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Book Review: I Love You But I Don’t Trust You

Author Mira Kirshenbaum

I Love You But I Don’t Trust You is national bestselling author, Mira Kirshenbaum’s, 11th book about healing relationships. I had the privilege of working with Mira when she was part of my medical expert team at Revolution Health, so I welcomed the chance to review her latest work. Although I had to endure some curious looks from my fiancé (who wondered why I was reading a book with that title), Mira’s writing sparked some interesting discussions between us and reinforced our own trust in each other.

When I first read the title of the book, I assumed that it would be focused on what to do when your partner has an affair. I was surprised to discover that I was utterly wrong. In fact, relational trust deficits can be caused by anything from broken promises, to misrepresenting financial situations, to lording one’s power over another. I Love You But I Don’t Trust You opened my eyes to all the subtle ways that trust can be eroded, and at the same time offered “actionable” advice for shoring up relationships.

Mira’s writing is particularly engaging because she illustrates her ideas with poignant, real-life examples. For every breach of trust under discussion, she offers a case study. Sometimes the couples she describes make outrageous gaffs, and the emotional train wreck that ensues is both terrifying and riveting. Example after example of poor judgment, bad behavior, and selfish acts could potentially be depressing, if it weren’t for the good news that follows. Many of these couples were able to resolve their conflicts and restore trust against all odds. Illustrating how that happens is part of the reason why Mira’s book is a page-turner.

Beyond advice for couples, I Love You But I Don’t Trust You is actually quite relevant for anyone who has been deeply wronged. Mira describes how she herself was able to offer true forgiveness to a former Nazi soldier who had participated (indirectly) in putting her own parents in a concentration camp. She describes a life-changing moment when she was traveling in Europe as a young woman, and she became very ill and fainted at the train station. A German couple took her to their home and nursed her back to health. Mira learned to trust the “untrustable” and became convinced through this experience that no relationship was beyond help. She devoted the rest of her life to relationship counseling, and her passion fosters hope in each of her books.

Some things you will learn from I Love You But I Don’t Trust You:

*All the ways that mistrust can enter a relationship

*Is your relationship worth saving?

*The typical response to broken trust, and the way to minimize collateral damage

*Suggested timeline for change and trust repair

*How to restore trust by working through 6 key questions

The only downside to Mira’s book is that it is based upon, as far as I can tell, the informed experience of only one therapist. Mira does not refer to the academic literature to support her theses or suggestions, nor does she appear to rely upon outside sources for additional insight. Mira speaks from her gut – she has a brilliant way of positioning arguments, and helping people to approach each other in ways that are minimally inflammatory in what is otherwise an emotional mine field. Beyond that, I can’t say if Mira’s approach to conflict resolution is optimal. My instinct says it’s as fine a methodology as any I’ve seen, but from an evidence-based perspective, there isn’t necessarily a lot of data behind it (just had to add that caveat for my science-loving friends).

Nonetheless, in my opinion, I Love You But I Don’t Trust You would be an excellent workbook for people in couples’ therapy. In fact, the Appendix lists suggested topics and questions for discussion groups, so I’m sure that Mira was thinking the same thing when she wrote it.

But most importantly, I think that reading the book in advance of any trust violations in your relationship, could be the best course of action. Simply learning about all the damage that one impulsive decision can cause to a lover and/or family could make you less likely to make that decision! I Love You But I Don’t Trust You might best be used as a preventive health measure for your relationship(s). I’m sure it has strengthened me against trust violations in my future.

**You can order the book on Amazon.com here **

Surprising Exercise Science: What’s The Use Of Stretching?

If you’re like me, you  probably feel guilty about not making stretching a part of your regular exercise routine. I attributed my history of low back pain to lack of stretching, although when I began practicing yoga last year I experienced no lasting benefits. Stretching was uncomfortable and I saw very little improvement in my flexibility for all my efforts. I eventually gave up after one well-meaning yogi told me that I may just be “genetically incapable” of making much progress. I turned to strength training and running with complete resolution of my back pain – though with a continued inability to bend over and touch my toes or sit cross legged for prolonged periods. Oh well. No traditional Japanese dining for me!

And so it was with great surprise that I read the conclusions from a recent analysis (by Alex Hutchinson, Ph.D.) of the science of stretching. I recommend that you read it for yourself (along with the links to the primary source literature). But I’m going to summarize his findings here:

Q: Does stretching reduce the risk of injuries during exercise?

