Do we need art?

I have always liked art– drawing, reading, museums. But I went through a very literal phase as a teenager where I sort of didn’t get it. What’s the use? I’d ask. What’s the benefit? That’s nice, that’s fun, but is it important? Do we really need art? Shouldn’t we study engineering, or microbiology, or something? Now, I think the answer is yes, and yes.

We all have feelings, thoughts, orientations to the world. These can arise seemingly on their own and sit there, uninterrogated, shaping our lives. They may or may not be visible to us. Are we at their mercy, or do we have the capacity to guide them, direct them, respond to them deliberately? And how does this impact our well-being, as individuals and as communities?

I think that art— experiencing it, viewing it, reading it, hearing it, making it— is a way to engage with our thoughts and feelings outside of the direct lens we usually experience through. Like maybe we can sidle up to them and get close to them before we put up our guard. Or we can see them from a different angle than the head-on way we usually do.

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On Alignment

What do you think of when you hear the word alignment? The wheels on your car? Your body position in a yoga pose? I bet it’s not online education. . . but hear me out.

Because I believe breakthroughs come from cross-pollination among disciplines, I’m going to borrow this concept from Quality Matters— which is a system for evaluating the quality of online courses. In this context, alignment refers to the relationships among course objectives, unit or module objectives, instructional materials, learning activities, and assessments. Are the outcomes measurable and appropriate, at both levels? Are the course components aligned with those outcomes? This sounds basic, but it can be surprisingly challenging to achieve. Mapping out these connections can be difficult– and enlightening. I’ve done it as both a course instructor and a peer reviewer for other courses, and found it enormously valuable.

So let’s distill this idea down to the basic components: set high-level goals, set smaller goals to support the big goals, and choose actions and assessments that align with those goals.

Where else can we use this simple structure to improve things?

  • Clinical management. The patient’s “big-picture” goals are surprisingly frequently absent from the conversation. But patient-centered care demands identifying goals for health and for life. A care plan that doesn’t include an assessment of goals is in peril before it even gets off the ground. And I don’t mean goals like “get A1C less than 7%”. I mean goals like “extend my healthy lifespan so that I can travel in retirement”. That might be a radical shift and it might alter management. Or it might mean the same basic management plan is perceived very differently by the patient. I’ve written about the concept of concordance in healthcare before– it’s similar. Aligning our plans to treat, follow-up, and assess our patients with our shared goals, both long-term and more immediate, is crucial to effective care.
  • Career trajectories. I recently wrote about the challenges of focus in an academic/clinical career.  What if, instead of a single-minded focus on a narrow area, each opportunity is considered in terms of alignment with “big-picture” goals? This approach allows for more bricolage (which, BTW, can make work relevant and grounded), more cross-pollination, more serendipity, more diversity– without falling into a scattered mess. I have a couple of broad interest areas and goals, and I find that rather than continue to narrow into extreme sub-specialization, I prefer to exist as a practicing member of the communities I’m a part of, and participate in projects that align with those areas.
  • Self development. This is what tools like the Passion Planner promote– making big goals, identifying smaller pieces of those goals, and taking steps to move towards them. The act of identifying goals, and identifying small steps, is enormously powerful in making progress. It takes deliberate thought and reflection, but the outcomes of small actions over time that are all aligned with a goal can be mind-blowing.

So there you go. Take a simple principle, and see how powerful it can be in different contexts. Think about how Atul Gawande used a checklist strategy from aviation to improve surgery, and think about what big ideas might disrupt your regular practices.

From hard targets to risk models: Who are we helping?

There’s something appealing about a threshold-based approach to treatment: if your cholesterol is over 200, it’s high. If your blood pressure is over 140, it’s high. If you A1C is over 7, it’s high. It’s clean, easy to understand and easy to communicate. But is it helping to improve meaningful outcomes, and is it doing so equitably? Does 140 for me create the same problem as 140 for you? Is 141 worlds away from 139? These aren’t easy questions to answer. It complicates the already complicated conversations around taking medications for prevention.

We’re starting to see evidence across different conditions that risk-based approaches to treatment, i.e. those that treat based on aggregation of multiple risk factors into a predicted risk of some adverse outcome, might be better. The first major test-case for this was lipid guidelines, but recommendations for other conditions are starting to change too:

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Women’s Health: Beyond the Bikini

Health is complex. Women are complex. Women’s health is complex. So why does “women’s health” so often refer to reproductive issues alone?

The American Heart Association and the American College of Obsetricians and Gynecologists did something smart. They looked at the past few decades of progress in women’s cardiovascular health and asked “why are women still under-informed about their risk of heart disease. . . and why are we still not better at lowering risk?”

Those of us who practice primary care day-in, day-out could probably tell you a lot of reasons: competing priorities, limited time, siloed care— leaving a void for a big-picture assessment of health and health risks. This is a problem for all kind of patients and providers, but it’s particularly acute in women’s health, where issues of reproductive health often take center stage (especially in younger women). A well-woman visit is an opportunity for more than pap smears and birth control! This might be in a primary care practice or a gynecologist’s office (where many young women get their only care). What are we telling women when they come for a well woman visit, and what are they telling us? Are we communicating well, or are we checking boxes on the EHR and making sure we get reimbursed fully? I had a well woman visit myself this year, and I heard a lot about pap tests and nothing about blood pressure or depression.  This is not unusual, but it’s not good.

