My Journey: Questing After the Perfect Smoothie

How do you improve health?

About nine years ago, I quit my job in investment banking and went back to school to study physics and organic chemistry. In the morning, I studied batteries, circuits and resistors; in the afternoon, I spent three hours wizarding with strange liquids in beaker-shaped flasks, heating, mixing, measuring and freezing various chemical concoctions.

Understanding why my microwave invariably conked when I turned on my hairdryer, battling "goggle-face", and navigating the terrorizing uses of the word 'titrate' were the apparent stepping stones to a dream: improving health.

This dream - this idea of improving health - nestled within a cozy little niche in my stubbornly idealistic personality. Coming from the world of ergonomic mesh swivel chairs, Office Depot bulk orders and Ann Taylor structured jackets, "improving health" shone as pure, gleaming Achievement. It was a vibrant Vitamix-quality smoothie of do-gooding and impact; so virtuous, it boasted probiotics and blue-green algae. Investment banking, on the other hand, was an overmixed fruitcake. Deceptively pretty to look at - if a bit gaudy with those fluorescent cherries - but a sure source of heartburn, and a mind-numbingly monotonous chew.

One morning around 3 am, in the middle of figuring out whether the $50,000 worth of renovated cubicle walls listed on an IT firm's balance sheet was truly a "one-time" expense, I stopped. I lay down the stack of courier-fonted reports on the mahogany desk next to the other 30 piles of courier-fonted reports stacked in Office Depot desk trays, gazing out the 40th floor window onto the not-so-twinkling Dallas skyline. I asked myself: If I am fundamentally a smoothie person, why am I putting myself through the indigestion and certain tooth decay of a pretty lousy fruitcake?

It was a pivotal moment: I pushed the fruitcake away and decided to create smoothies. A few details later - including some pre-requisite science courses and a pesky test called the MCAT - I entered medical school in search of that dream, ultimately improving health.

In medical school, the portraits of white-haired, famous healer-alumni-leaders lining our lecture halls seemed almost sympathetic as we struggled to memorize more than we thought normal brains could hold. There were the complex biochemical pathways dictating human function, the alphabet soup of genes and molecules swimming in our cells, the maze of nerves and muscles that we carefully untangled in anatomy lab. We were learning raw ingredients of health, and I marveled at how they adjusted themselves automatically, without our conscious effort. This balance of ingredients enabled our healthy existence.

Four years later, I walked across the stage of a big auditorium, wearing a fancy robe with gigantic puffy sleeves, receiving a fancy diploma written entirely in Latin (personally double-checked, courtesy of Google Translate, to verify that its message indicated I had indeed graduated). At this point, I had the basic skills needed to blend without disaster - there would be no turning on machines with uncovered lids, and no combining potentially toxic combinations of, say, radishes and bananas.

But as far as fine-tuning the process - i.e., appreciating the subtleties of crushed vs cubed ice, the secret to cleverly concealing spinach in a sweet smoothie, or the trick to creating luscious mocha granitas? This practical toolkit would be acquired in a "blending apprenticeship": residency.

The apprenticeship unfolded for me as an internal medicine residency at a busy San Francisco hospital. Here, we treated patients with "bread and butter" conditions: they were the foundation of medicine, the common ailments that affect > 70% of all hospitalized patients. These were like the ubiquitous crushed ice in the classic slushie - heart disease and heart failure, infections, liver failure and stomach bleeds. 

Then we had "zebras": patients presenting with one of the one-in-a-million genetic syndromes - rare syndromes, cancers, metabolic diseases and tumors. Those experiences were the exotic ingredients - i.e., the goji berries, Spanish saffron or whole Madagascar vanilla pods of medicine. When confronting a "zebra" condition, we proceeded with caution, researched everything we could, and if we figured something out, presented the recipe to each other at morning conferences and tumor boards.

But after nearly a decade spent seeking the secrets to bettering health, something happened. It was a nagging feeling of something not quite right, something that - at first - I couldn't quite identify. I chalked it up to exhaustion; after all, working stretches of nights and spending thirty hours in a hospital every third day wearing three beepers can trigger strange "feelings" in anyone. But as I started taking care of more patients and handling greater responsibilities as a physician, the troubling sensation grew in intensity, demanding attention.

I pondered, trying to conceptualize it, this sense of unease.

Was it related to the sky-high blood pressure and blood sugar readings in the patients already on fifteen different medications, who came back to clinic each time with even higher readings?

