Course Correcting Wellness
Dr. Lucy McBride discusses common sense medical practices for overall wellness, how the health insurance system is failing patients, and what corporate America is doing to improve health care in the United States.
This episode was recorded with both Charles and Lucy in our studio.
Podcast Transcript: Course Correcting Wellness
Charles: Hello and welcome to Open to Influence. I'm your host, Charles Lipper, Founder and CEO of Volubility Podcasting in downtown Washington, DC. Today we're joined by native Washingtonian and 11-time Washingtonian Magazine Top Doctor, Dr. Lucy Mcbride. Dr Mcbride attended Princeton University, Harvard Medical School, and earned her masters in pharmacology as a fulbright scholar at the University of Cambridge, England. She completed her internship and residency at Johns Hopkins Hospital, and later joined their emergency medicine faculty. She currently practices general internal medicine at Foxhall Internist here in Washington DC and is passionate about promoting patient's physical and overall wellbeing by integrating what she calls the "Four Corners of Health". Lucy, thanks for joining us.
Lucy: Thanks so much for having me, Charles. It's a pleasure.
Charles: Absolutely. So, Lucy recently you approached our podcast production company, Volubility Podcasting, in consideration of launching your own podcast. Why don't you tell us what the four corners of health are and how that influences your medical practice.
Lucy: Most primary care doctors in the United States do a good job of addressing what I would call the top left corner of patients' health, the medical data, the patient's heart rate, blood pressure, cholesterol levels, diabetes testing, screening for common and not so common medical conditions, and then treating those conditions. But what I like to do is treat patients from a bird's eye view and look at the four corners of health, so I would consider the medical data just one corner of the patient's health. The other corners are these. The top right corner is nutrition. Bottom left corner is body mechanics. Now, modern medicine does a decent job of understanding and explaining to patients that nutrition and body mechanics and exercise improve or tend to improve certain health outcomes. Most patients in the US have read or have heard of nutritional pearls that would inform their health. They know to eat well, exercise and that would help their health.
Charles: And you consider those each individual corners? So nutrition, one, exercise is another.
Lucy: I would argue that these corners are weighted absolutely equally, because what you eat and how you eat and your relationship with food, and I'm going to put in that corner relationship to alcohol, relationship to any sort of substance you consume, whether it's broccoli or marijuana or alcohol...
Charles: If you do drugs, you still need to exercise.
Lucy: Well, yeah, yeah, I mean, anything...
Charles: Not to make light of it.
Lucy: Exactly. So we all know that exercise is important for our health. Exercise helps with everything from cardiovascular disease to diabetes management to mental health and so what I see everyday is people who have been in the traditional medical system in the United States who are... they've got the Fitbit, they have been told by their doctor perhaps to lose weight, exercise more, cut back on the booze and they'll be better. But what I see everyday also is people who are walking around like a three legged dog, meaning they don't have any sense of agency, and they don't necessarily participate with their Fitbit or their Weight Watchers app and nothing's happening. So they're not healthier. They don't feel any better.
Lucy: And so what I call the cornerstone and the fourth corner here is mental health.
Lucy: Mental health or behavioral health to me is the cornerstone because our brain is an organ like any other organ. It sits at the top of the totem pole for a reason. Thoughts and feelings inform behavior and behavior informs health. Genetics, environment also inform health. Luck informs health. But...
Charles: So the fifth quarter is luck.
Lucy: The fifth corner is luck, you know, because layer on...
Charles: The pentagon of health.
Lucy: Yes, the sort of je ne sais quoi of the universe I can't control nor can patients. But because our thoughts and feelings directly inform how we behave and how we relate to the environment and how we relate to our own bodies. We have to, in my opinion, incorporate mental health and behavioral health into the framework about whole health. Everyday I see patients who are struggling with anxiety, mood disorders, stress, relationship issues, problems regulating their relationship with alcohol or other substances and those things directly inform their ability to be healthy. So, it's only when I put that fourth corner behavioral health, mental health into the doctor's office, which I think that we can really start to unlock a lot of intractable medical issues.
Charles: Yeah, and I want to kind of break this down too before we get too far along. So, we have what we have come to know in this country as medicine. Nutrition being the second corner, exercise, and mental health. I've spoken with a nutritionist before and I've spoken with a couple, but one in particular said look, if you're just trying to lose weight and be generally healthy, you know, nutrition is like 80 percent of it and exercise is maybe 20 percent. And those numbers might not be completely accurate, but she heavily weighted nutrition being more important. And I know just me personally, if I diet and don't exercise, it doesn't work. I literally have to do both. So I'm assuming it comes down to the individual, right?