There’s mounting evidence about sex (biological and physicological) and gender (sociocultural) influences on cardiovascular health and disease. Cardiovascular disease was first identified, studied, and treated in men. Our entire paradigm of the disease is based on men. Yet women’s disease is different, women’s response to disease is different, and the healthcare system’s treatment of women is different. Still, we too often fail to appreciate how these differences matter, and that undermines our efforts as health professionals to address risk.


The million dollar question: How do we identify, communicate, and mitigate women’s cardiovascular risk effectively?

One approach? Treat women’s health as a holistic issue rather than just focusing on the parts covered by a bikini.

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Advice beyond “focus” for academics

I’m an early-career academic and clinician. As such, I need– and receive– a lot of guidance. I have mentors, I have bosses, I have colleagues. Everyone says to focus. Which is nice, but is it helpful? Certainly focus is critical to build a solid and impactful program of scientific research. Does it capture the goals of a long career for someone like me, with varied interests and broad educational preparation? Does “focus” give me the opportunity for impact across different areas or on different levels? Does this idea of “focus” get me to a place where I want to be? The use of the term is so pervasive, it got me thinking. I’m not a photographer, so forgive any technical errors, but what if we thought about an academic career with a more nuanced set of variables?

  • Depth of field. Can you have multiple objects in focus, even if they aren’t right next to each other? If you adjust the aperature, you can let in more or less light, and along with changing the exposure, this can make your focus shallow or deep. Often in a PhD world, you are compelled to bring sharp focus to a tiny part of an image (big aperture) and blur the rest. This can be a good thing, but it’s not the only way. Say, hypothetically, that you want a career with research and clinical practice both, and you also want to be a policy voice. Change the aperture to a smaller size and see— multiple object can be in focus at once. It’s not better or worse, but it brings a different quality to the image.
  • Shutter speed. So you’ve adjusted the aperture— to keep the exposure right, you need to think about how long the shutter is open. A smaller aperture means you need more time. That’s OK, but you have to be aware of it. You want more things in focus? You need to spend a little longer letting light in.
  • Composition. What’s in your shot? How is it framed? Is it a close-up, or a landscape? Is your subject in the center, or are you more interested in a rule-of-thirds kind of thing? The key here is that THERE ISN’T A RIGHT WAY. It’s all about what you want to show and how you want to show it.  That said, some institutions like certain kinds of images more than others. Does your picture fit into their album?
  • Frame rate. Are you shooting a single, perfect image, or a series? Do you want a smooth, seamless progression through a moment, or do you want to capture discrete pieces over time?

varied interests

you want me to pick just one??

So, what’s the upshot? Should we just throw out the advice to “focus” when it doesn’t suit us? No. . . but I do think we should consider it in a broader context and check to see whether our goals are aligned. I may not want to get on a rocket ship to the moon– I might rather be on a cruise ship through different ports.  Well, now that I’ve thoroughly mixed my metaphors, I suspect it’s time to sign off. What are your thoughts on the ups and downs of focus?

France, Food, and Fat

Oh, the french. They smoke like chimneys, drink like poissons, and bread and cheese is practically a religion there. But I can count on one hand the number of obese people I encountered on my trip— and two of them were from Texas. Now, I’m not suggesting these habits are a path to health. Indeed, the idea of the “French Paradox”— that coronary heart disease death rates are low despite high consumption of saturated fat— has been pretty well put to bed (here,  and here). Yet still, obesity is not the problem there that it is here. Why are Americans fat and the French aren’t?

You’ve heard it before, but in my observation, it’s true:
  1. Meals are an event. They are eaten at a table, in good company and with plenty of time. Hardly ever on the go or in the car or at the desk.
  2. Food is high-quality. Organic, fresh, made in farms and shops and kitchens more than factories.
  3. Portions are much smaller than what you get in the U.S. It’s always enough, but it’s less that we’ve come to expect You don’t have to feel completely full to be nourished. Indeed, by lingering over the meal, you often realize you are, in fact, satisfied.
  4. They walk, bike, skate, and otherwise get around using their legs.

Nothing here is surprising, not even a little. But it’s powerful.


FROMAGE

hello, lover.

I just got back from a week in Paris, and despite my living the vacation life, wine,cheese, and croissants included, I don’t feel gross. I like this food, when I have it. BUT: I like it in small portions, when I’m walking six miles a day and enjoying the beautifully crafted and plated meals. And interspersed with beautiful veggies and fruits, of course.

I don’t have the same love for this rich food that I do for fresh vegetables, light flavors, greens and berries and flowers and fruits. Some of it is in the taste and the aesthetics, certainly, but most of it is in my body, my energy. Maybe my spirit too, if that isn’t too woo-woo (I know. I know. It is). I don’t live the French life all the time— sometimes I eat at my desk, or watching Netflix. Sometimes I’m in a rush. So eating a primarilty plant-based diet works for me, at home. But I sure enjoy the reminder to put that food on a pretty plate and sit down for a few minutes to enjoy it.