Was it related to the textbooks which, when referred to for help, directed me mechanically down a set of algorithms and pathways all of which seemed to end with the step of "add medication Z to patient's regimen"?

Was it related to the thing that brought back the hospital's "frequent flyers" - the patient who checked himself at least once a month requesting room 6408B - with the telltale symptoms of heart failure?

Was it related to the reality that more than 80% of patients ended up leaving the hospital without a truly unifying explanation for their symptoms?

Or was it something about our training, which emphasized managing day to day laboratory findings and physical symptoms until patients were "objectively stable" enough to go home, rather than finding and treating an underlying cause?

Was it related to our "rounds", where every morning at 8:30 am, we spent four hours seated around a decidedly investment-bank-ish table, "running the list" of all the patients in the hospital under our care with the head physician - and then spending < 1% of this time as a team actually seeing, talking to and examining these same patients?

 Was it manifested by the growing number of morbidly obese patients - some of whom could not fit into standard CT and MRI machines, and needed ambulance transport 60 miles away to an "open" scanner?

 Was it something underlying the seeming epidemic of pain? Not the clear pain of a broken bone or sprained shoulder, but the debilitating, diffuse, persistent pains patients suffered in their lower backs, hips, knees, stomach?

 Or, perhaps, was it related to our solution for such pain, centering mostly on some progressively stronger mix of anti-inflammatory drugs and opiates- a stopgap regimen which could not cure, but simply toed the line between intolerable pain and intolerable side effects?

 The source of my unease, I found, lay in a fundamental paradox: Although I had come to medicine to heal, I found myself maintaining - and even contributing to - an unhealthy status quo.

 In the process, I found I was beginning to lose my own health. I was sleep-deprived, jumpy and constantly exhausted. Yet, after sleepless nights on call and emotionally draining weeks spent caring for dying patients in the intensive care unit, jangled nerves left me lying awake in bed, staring at the ceiling for hours. Books and medical journals piled up on my desk, reminders of my responsibility as a physician to "keep up with the literature". Where the constant learning in medicine had once beckoned to my inquisitive mind, now the growing stacks loomed as daunting symbols of a Sisyphean endeavor. I'd entered residency confident, happy and idealistic; now, I felt more jaded, timid and self-critical. I started to question whether my dream of improving health was just that - a naive student's pipe dream.

 My training had essentially occurred in a smoothie-worthy healthcare system featuring an impressive array of state-of-the-art blenders with the most powerful motors; yet, I had discovered these tools were only as good as their inputs. More often, they mechanically minced sub-par and limp ingredients of health. The result: an off-tasting, poor quality and unsustainable concoction providing only inconsistent nourishment.

 I was determined to put in the research and work needed to find a better recipe. And so I entered the comfort zone tailored to people who want to think, learn and figure out theories in a guided setting: university. 

At the  School of Public Health at UC Berkeley, I learned - in the presence of researchers, mentors and fellow classmates motivated by similar calling - how to find the root cause of the problems in medicine. And it's here that I began to figure out how I can work to fix them.

Luckily, the recipe isn't exclusive or copyrighted - and a winning recipe for health has to be nearly as popular as that viral Neiman Marcus' Secret Recipe Chocolate Chip Cookies recipe (Were those really that good?). Shouldn't everyone who wants to be healthy know how health functions and what drives illness? Isn't that knowledge itself a fundamental bridge to sustaining health?

I think so. And thus, the purpose of this blog.

This post describes one person's story, but I am part of a bigger one.  Currently, I work as an Internal Medicine Community Medicine fellow in Los Angeles. There are six of us fellows in the program: all of us passionate, dedicated and fervent about the idea of improving health. Our mission is to build health - the perfect "health smoothie" -  from the ground up: the community. 

As you'll see in subsequent posts, us fellows know intimately that health starts in the community; outside the hospital.  This, despite the fact that 90% of our training has essentially, thus far, been confined to the all-too-familiar confines of our residency programs' hospitals.  But now, funded by the generous nonprofit arm of a major tertiary care hospital, we are spending a year navigating the world of health, figuring out how to build it and sustain it. This year, we'll find clues inspiring new "smoothie" ingredients, test-drive and formulate recipes, and think about this subject in earnest. 

We want to share what we learn and find - with you, the reader.  Think of it as a community potluck inspiring you to taste something new.

Last week, six hyper-educated doctors went back to school, and their classroom is the vast expanse of the community. And that is where our story begins.