to emphasize that all patients don’t have the same luck I had. I know that, but my words didn’t embody it. It’s something I’ll work on going forward.

I’m grateful to those of you who take the time to write comments. Your words make me look inward and think. That’s a good thing for a learner to do. Thanks.

Perspective means a lot.


6 replies on “Healthy Privilege, Social Fabric, Education — Perspective means a lot.”

Thanks so much for this, Dr. John. Thanks especially for sharing your own experiences in the ‘social fabric’ paragraph here – you were indeed blessed. This background helps to reveal a pretty basic chasm between you and the kind of heart patients I hear from online and at my presentations. I’m frequently gobsmacked by the types of questions/comments I get from women who, externally at least, seem pretty competent/articulate/intelligent.

What (usually) helps me fight the urge to figuratively smack them upside the head was one powerful moment I experienced shortly after my own heart attack. I was back home but still in shock, feeling very ill, barely functional, and depressed about what the hell had just hit me. So severely depressed, in fact, that my doc referred me to a cognitive behavioral psychologist, who on our second visit looked brightly at me and said in her too-perky voice: “I know! Why don’t you sign up for an interesting class at the university?” This statement told me everything I ever need to know about this professional; I was too exhausted to say what I wanted to: “You have NO CLUE about what it’s like to be me!” I could not manage to brush my teeth – how on earth could I take even the first step to sign up for a !@#$!! class, never mind attend?

So much of what you’re writing here (and certainly the ‘telomere’ comments from your readers) reminds me of Dr. Victor Montori’s work on what he calls “Minimally Disruptive Medicine” at Mayo Clinic, and particularly his belief that often the “burden of treatment” can simply exceed a patient’s capacity to cope. It reminds all of us that so often, we simply have NO CLUE about another person’s real life. Here’s his illuminating explanation:

Great reflective post by John. Agree completely with his points that it ain’t always easy. John has been lucky (and I thank my lucky stars each day for my own luck) – though in addition to luck, we’ve both made overall healthy lifestyle changes consistently over a period of years. That at least helps to optimize possibilities.

That said – I’ll add that I’ve spent a 30-year academic career seeing patients and overseeing primary care medical students and residents that I taught seeing their patients in a family medicine center that had a high proportion of less than well-to-do people as our patient panel. I fully acknowledged that I could never totally know what it was like to be them – but I could listen; I could reflect; and I could work with these patients as a team to discuss their situation and what might be done given their circumstances to improve whatever their medical and life situation was. Being open to truly listening and contemplating with these patients what would be realistic choices for them worked. Many of these patients got to a point that was clearly better than their starting point – and to me, that was success. Full (expensive) workup and the latest (expensive) medications were not necessarily the treatment options aimed for.

I continue to find your honesty and transparency so refreshing when it seems so much effort is given to “better health in ten easy steps!”
As a NP who worked with homeless patients primarily and the cacophony of reasons for their situations, talking about their “health” was like asking a student who had never had lower math to do algebra. Safety, food, shelter were absent so management of diabetes (where to keep insulin?) was a bit down on the hiearchy of needs list. I always felt the truly most caring and sensitive gift I gave them was being truly attentive and ‘hearing’ their story. Cause there was ALWAYS a story!
Now as a heart patient, I sometimes find myself in the same circular thinking prison. Do ‘this’ to feel better – but making the choice depends on so many ancillary components– feeling good enough to try to do it, eating right to feel better, taking all my 12 meds for CAD and DM and thyroid and—affording them! Then I listen to myself and hear whining. What would I tell my patient? Let’s just tackle these one at a time! I readily admit choices I’ve made since my CABG in 2004 have probably kept me here beyond my expiration date!
Do you know we have Mandrolas in Houston who have been fine purveyors of delightful Italian cuisine for many many years? Related?

Dr. Mandrola, sometimes truth is not supposed to be palatable! i love your posts & your honesty & humility! As one of my mentors says, “i (you) dont make the rules ; i (you) only observe them.” So it is with good health & exercise!

I came across these words recently, written by Dietrich Bonhoeffer: “The man who despises another will never be able to make anything of him. Nothing that we despise in the other man is entirely absent from ourselves…We must learn to regard people less in the light of what they do or omit to do, and more in the light of what they suffer.”

The last sentence hit me right between the eyes.

I hope it helps.

Like Sir Osler, I believe phlegm is an essential quality forma doctor. You sir notmhave phlegm but a better, happy sort of phlegm. I admire your energy for writing.

I practice out in Colorado. Today I saw a patient visiting from Kentucky, whose problem list included atrial fibrillation, resolved after ablation. I almost blurted your name out!

Anyhoo, I appreciate your blog.

Comments are closed.