Do You Want to be Well? How About Healthy?

Crowds of sick people—blind, lame, or paralyzed—lay on the porches. One of the men lying there had been sick for thirty-eight years. When Jesus saw him and knew he had been ill for a long time, he asked him, “Would you like to get well?”
John 5:3-6 NLT

“Would you like to get well?” Seems like a silly question. Who wouldn’t want to get well? Yet Jesus asked, and we can be sure that he had a good purpose in doing so. For this paralyzed man, getting well would mean a whole new life, and change, even positive change, is hard. He’d been ill for a long time, 38 years; perhaps he was middle-aged or even elderly at this time. If he got well, where would he find work? Where would he live? Life would be more uncertain and maybe considerably more difficult. Was he sure that’s what he wanted?

Jesus, in his person, poses the same question to all people. Do you want to be well? Do you want to be reconciled to God, to have life in abundance, to be healed? If so, come and follow me. Yet Jesus warns us that the cost is high.

A large crowd was following Jesus. He turned around and said to them, “If you want to be my disciple, you must hate everyone else by comparison—your father and mother, wife and children, brothers and sisters—yes, even your own life. Otherwise, you cannot be my disciple. And if you do not carry your own cross and follow me, you cannot be my disciple.”

“But don’t begin until you count the cost. For who would begin construction of a building without first calculating the cost to see if there is enough money to finish it? Otherwise, you might complete only the foundation before running out of money, and then everyone would laugh at you. They would say, ‘There’s the person who started that building and couldn’t afford to finish it!’”  Luke 14:25-30 NLT

Many, like the rich young man (Matthew 19, Luke 18) or the disciples that leave after Jesus hard teaching about himself being the bread of life (John 6), are not prepared to pay the cost and turn away.

Even those of us trying to follow Jesus probably don’t fully understand the cost either, at least at the beginning. But as the Holy Spirit works in us, and we are drawn into a deeper relationship with God, we begin to understand what Jesus meant. New character and new desires accompany this new understanding, and we begin to separate ourselves from worldly vices and preoccupations. We don’t think like everybody else. We don’t live like everybody else…  except when we do.

Healthwise, the average follower of Jesus doesn’t seem to be living a great deal differently than the average American – too much sedentary screen time and empty calories, too little vigorous exercise and restful sleep. Now to be clear, in Christ, there’s no condemnation for this. Feeling guilty is neither necessary nor helpful. We are all very flawed individuals, and we will not be perfect in this lifetime. Grace is our watchword.

“No condemnation” is good! “No results,” not so much, and if you’re looking to be healthy while living just like everyone else, no results is what you’re likely to get. If you want to be healthy, you will have to pay the cost and live differently. The cost is real. It’s hard to be different from your family and friends; to eat what’s healthy, and not what’s tempting; to exercise when you feel lazy; to turn off the TV and read a helpful book.

As for me, I sometimes wish that I could just live like everyone else, but, deep down, I know I can’t. I want to be well and I want to be healthy. But it is hard to be different and my improvement has been gradual. Honestly I’m still learning the cost, and I’m not always prepared to pay it. The Holy Spirit seems to be taking his time with me, like he does with most people.

How about you? Do you want to be healthy? Under grace no guilt is required, only change. So start small, but do something different. You don’t have to understand, or pay, the whole cost upfront. I didn’t, don’t and haven’t. Nobody else does or has either. Just get started, and ask God to help you. Integrate your lifestyle choices into your faith and follow Jesus. It seems to be working for me.

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So now there is no condemnation for those who belong to Christ Jesus.
Romans 8:1 NLT

A Primary Care Therapeutic Alliance? Love in the Doctor-Patient Relationship

file1141234819793Recently I had the opportunity to have a conversation with Dr. Marc Braman, a national leader in “lifestyle medicine.” Marc’s an integrative, out-of-the-box thinker. He’s dedicated to serving his patients well and has decades of experience in helping patients to change for the better. Naturally, I asked him to tell me how he goes about it. So how do you help people give up bad habits and adopt new health behaviors? Marc, what’s your secret to that?