Lucy: It absolutely comes down to the individual because you could never say that someone who has a weight problem, which is as you know, a health epidemic in this country is 80 percent nutrition and 20 percent exercise and that that is a general rule for the population, because there are so many complexities to the way people have gotten to the overweighted condition that they are in. And by the way, to me, obesity is a symptom. It's not a diagnosis. I mean we treat it as a diagnosis, and when we treat it as a diagnosis, we unfortunately don't really try to unlock the complicated features that drove the obesity. To me, it's a symptom. It's a symptom of disregulated behavior and when we treat it as a symptom, when the doctor and the patient work together and we understand it as a symptom of disregulated behavior, then we can try to unlock the ways in which patients got there. Let me give an example.
Lucy: The patient who I see all the time is someone who is smart, educated, has heard over and over they need to lose weight; they need to exercise more; they need to eat less starch, and if they did then their blood pressure, their cholesterol, their diabetes, their sleep apnea, and their knee pain would be a lot better. This is the patient who's walking around with the Fitbit, the Weight Watchers app, yet they're not any healthier. And the problem where medicine is failing these patients is that patients like this will come into the doctor's office and get checked and there are a lot of boxes being checked and the patient is being told basically lose weight, exercise more, eat less, see ya next year. Now, the problem is that eating and moving are so fundamental to how we behave and live every day that the habits and the behaviors that inform the way we eat and the way we move are so kind of locked in for people that it's really, really hard to wake up one day and say, today I'm going to be an exerciser and I'm gonna eat less.
Lucy: In other words, to change human behavior, which is ultimately what I'm interested is behavioral change as a way to inform health, is so difficult to do without support, so it is really unlikely for someone who say, drinks too much alcohol to say, tomorrow I'll do better. Same thing for a patient who's an overeater or an emotional eater to wake up and say, today is the day I'm going to be healthy, because these habits are so hard wired at the end of the day when you become an adult. If you have been an overeater or a binge eater or a stress eater since you were a kid, it's not gonna happen overnight with the help of a single Fitbit that you're going to change your behavior, so you really have to look into the behavioral health, mental health component with the help of say, one of my behavioral health therapists to understand the relationship to food so you can then understand how you behave with regard to food.
Charles: Right? And I mean the critical thing you said there was stress eater. I mean really your behavior: stress, dictated your behavior: eating.
Lucy: Right. And so what I see all the time is that let's call someone a stress eater, which is code for lots of different things. There are actual diagnoses that we could name under that larger umbrella, but let's take a stress eater. It's only when you can address the stress, aka that fourth corner, mental health and behavioral health, that you can help someone manage their relationship with food. We have to deal with food all day long. I mean you have to make decisions about eating every single day. Unfortunately you can't live without food. I mean it would be easier for a lot of people to just have an IV of food and not have to make decisions, but unfortunately we have to deal with food. So if you have someone who is under a lot of stress and who's had stress that dates back to say their adolescent years or their young adult years, it's really hard to unlock the thoughts and feelings about body stress and then how they eat with a simple app.
Lucy: Or with a doctor just telling them to change their. It's not like telling someone what to do equals therefore they do it. So my job is to get into someone's head and figure out, okay, where's this coming from? What's the root cause of this person's relationship to food that is not appropriate?
Charles: Right, and I mean I think the cornerstone of both the patients' and the doctors' behavior here is time, right?
Lucy: That's it.
Charles: So, I mean, especially here in Washington, we are busy people and young professionals are busy. Then you move out to the suburbs and your commute's longer, and then you have kids and now you're responsible for taking your kids to daycare, and it just gets busier and busier and busier. So A) the patient's time has gone to how do I take care of myself?
Charles: And then from the caregiver's perspective, the way health insurance and just medicine in this country is treated, your job is to get through a patient and move onto the next one, and how many patients can you squeeze in a day?
Lucy: That's right.
Charles: So, how do you as a person and as a doctor balance what seems to be really challenging for most of us?
Lucy: That's exactly right, Charles. You've hit the nail on the head. The commodity is time, and what we all need is more time and it's not that we can lengthen the day from 24 to 30 hours, but I think what my job is is to help patients zoom out from their lives and figure out how they can incorporate simple, achievable behavioral changes within the stressed framework that they may have and part of my job is also to help the patients figure out where they are wasting time and abusing their time.
