Excellent overview on patient care today again for you from Dr Yanuck. I love the way he explains how we try to keep patients further back from the ditch so they are less likely to fall in. This is so true. I have to try and explain the benefits of the foundational bits of health even though I am not specifically focusing on their symptoms at that point, which some see as frustrating.
I like to share these patient care type posts sometimes as I think it is important patients see how our minds work on their cases! And it makes me feel I am on the right track with my functional medicine practice!
Patients with chronic illness tend to track the factors that worsen their symptoms. It makes good rational sense to do it that way. And yet that approach gives an incomplete picture of the case. If the patient tries to win by eliminating factors that drive symptoms but they don’t pay attention to the rest of their biology, they’re not likely to win.
Dr Yanuck
So how do you help patients understand the importance of factors that could be making them more fragile, increasing the frequency, duration, and intensity of symptom flares, when the factors involved don’t change their symptoms directly? In short, how do you help the patient connect with the idea that they need to build their biological robustness?
I help patients connect with this part of case management by talking about Horizontal vs Vertical Thinking. Many of you have heard me say that the patient’s biology is like a meadow or a landscape. Their primary problem, an autoimmune flare activation, for example, is like a ditch in the meadow. The ditch is always there. It’s part of how that patient is constituted biologically, part of their landscape. Sometimes the patient is in the ditch (having a flare), sometimes the patient is out of the ditch (not having a flare).
So, the patient experiences how they’re doing as “down in the ditch” or “up out of the ditch.” That’s a vertical difference. “I’m doing well,” means they’re up. “I’m doing badly,” means they’re down.
But the problem is that the patient could be up but could still be standing at the edge of the ditch. If you’re standing at the edge of the ditch, a stiff breeze can knock you into the ditch. It’s too precarious. These are the patients that are thrown into flares too easily.
Standing at the edge of the ditch feels exactly the same as standing fifty feet from the ditch. These positions are different horizontally, rather than vertically. No flare either way. So, the patient gets zero guidance about how precarious their position is. Symptoms don’t give the patient any horizontal information.
I tell patients that the first job is to help them get out of the ditch. We monitor the frequency, duration, and intensity of flares. This is important because most patients are only aware that they have flares or don’t. So, if they go from flares that last three days, happen weekly, and are intense, to flares that last one day, happen every other week, and are mild, it’s crucial that they recognize this as progress. Your ability to compare quantified reports across sessions and report their descriptions back to them helps them (and you) stay anchored in the process and helps them appreciate the trajectory.
And, at the start, I make it clear that getting out of the ditch isn’t the only job. We need to identify factors in their broader biology that can help them move away from the ditch. Better sleep? That’s fifteen yards away from the ditch. Better food pattern? Another fifteen yards. Lower stress level? Another fifteen. Pretty soon, the patient is fifty yards from the ditch.
At that point, if they encounter a perturbing factor, like an inadvertent food exposure or a stressful situation, it might move them ten yards toward the ditch. But if their new anchor point biologically is fifty yards from the ditch, the ten yard bump towards the ditch doesn’t dump them into the ditch.
That’s how you help the patient build robustness. That’s what takes the patient whose biology is fragile and vulnerable to perturbation if the wind is blowing the wrong way and give them a more solidly intact biology.