Of course, there is no secret knowledge, but Marc replied that it was critically important to form a strong and committed relationship with the patient. He likened it to the “therapeutic alliance” concept used in psychotherapy. Marc tells his patients plainly that he won’t judge or condemn them for their habits (say smoking) and won’t harangue or badger them to change. From the first appointment, he seeks to create a relationship of mutual trust and commitment where it’s safe for patients to be honest with him, and he can, over time, help them make positive changes.

We went on to share more of our ideas and experiences, but this particular idea of a “primary care therapeutic alliance” struck a chord with me, and I’ve been thinking about it a lot since then. My first thoughts went to Dr. Scott Peck’s description of the therapeutic alliance in his best-selling book The Road Less Traveled. He had this to say:

Genuine love, on the other hand, implies commitment and the exercise of wisdom. When we are concerned for someone’s spiritual growth, we know that a lack of commitment is likely to be harmful and that commitment to that person is probably necessary for us to manifest our concern effectively. It is for this reason that commitment is the cornerstone of the psychotherapeutic relationship. It is almost impossible for a patient to experience significant personality growth without a “therapeutic alliance” with the therapist. In other words, before the patient can risk major change he or she must feel the strength and security that come from believing that the therapist is the patient’s constant and stable ally. For this alliance to occur the therapist must demonstrate to the patient, usually over a considerable length of time, the consistent and steadfast caring that can arise only from a capacity for commitment. [emphasis mine]

I believe Dr. Braman has identified a very significant issue. How committed and non-judgmental is the average doctor with respect to the average patient these days? It seems to me, that if we’re not careful to guard against it, we’re pretty likely to find ourselves blaming and shaming the patient. What does the term “noncompliant” imply about the patient and the nature of the doctor-patient relationship? Should we ever dismiss patients for “noncompliance” or missing appointments?

Beyond the attitudes and behavior of the individual physician or other healthcare provider, how is the system working to foster such therapeutic alliances? Not very well. An individual’s insurance coverage often changes from year to year, necessitating a change in their doctors. Or the insurance company drops a physician from their panel. Or, in reverse, the physician drops the insurer. Or the doctor joins a new practice across town. Provider networks are not stable these days.

Clinic practice methods are not stable either. Financial pressures in healthcare are forcing a trend for providers to operate at “the top of their licenses.” This means, doctors only do what only a doctor can do. Let someone of lesser training and scope of licensure do the other things. Sounds nice in concept, but it certainly doesn’t make for strong doctor-patient relationships. Taken to its logical extreme, why ask doctors to talk with patients about their lifestyles at all? Let the health coach do it. It doesn’t take a medical license to help someone change his or her lifestyle.

So what do we do? I don’t know. Some of the structural shifts in healthcare (like “top of license”) that interfere with relationships aren’t going away. I do think that provider networks will become much more stable over time. Maybe the design of the system will not allow for the typical patient to have a therapeutic alliance with his or her doctor. But patients need a therapeutic alliance with someone! The patient needs a constant, stable, loving ally from within the healthcare system. It may not have to be the doctor, but if not the doctor, then who? Could it be a health coach, ARNP or social worker? Possibly. I think it depends on the individual person as much as the degree or training.

As a healthcare leader, I’m asking myself some questions – How do we design therapeutic relationships into our healthcare system? Where will healing happen in the future system we’re building? How do we love our patients like Jesus loves us? If you’ve got ideas, I’d love to hear them.

The Missing Ingredient

DSCN6836Last week I was invited to an innovation session with the goal of improving our ability as a healthcare system to help diabetics live healthier lives. Like most systems, we have an education and treatment program for diabetics. And probably also like most systems, the diabetic program is helpful, but it’s not that helpful. In general, lives are being improved, but not transformed.

Several people on my team (especially me) wanted to talk about transformation. How do we help people take control of their lifestyles? How could we help the obese to become fit and trim, possibly even losing the diabetes? At one point I asked the questions, “What is missing? What can we give them? What do they lack that prevents them from becoming well?” “Hope,” came the quick reply from my respected colleague, a senior physician, a man with decades of practical experience in lifestyle medicine. “They have no hope, and healthcare reinforces their hopelessness,” he continued.