Lucy: And this is also something that the therapist that I may send the patient to work on stress and stress management, would help with sort of executive coaching slash stress management, because ultimately you only live once and you have to figure out well what is important to you. And if your health is a top priority, then figuring out how not to be on your iphone at night for an hour just surfing and looking at images to prioritizing sleep, to saying no to the five different things that are on your plate, if you can say no. Those kinds of things, sort of time management, is key. What allows me to have time with patients is that I am in the very, very lucky position of being out of the system of the traditional medicine framework, so I am out of the insurance network, because insurance drives the way doctors behave in so many ways...
Charles: And just to clarify that, so you as a doctor and Foxhall Internists do not accept insurance. Is that correct?
Lucy: All of us at Foxhall Internists including myself do not accept insurance so patients can submit their claims out of network.
Charles: Got it.
Lucy: Because we're out of insurance. I am freed from the shackles of being a box-checking doctor. I do not have to have five minutes with a patient, check boxes, tell them to lose weight, eat less, drink less, see ya in a year. I get time.
Charles: And that's because insurance companies take their portion? Thereby, for the practice to remain open, you don't need to make as much per patient as a doctor who accepts insurance does. Is that accurate?
Lucy: That's accurate. Insurance companies do not reimburse doctors for time spent establishing a relationship, establishing a rapport, understanding the whole person, connecting dots, counseling on preventative health maintenance, not to mention understanding a patient's relationship to food, their relationship to alcohol, the stress in their lives. That is not something that insurance companies consider reimbursable. Therefore, if you want to be the doctor who takes time with patients to understand the bird's eye view, the whole person, you can't be in that system.
Charles: So, with the four cornerstones you have mentioned to me as well as on your website at lucymcbride.com, the idea of a medical home. So, a place where people can go to receive treatment for each of the four corners. It sounds like you have a good grip on all four corners. Do you consider yourself a specialist in all four or ideally, would you create a practice that had you as the medical and then three other people for the other corners?
Lucy: That's a great question. I consider myself the chief medical officer or CMO of my patient. So, I'm their treating doctor. I treat their high blood pressure, their cholesterol, their sleep apnea, their diabetes, their various health issues, thyroid disease, heart disease, kidney disease. I use specialists as needed. I don't claim to be a specialist in all different... But the medical home to me means that I'm a hub for problem solving. I'm not just a gatekeeper, I'm a hub for problem solving, and I have a lot of knowledge about nutrition, I have a lot of knowledge about body mechanics, and I do have a special interest and a lot of knowledge about mental health and how mental health informs behaviors that then inform health outcomes. So my job is, and what I think is a priority for patients and what patients are lacking in this country, is to be that medical home where patients can bring every health issue they have, whether it's mental or physical, and I then help connect those dots and then refer out as needed. I'm not a therapist. I'm not a nutritionist. I'm not a physical therapist. But some of those successful patients that I'm working with are patients who embrace the four corners, they understand how they inter relate, and then they see, for example, the therapist who will work with them on their stress management. They see the nutritionist who is a behavioral nutritionist to help them understand not only their relationship with food but how to eat to serve their particular health issues. And then they may see the body mechanic: that physical therapist to help them unlock their tight hip that's informing their back pain that's informing their knee pain and keeping them from exercising. So, I don't claim to be a specialist in all those, but I know enough about all of those to understand how to connect the dots.
Charles: Absolutely. So Amazon, JP Morgan, and Berkshire Hathaway are forming a unified nonprofit to provide healthcare to their 1.2 million collective employees. Obviously they have employees spread out all over the place. How would your idea of a medical home apply to the individual all over the country, potentially all over the world?
Lucy: It's a great question, and I think it's an exciting, exciting, bold venture into the healthcare space that these three companies have taken on. With Atul Gawande at the head, I think they are poised to make important changes if they do it right. I really hope that they will adopt this concept of the medical home, where instead of paying specialists and doing extensive testing, we really can solve so many problems in the medical home if we treat it as the hub for problem solving and not just a place for gatekeeping. I think the benefit that these companies have, and particularly the tech company, Amazon, is that they have this ability to reach people all over the world. So, they could use everything from telemedicine to artificial intelligence to access people all over the world. For example, the VA Hospital already is using telemedicine and a cool way.
Charles: Can you define that for us real quick?
Charles: What telemedicine is, yeah.
Lucy: Telemedicine is virtual medicine. Basically. If you take someone in Guam, for example, who has a doctor at the VA in Washington DC, the VA has hired high school and college students to do virtual physicals with these patients.
Charles: I'm sorry, high school students are performing physicals?
Lucy: Let me explain that.
Lucy: They're not performing the physicals. The VA has hired people, who are basically techs, to place the stethoscope in the right space, to put the otoscope in the ear to look at the ear, but the doctor in Washington, DC is the one who's listening to the heart.
