Random Thoughts from a Restless Mind

Let’s talk about stress, shall we? It’s the Holiday Season in North America after all. Frankly, it’s been on my mind pretty much all day, every day, for a couple of years now. Probably because it appears to have taken up permanent residence in my body and soul for that same couple of years. Lots and lots of talk about stress around me, too. Everybody is talking about “having stress” in their lives, especially as the holidays roll around, so let’s talk.

First of all, as in all things it’s important that we lay some ground rules, establish some definitions so that we are sure to be talking about the same thing. Stress is what appears in your body in response to stressors; stressors are what you have in your life that produce stress, like serving dinner to family on Christmas Eve. I know, I know, it’s a pretty fine point, but bear with me because I think it will make a bit more sense in a moment.

In my day job I am constantly asked if various and sundry ailments are caused by stress. The most accurate and honest answer, from a strictly medical/scientific standpoint, is “yes”. What people are actually asking me, though, is: are the ailments that they have a direct result of the stressors in their lives? Again, perhaps a bit of a fine point, but it will matter. Everyone routinely conflates “stress” with “stressors”.

You can reduce the stress in your body; you may or may not be able to effectively reduce the stressors that cause it.

Think about that for a moment. You can do quite a few things that will reduce the ailments you may have because stress has been induced in your body. The simple science is that chronic stress throws your neuro-endocrine “fight or flight” response out of whack. Our bodies secrete cortisol when faced with acute stress. This is in turn associated with a release of adrenaline. Your pupils dilate, your BP and heart rate go up, and you shunt blood to skeletal muscle in preparation to do battle or to flee.

Chronic stress, on the other hand, causes an increase in both the basal cortisol secretion and a blunting of the normal daily secretion pattern of more in the AM and less in the PM. You have a flatter curve over the day, and the whole curve is elevated. In time you have a chronically elevated BP, and your state of chronic “readiness” begins to affect all manner of the rest of your systems. Stress then becomes a stressor itself, a repeating negative feedback loop. For example, your sleep pattern gets fried. Heck you may not sleep very much at all. That makes stress worse. That “lump in your throat” feeling when you are just pre-panic”? Yeah, that can be there all the time. It even has a name: globus.

Rather ominous word, that. Globus. Stresses me out just typing it.

Here’s the rub: if you could avoid stress—the adverse affect on your body—who wouldn’t do so? When people talk about trying to have less stress in their lives what they are actually saying is that they wish they had fewer and less powerful stressors causing that stress. Work issues, illness, family strife, money issues…life would just be better if we didn’t have them. Pretty simple. Get rid of stressors, get rid of stress. Sadly, our ability to excise stressors from our lives, or even insulate ourselves from them, is somewhere beyond inadequate and approaches impossible.

What to do then? If we cannot avoid the root causes of our stress, how can we relieve it? It turns out that both the magnitude and particular variety of stress can often be measured. Specific symptoms (sleep abnormalities, globus) will point toward equally specific interventions. There are laboratory tests that can be ordered given your particular stress (e.g. midline fat deposition); nutrition adjustments can be made in response (elevated cortisol reduces insulin sensitivity->consume carbohydrates during periods of lower daily cortisol levels).

For me the bottom line is this: we likely have little to no ability to control stressors, those exogenous factors that incite stress. Further, left to its own devices, our body will respond with stress. We can manage that stress by acknowledging it, evaluating it, and then proactively going about counteracting it. You are a Black Box experiment with an n=1.

Attack stress in exactly the way you attack fitness or nutrition. Weigh it, measure it, analyze it, and then attack it.

“Life’s not fair.” –Scar

What does equality mean? What does it mean to be equal? This came up this week in my day job. A study was done that proports to show that male and female eye doctors are paid unequally. The conclusions are false at the outset in this particular case because by law, services in this particular arena are paid exactly the same no matter who performs them, when or where. Unfortunately, the sensational lede taps into all kinds of notions of fairness, and all kinds of perceptions about what people assume must be true, that women make less than men for equal work. There is no question that this is the case is some walks of life, but interestingly the data (some of which the authors ignore in their quest to prove their preconception) proves otherwise in medicine. An opportunity to examine real differences in how men and women practice medicine is thus lost in the pursuit of an examination of the spiritual quest to combat inequality, even where none exists.

Is this the unicorn of equality? Is payment under government programs the only place where equality actually exists? Heck if I know. What interests me is the fact that the first assumption is that inequality is present. Inequality is the default setting. That there is an inherent degree of unfairness in pretty much any and every setting. Know what I think? Equality doesn’t exist. It cannot exist if we are to have an ever-improving world. There is nothing unfair about that in the least.

A just civilization establishes a floor below which allowing people to live is ethically wrong. For example, in healthcare it is my contention that we have a moral obligation to see that every citizen has access to care when they are sick. Inherent in this contention is that there is a basic level of care that meets this moral obligation by ensuring the same outcome as any other level of care. One could apply this same concept to food, clothing, and housing without missing a beat. We can think of the rights enshrined in the U.S. Declaration of Independence as a proxy for this baseline if you’d like. Life, liberty, and the pursuit of happiness make a very fine baseline.

One’s right to “life” necessarily includes a right to be fed, would you agree? Equality would mean that if one among us dines on Beef Wellington, than each among us must do so as well. This is where unthinking and unquestioning fidelity to “equality” brings you. In so doing it forces everyone to expend energy protesting “inequality” better put toward fulfilling the moral obligation to see that no one goes without protein. In healthcare we see all kinds of protests againts the inequality of care demonstrated by the horror of a VIP of some sort or another recuperating from a procedure in a luxury suite, while the proletariat must recover in the equivalent of a Hotel 6. The reality is that the outcomes will be equal; the moral obligation has been fulfilled. Above a basic level in pretty much any domain you wish to examine, equality does not exist. Sorry. Scar is right. Life’s not fair.

Is he really though? Saying that it’s not fair is the same as saying that inequality above that level at which everyone has a right to live is wrong. Here is where I part company with those who hew to this viewpoint. What does it matter that someone drives a Cadillac while another drives a Kia? Do both not get you to work on time? Or that Beef Wellington again: do you not get the same amount of protein from a hamburger? The example I am using in another conversation about equality in healthcare is similar: if a medicine is effective taken 4 times a day, is the fact that someone can pay more for a version that must only be taken once a day a measurement of unfair inequality? I vote “no”.

My strong feeling is that energy spent in some way protesting “equality” is energy that is not expended on the much more important task of fulfilling the moral obligation of raising everyone to that acceptable basic level. In may, in fact, work against that effort. That constitutes unfairness in my opinion. Advocacy and protest should be directed there, toward making sure that everyone has that most basic obligation covered. Once universal entry is accomplished across all applicable domains, the next task is to continually raise that basic level for everyone, no matter how far the gulf may be between that level and whatever the “sky’s the limit” level might be. One need only look at “poverty” or “hunger” and how the bar has moved ever upward there to see how this might work.

We have a moral obligation to see that true rights are available to all. It is unfair to those who have not yet achieved that most basic level when efforts to help them are diverted to the pursuit of an unachievable conceptual goal that neither feeds nor clothes nor cures those in need: equality.