So we talked a little about hope. If hope is the expectation that things can and will improve, then it certainly makes sense that hopelessness would be a major impediment to action. As I wrote about recently, healthcare authorities have proclaimed that obesity is a disease, and that type II diabetes is not only a disease, but also that it is incurable. Not a recipe for hope.

In the trenches, doctors and other clinicians get tired of advising patients to eat better, exercise and lose weight. It seems to them that such advice never works (which is mostly true). Gradually weariness and cynicism (or maybe “realism”) sets in. “People can’t change,” they think and then act accordingly. Many doctors have no hope for their patients to truly be well. I’ve been there myself.

This has been weighing on me ever since. How could we help give people hope? I’m not sure, but it’s a powerful question. I think part of the answer is stories. Some patients have changed dramatically, losing the weight and the diabetes, and transforming their lives for the better. Other patients could benefit from hearing about it. Inspirational stories give us hope. Even the thought, “If he could do it, I might be able to it” is a great start. Maybe we should institute a story time among patients for sharing successes and challenges. Why not?

It’s also occurred to me that hope probably isn’t the missing ingredient for everyone. Individuals are unique, and certainly people can have more than one lack or need. What else might we try to give to (or grow in) an individual looking to change? How about: Inspiration, Desire, Motivation, Knowledge, Faith, Understanding, Wisdom, Methods, Tools, Resources, Encouragement, Structure, Discipline, Accountability, Drive, Determination, Commitment, and Tenacity? You can probably think of more helpful traits, skills and factors.

More will be revealed about our innovation effort, and I’m looking forward to our follow-up session in a couple of weeks. Meanwhile, it’s my hope that you will find inspiration and more of the “ingredients” listed above here at Health Discipleship. My goal for you is the same as for the patients in our clinic program, to help you make a major change for better health. If that’s why you’re reading, put your hope in God, and let me know if I can help.

Thinking About Truth, Obesity, Diabetes and Healthcare

file0002062211258I’m still thinking about truth. As you know, I’m trying to live an integrated life, to be less compartmentalized and follow Jesus as a whole person. Partly, that’s a matter of just doing what I know is right, but, increasingly, I think it’s also a matter of discerning the truth about issues of importance. It’s easy to just go with the flow and internalize the prevailing views without a great deal of thought, and I have probably done too much of that.

In healthcare this issue of, “what is true?” and “how do we know?” is supposed to be settled by evidence. We presume to be operating on the basis of science as we go about diagnosing and treating, and I think mostly that’s true. However doing what’s right typically requires more consideration than just “evaluating the evidence” for what works. Rendering good whole-person healthcare is more complex than it seems on the surface.

I’ve not studied philosophy or epistemology, but here’s how I’m thinking about various categories of truth right now:

  • Revealed truth – Truth as revealed by God through the Scriptures and Jesus, including our reasoning applied to that revelation. This is our Christian worldview, which includes the nature of reality and moral judgments of what’s right and wrong.
  • Empirical truth – What we know or believe based on our experience and evidence. Most of western medicine is based on empirical truth, or at least we want it to be.
  • Definitional truth – Truth that is created by definition. It’s important to highlight this because when definitions change, “definitional truth” changes, but reality does not. In medicine, definitions (for example diagnostic criteria for diabetes) change frequently, and definitional truth is often a basis for action.

In the ordinary course of healthcare, as clinicians and administrators make decisions and take actions, I think we’re usually operating from empirical truth and definitional truth. That’s fine as long as we ensure that those decisions and actions are integrated (or in accordance with) the deeper truth that has been revealed to us. Yet, how often do we take the time to think it through?

Here’s an example (which may be controversial): If the empirical evidence shows that surgical treatment of obesity “works” to bring about weight loss and reduce complications, does that make it the right thing to do? Maybe, maybe not depending on how you answer some other questions. Is obesity caused by a physical defect in the intestine, and surgery sets it right? Is obesity a disease? Or is obesity a behavioral issue that should best be addressed through emotional and spiritual intervention? If the underlying problem is not physical, do we help or harm the patient with surgery? Do we honor God or not when we offer surgery in such cases? For Christians, the ends cannot justify the means.