Charles: Okay, I was imagining a room full of high school students telling someone in Guam, okay, so...
Lucy: Bend over.
Charles: Well yeah, or let me prescribe this medicine for you. Um...
Lucy: No. The doctor's expertise is on a TV screen and can see the findings, the physical findings, that the high school student is simply placing...
Charles: Got It. Okay. So is there a video chat elements there?
Charles: Okay, so we've got a doctor in America treating a patient in another country connected over video chat.
Lucy: That's right.
Charles: Then, with the patient is a high school student performing the physical needs that the doctor is telling him to do. Say, put the stethoscope here.
Lucy: You explained that perfectly. Exactly.
Charles: Got It. Thank you.
Lucy: So, telemedicine is really fascinating. I mean there there's no substitute of course, for the laying on of hands by a trained physician to a patient. Certainly there are certain emergency situations and surgeries that can't be done by a high school student, but there are basic physical exam and dialogue that you can have virtually on a telemedicine platform.
Charles: Right. I've heard a number of internal medicine doctors as well as mental health professionals say, there's just something about sitting in a room with a person. Like, I will not do that because I want to be in the room with them. I don't do that. But there's obviously for people that can't receive that medicine, or like we said with time maybe don't have time to get to a nutritionist and a mental health professional and a physical therapist, they don't have time... Maybe this would be a way to get toward an overall wellbeing.
Lucy: That's right. As you said, there's no substitute for human connection, contact. At the same time, if you are someone who is extremely busy like most people are, so let's say you work for one of these companies, and you're going to be insured, and your healthcare is going to be delivered by your own employer through this new venture. If you are very busy. If you're a 30 year old guy who works in tech, you don't have a lot of time to see a therapist, to manage your stress, to...
Charles: Let alone stand stand up on a regular basis throughout the day...
Lucy: ... to see a nutritionist, to work on your relationship with food and the way you eat, to see a body mechanic, physical therapist to work on your bum knee. But if you could have a medical professional who you see once a year, three times a year, to frame the sort of four corners of your health, to be your chief medical officer, and then to direct you to the right people that you could then see virtually... That would be progress.
Charles: Got It. So virtual throughout the year and then occasionally when we can squeeze it in for a day, go see your people in person.
Lucy: That would be cool.
Charles: That would be very cool.
Lucy: I mean if you can see all those people in person, that would be even better. You know, it's very hard to do physical therapy virtually, but certainly psychotherapy to work on stress, stress management, I mean that can be more readily done virtually than a physical exam of course.
Charles: So are we talking about if I am a banker at JP Morgan and I say, Hey Alexa, build my menu for the day. Hey Alexa, let me tell you why I'm stressed out right now. I mean, hopefully we're talking about real people, not Alexa.
Lucy: Yeah, I mean until Alexa knows kind of emotional intelligence, you know, I think we're kind of stuck. But Alexa could certainly order takeout from the place that the nutritionist recommended that's healthier for the person. So, there's a lot of promise with this new venture and certainly the tech arm could be employed to deliver healthcare in a meaningful way to lots and lots of people, but it depends on how they do it. If we prioritize the medical home and time with a trusted doctor who can then connect all the dots, that's ideal.
Charles: Got It. Cool. Right now in this country, a single-payer system or working toward a universal healthcare system is a hot topic and will be going into this year's elections I'm sure. These are very large organizations that are tackling what they hope they can do within the current health insurance environment. If we were to move toward a more universal healthcare system in this country, would that kind of scrap all the work that they're doing right now or...
Lucy: I think their goals are to improve their employee's health and wellbeing, but also to save money, and then thirdly potentially to be a leader in the healthcare reform movement. So, it remains to be seen what they will do, but if they do it well, where there are healthier people at lower cost and it's scalable, then they could be leaders in the healthcare reform movement.
Charles: Sure, and I mean by saying that, the healthcare reform movement, obviously everything they do is still going to be dictated by their employees' health insurance, and they're going to be doing all these things as free benefits, maybe within the company?
Lucy: They are going to self-insure, so they are going to not only deliver the healthcare to the employees, but they are going to be their own...
Charles: ... insurance company.
Lucy: Well, this nonprofit is going to be a way of handling the benefits and delivering the actual product that is the healthcare.
Charles: Got It. So, obviously we don't know exactly what they're going to do, but do you anticipate this being administered by a Blue Cross Blue Shield or a United Healthcare? Or it's literally going to be its own thing.