“Obesity is a disease.” That’s a “true” fact, definitional truth that is. Obesity is a disease only because it has been defined as a disease by the healthcare powers that be. Naming obesity as a disease implies that there is some state malfunction of the body or of the physiology; however, the vast majority of overweight or obese individuals in our society have no causative underlying abnormal physiology. The cause of our obesity epidemic is our habits. If mistreatment of your car causes many mechanical problems, it is not justified to call it a lemon and return it to the dealer.

A recent study suggests that defining obesity as a disease is making our national problem worse. No surprise here, truth matters. But like we discussed in the last post, the truth hurts and we don’t always want to hear it. When we avoid the hard truth, we feel better in the short run but do ourselves little good.

Now diabetes is certainly a disease, and type II diabetes is often secondary to obesity. One of the best and first line treatments for diabetes is metformin. That’s the empirical truth. It’s also empirically true that weight loss may benefit diabetes more than metformin (depending on the bodyweight, not all type II diabetes is secondary to obesity).   Both are true, but the latter is a more “upstream” truth about diabetes than the former. It would be best for most patients to lose weight, than to remain overweight and be treated with metformin.

For integrated, whole-person care we need to understand the whole truth, we need all of the facts, and, importantly, we need to understand their proper order. The deeper, more upstream truths about how humans are created are the more powerful. How do we in healthcare operate from those truths more, and from the downstream truth of “there’s a pill for that” less? I don’t have the answers, and many will say, “but most patients simply don’t lose weight.” Yes, but still we must not lose focus on the deeper answers we have for them.

A definitional truth that particularly bothers me is “type II diabetes is incurable.” That’s another one that I don’t think is helping us. According to medical orthodoxy, if a diabetic person’s blood sugars return to normal limits after weight loss and off medication, that individual still has diabetes that is “diet controlled.” Makes no sense to me, but the argument is that the individual has proven a propensity (or genetic predisposition) for diabetes and that it may return someday so we should still label them with the diagnosis.

Hmm…

Try this thought experiment: Bob, age 25, is a fit, healthy, 155 lb. movie actor who wins a new role that calls for him to become obese. His blood sugars have always been well within normal limits. But after gaining over 100 lbs for the role, when Bob sees his doctor in middle of shooting he has a fasting blood glucose of 140mg/dL. Bummer – Bob now has diabetes. After discussion with his doctor, Bob decides on no therapy because the movie is about wrapped up and he plans to lose weight promptly. Within 5 months, Bob’s back to his baseline weight and his fasting blood sugar is 90mg/dL.   According the healthcare system, Bob still has diabetes. Does that sound right to you?

Sure, Bob might get high blood sugar again later in life, especially if he gains weight. But does that mean he has diabetes now? Is it helpful to tell him he still has diabetes? It is true, really? What if Bob, had an identical twin (exactly the same genetics) named Mark. Should we diagnose Mark with diabetes based on Bob’s experience?   It would be logical to do so based on the definitional truth. (Imagine Mark’s surprise when we tell him!) On a practical basis, is it helpful to tell the average obese person with type II diabetes that his obesity is a disease and that his diabetes is incurable?

We don’t do that with other conditions. Grief is one my family is familiar with lately. People expereince grief after a close friend or relative dies. Gradually they work through it until it’s resolved. We don’t continue to say that they have, “thought controlled” grief or “quiescent” grief or “latent” grief. No, we say that it’s “resolved” or gone even as we know they may likely experience grief again in the future. Imagine if we told every grieving person that his or her grief was “incurable” and the best we could do was “control” it. That is the orthodoxy is with type II diabetes.

Mostly, I don’t think we are doing ourselves any favors by creating more and more “diseases.” Much of our problem is our behavior and our thinking. Many of our social problems, and our national ill health, arise from our culture. We don’t help ourselves by sweeping the hard truths under the carpet in favor of easier “truths” – classifying our problems as diseases and seeking a solution from healthcare.

Don’t think I’m against healthcare. We have amazing abilities in healthcare today, and people do suffer from many ills for which we now have effective treatments and cures. Praise God! I’m not against healthcare; rather I’m for health! And sometimes the facts you need on the road to truly good health are not the facts you get from the healthcare system. I don’t claim to have the answers, but I feel that questions such as I’ve outlined here can lead us in the right direction.

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Always beware of any assessment of life which does not recognize the fact that there is sin. Oswald Chambers

Getting Odd with God

How about something new – a short test? Choose the single best answer to the following statement:

You shall know the truth and the truth shall ________.

A – hurt.
B – piss you off.
C – set you free.
D – make you odd.
F – all of the above

I’ve been thinking about truth lately. In today’s world (and perhaps it’s been always thus) many people believe what they want to believe. To them truth is relative, or perhaps unknowable. “Whatever works for me is true for me” is the spirit of the age. But truth matters, doesn’t it? Our thoughts guide our actions, and actions have consequences. It’s clear that we’re usually better off if we act based upon truth. Not sure? Ask the folks who invested with Bernie Madoff, or maybe Tiger’s ex-wife. I think they would have acted very differently if they had known the truth about the men they trusted.

So what answer did you choose? They all have merit. Let’s take them in turn.

You shall know the truth and the truth shall hurt. Yes, pretty often the truth hurts. In my own case, the truth is that I create a lot of my own problems. The truth is I’m not that good-looking or that important at work. The truth is I haven’t been the best father or husband. All true, all painful, but necessary to hear if I’m going to have less problems and be a better father.

Hurting is no fun. That’s why, as fallen people, we commonly fight the truth. Defending our egos, we react in anger. We have heard the truth, and we are pissed off! This happens a lot in the wellness field. Way more people are overweight because of their habits than because of their genes. But try saying that, even delicately, and you may be accused of “blaming the victim.” Another example might be alcoholics or drug addicts who fight and deny the truth of their condition beyond the point that it’s obvious to external observers. Unfortunately, fighting the truth does not help us. It’s okay to be angry, but if we want to be better, we have to get to acceptance.

If we can accept the truth, we can be free. I’m sure you know that it was Jesus who said, “You shall know the truth and the truth shall set you free.” But knowing isn’t the whole picture. Not only must we know or accept the truth, we must act upon it. Jesus prefaced his statement with, “If you abide in my word…” (see below) That’s an action step. Both knowing and doing are required. Even demons know the truth of Jesus.  For Christians, faith is an action step.

Same in the wellness space. If you have a lifestyle illness (or more than one because they usually travel together), knowing that your habits are the cause of your problem does not magically solve the problem. You’ve got to do something different. Perhaps many things – eat less, eat “better,” watch less TV, move more, etc.

And, collectively, we have a national lifestyle problem. We’re sick and getting sicker.  Basically our American culture creates illness.  Healthcare and governmental authorities and officials wring their hands and make their plans, but the country stays sick. They ask, “What can we do to make people well?” In my opinion, not much until we grapple seriously with the truth.  We are our own problem.  Our culture is a problem.  Yet we deny and fight the truth and look for external solutions.

I believe that deep down, most people with lifestyle illnesses do know the truth about themselves at least, even if they still fight it in public. As Christians, our knowledge of, and trust in, Jesus and his Word, should allow us to confront and act upon any of the many uncomfortable truths about ourselves, including our unhealthy lifestyle choices and self-created poor health. That is the premise of this blog.  There is no condemnation for those in Christ Jesus, but God has made a change in us and calls to keep growing in the Holy Spirit.

Sadly, few people actually get to the action part. In our passage, immediately after teaching about the truth setting us free, Jesus (who is the truth) confronts the unbelievers, and the more he talks, the angrier they get. That was me once. Hopefully it’s not you. Probably not. You’re here, you’re mind is open and you’re working on yourself. Great! Prepare to be odd.

Knowing and acting on the truth will make you odd.* In our society Christians are odd. Faith in technology and “human goodness” is normal; faith in God is odd. Self-indulgence is normal; self-control is odd. Overweight and sedentary is normal; fit and healthy is odd. I could go on and on.  You probably can too.

In my own case, the longer I follow Jesus, and the more the Holy Spirit reveals to me about the world’s ways vs. God’s ways, the odder I get. And really, I’m just getting started. Let’s face it, I’m going to be pretty strange by the time I’m old.

How about we become odd together?