Lucy: It's going to be its own thing, which is why it's exciting, because as we've seen, the federal government has had its challenges figuring out how to deliver healthcare in a meaningful way to its citizens. And the insurance company is so bogged down. It's not in my opinion, prioritizing the right things when it comes to treating basic human condition issues. And so I think it's now time for the private sector to see if they can shake loose some of the problems with our healthcare system, and so they have this golden opportunity to shape the future of healthcare if they do it right.
Charles: Got It. So in order to cut out the health insurance companies, they provide the doctors and the physical therapists and the mental health professionals to take on this work for their employees. I've heard some people say their fear for socialized medicine is, hey, I'm not going to get to pick my doctors anymore. This sounds like a bridge from the old system to potentially the new system.
Lucy: It could be.
Charles: But is that the situation, whereas I can only see an Amazon provided doctor? Much like Kaiser Permanente, if you use their insurance, you have to use their doctors. Is it kind of like that?
Lucy: Totally. There is that potential problem where employees might think, number one, I don't know if I want to see the doctor that Amazon has suggested. And number two, there are privacy issues. I'm not sure every employee is going to want to think that their employer is part of their health. I mean we already have this sort of big brother fear of these giant tech companies. Do you as an employee, want to think that your employer knows everything about your emotional health, your physical health. There's a lot that needs to be worked out, but as I said, the insurance companies are so bogged down and the federal government is not making headway for political reasons, and so the private sector has a golden opportunity to make some major changes.
Charles: And I think you said it was a nonprofit that they're organizing, so it's not even a for profit insurance company? It's like...
Lucy: That's right, and I think it's important that they did it that way, because you know, when you think about health, we hope that the motivation for improved health is not financial. We hope it's for the good of the patient, for the good of the individual, for the good of that person's family and community and for the good of the country that individuals get healthier and that high tide floats all boats. When individuals are healthier, then families are healthier, and then businesses are healthier because these people are employed, and then the country is healthier, so every little bit helps. If we can move an individual towards better health. Right now, people are not getting healthier. In fact, we are the most unhealthy country given the amount of money we spend on healthcare. And it doesn't have to be that way. There are simple solutions out there that need to be adopted, and again, in my opinion, it's prioritizing that medical home and the grassroots.
Charles: So this has been awesome. We have learned a tremendous amount from you today about your medical principles and how they can impact our society. If you were to launch your own podcast, what kind of topics and guests would you want to explore?
Lucy: Great question, because I want to launch my own podcast. What I would want to discuss is what I would call the human condition, so I would want to have a couple pieces on, for example, death and dying: one of my favorite subjects.
Charles: That'll be in the mental health corner.
Lucy: That would be in the mental health corner. I would do a lot on the mental health corner, because in my opinion that's where we're missing a lot in terms of healthcare. So, I'd have a series on the effects of work, work stress, burnout on behavioral health and on health. I'd have a series on substance abuse, relationship with alcohol, relationship with food, that kind of thing. I would focus on the different corners, and I'd have a series on different components of mental health, grief, addiction, anxiety, work stress, mood, and how those things inform health.
Charles: Gotcha. And by series, you mean like a three part series? We'll do three episodes on X, three episodes on Y.
Charles: And so, we discussed the notion of a medical home being constructed of your medical network that you pull from for a specific patient's needs. Would you bring those folks on to interview?
Lucy: Absolutely. So I would do some interviews with say the therapist I work with who treats my obese binge stress-eating patients, and we would talk in tandem about how we together promote patient's health by affecting behavioral change and affecting health outcomes.
Charles: Sure. And with a patient with a broad-stroke issue, like with obesity, we could obviously have a panel of you discussing their physical symptoms. We could have a nutritionist in here talking about how your nutrition impacts, your physical therapists saying, hey, well you're overweight, so it's making it harder for you to exercise, and really have a discussion of a group of the four corners.
Lucy: Yes, that's what I'd love to do. I mean, ultimately patients get better with the team-based approach, so you can have the team on the podcast explaining how each component of that patient's health is being addressed and how it's affecting outcomes in a positive way.
Charles: I love it. It's awesome.
Lucy: Thanks, Charles.
Charles: Cool. So Lucy, thank you so much for joining us. I think your ideas would be of tremendous value to the public, and I'm so thrilled you were able to come in and talk with us today. To learn more about Dr. Lucy McBride, please visit foxhallinternists.com and lucymcbride.com. If you liked what you heard today and think Dr. McBride should have her own podcast, please let us know at facebook.com/volubilitypodcasting, on Twitter @VolubilityPod, or you can email me directly at firstname.lastname@example.org. If you enjoy Open to Influence and would like us to create a similar podcast for your organization, you can email us at email@example.com. Thanks for listening.
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