 

* “You shall know the truth, and the truth shall make you odd” is a quote from the author Flannery O’Connor. I’ve not read any of her work, but one of my pastors quotes her (including this quote) frequently. Maybe I should put her on my reading list.

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So Jesus was saying to those Jews who had believed Him, “If you continue in my word, then you are truly disciples of mine; and you will know the truth, and the truth will make you free.” John 8:31-2

Surrendering for Better Health

Verso01_1203261263I was traveling for business last week and one evening I relaxed by watching some television (which was kind of fun since I’m not able to watch TV at home). A little channel surfing in the hotel room turned up a World War II documentary that held my attention for a couple of hours.

There’s a lot to find interesting about WWII, but what struck me this particular evening was the similarity of the end games in Europe and Asia. In both cases, at a certain point, the war was effectively lost to the aggressors, Germany and Japan, but neither could surrender. The insiders knew it was over, that it was just a matter of time. Yet still they fought, absorbing overwhelming punishment from the Allies rather than surrender. Much of the death and destruction of the late war period could certainly have been avoided by an earlier surrender.

After the eventual surrender, of first Germany and then Japan, reconciliation and reconstruction could begin. Uncomfortable truths were confronted. Some leaders, not all, were held accountable and it was a very painful time for all concerned. Eventually the situations improved markedly as physical and cultural rebuilding progressed. Today Germany and Japan are modern, friendly nations and our allies despite their wartime behavior. But the Allies’ generosity, charity and forgiveness required for this positive outcome could only come after their unconditional surrender.

It left me thinking about the benefit of “early surrender” elsewhere in life. One thing I’ve learned in my business role is that it’s best to lose gracefully. Pretty often business dealings aren’t going your way, and you can’t always force it. You may be “losing” a deal or a negotiation, or even your job. When losing is a certainty, then it’s best to accept reality, make peace with the situation, cut the best deal you can, maintain friendly relationships, learn from it, and move forward. Easy to say, hard to do.

My thoughts also naturally went to the lifestyle illnesses, like obesity, type II diabetes, hyperlipidemia and hypertension. These conditions typically attack patients as relentlessly as the Allies fought the Axis late in the war. The attacks always begin slowly and, at first, things seem fixable, but they almost never are. Also the lifestyle conditions usually progress despite treatment, which is aimed at the result, not the cause, of the problem. For example the blood sugar and the blood pressure may be lower this year but the underlying diabetes and hypertension are often worse.

Clinicians will recognize the following rough sketches:

  • A little numbness in the feet.  No big deal.  A poorly healing wound on the big toe.  A couple of hospitalizations for surgery/antibiotics to “save the foot.” Toes are amputated here or there.  Gangrene and/or poor healing leads to amputation of the foot.  Bad news.  (And don’t forget this is happening to the other foot too.)  Wheelchair for life.
  • Chest pain, catheterization, stent(s).  Stable, for a while.  More chest pain.  Medical therapy. Minor stroke. Heart bypass and carotid artery bypass.  Slow recovery.  A few decent years.  A big heart attack and another stroke, this one significant.  Years of progressive debility.  Death.

Trust me. It really is like that. Diabetes, hypertension and the other lifestyle illnesses are persistent and remorseless foes for most affected patients. The patients go on fighting, using all the defenses in healthcare in an attempt to neutralize the enemy’s attack. That’s normal in the healthcare world. But for many, the war is lost; it will just take a little more time. If only they could surrender.

Yes, surrender. Surrender is the answer, because what these patients are fighting for is to maintain their lifestyles. These foes are self-made. Our habits create the enemy, but we sure like our habits, even if they are killing us. If patients were to “surrender” their lifestyles and to accept the terms of the peace treaty – less meat, more vegetables; less processed food, more natural foods; less calories fat and sugar; more exercise; a lower body weight; less alcohol and no tobacco – the war would be over and the reconciliation and reconstruction could begin.

Few will do it of course. Surrender is scary. It involves admitting your complicity in the war, and it will cost you your lifestyle, a lifestyle that you probably enjoy. But, be assured, as with the real war example above, the ultimate outcome will be a major improvement. You too can be better, but you have to give up first.

What do you need to surrender to improve your health?

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