A: Not that we can prove.

Q: Does stretching help you avoid soreness after exercise?

A: No.

Q: Does stretching make you stronger or faster?

A: No. In fact, there is some evidence that stretching can have the opposite effect. Why? Muscles have spring-like properties, so that when they are stretched out, they become less able to transmit as much force. Imagine the difference between the power of a thick, metal spring and a thin metal spring. Studies have shown that the more flexible you are, the less efficient you are as a runner.

My take away message is that there’s no need to flagellate yourself into stretching if you don’t like it. It really depends on what you need to do with your body – if you’re a gymnast, then stretching will always be a part of your life. If you’re a runner who hates yoga, so be it. You may never win a toe-touching competition, but then again, you can probably crush the Primal Games competition. Wish me luck as I attempt to do just that in two weeks!

Awesome Hydrocolloid Bandages Reduce Scarring After Mole Removal

I’m a dermatologist’s dream – a fair-skinned, freckly person with lots of small moles. The perfect candidate for a lifetime of 6-month skin checks!

Luckily for me, none of my moles have ever been cancerous. To be honest (please look the other way, dermatologist friends) I have sometimes put off skin checks for fear of being invited to undergo yet another biopsy. I’ve had about 9 procedures so far, and I have the scars to prove it. But this time around, I found a product that really reduced my healing time and scarring. I’m so excited about the results that I don’t care if I need a total-body shave biopsy next year. Bring it on! No one will be able to tell.

It is a little surprising that hydrocolloid gel technology hasn’t been on the consumer market for all that long (I wasn’t able to figure out when this product was launched in retail stores but it seems to me that I’ve only seen it around for the last few years or so). Hydrocolloid dressings are a staple in wound healing in the hospital setting, and I’ve seen marvelous results with pressure ulcer repair in the hands of experienced wound care nurses. The gel essentially creates a moist scaffold for skin cells to fill in defects and divots. The gel absorbs moisture from the skin and wound “oozing” while creating a sterile barrier against dirt and germs. The scab-less healing creates minimal scar tissue and the bandage is hypo-allergenic and incredibly flexible.

The product I used is called ActivFlex premium adhesive bandages (a Johnson & Johnson Band-Aid brand). I’ve seen generic knock-offs on store shelves but haven’t tried them. All I can say is that the experience has been terrific, and it’s such a relief to know that I don’t need to worry about scars from small cuts, burns, or mole biopsies any more. This is a fantastic invention – and I’d love to hear from others (be they dermatologists, plastic surgeons, or regular users of the product) to find out if they’ve had the same luck!

No need to fear skin checks anymore, my fair-skinned friends. You can recover nicely from procedures with a little hydrocolloid help from your local grocery store or pharmacy.

Another Ridiculous Article From The Economist: Doctor Shortage Is A Win For Patients?

I don’t read The Economist frequently enough to be sure that I dislike its entire staff of writers, but I have been repeatedly disappointed by its health coverage. In this latest article, “Squeezing Out The Doctor” the writers describe the increased healthcare needs of an aging western civilization, combined with a relative shortage of physicians to care for seniors. The conclusion? This is a “win” for patients.

Now, in case you find that conclusion as irrational as I did, let me summarize how they arrived there. The argument goes something like this: doctors have been unfairly controlling the practice of medicine for the past century, and now with the oncoming flood of patient need (and relative MD shortage), they won’t have time to do everything they have in the past. Physicians will therefore be forced to narrow their scope and outsource many of their current tasks to nurses and support staff. This is a win for patients because they will have shorter wait times for care and lower healthcare costs with the same care quality because most of what doctors do can be replicated by ancillary staff. At last we will be able to remove the self-important, over-educated, control freak physicians from the delivery of healthcare!

Oh, here’s another great idea: why don’t we improve our school systems by squeezing out the teachers?  Who needs teachers when mature students could train others in the same subject matter? Most of what teachers do is just baby sitting, right? We could easily outsource that to daycare centers or teens with a little baby sitting experience. The few teachers we retain should be reserved for only the most difficult cases: severe learning disabilities. Just think of the cost savings in teacher salaries! Imagine the improved access to schools if we didn’t have to adhere to some arbitrary teacher to student ratio. What a win for students. The only possible downside is that teachers may lose some of their current social standing, but so what?

The oncoming physician shortage will not bring the glorious improvements in healthcare delivery touted by The Economist. More likely it will create a two-tiered system whereby the poor and underinsured will get a substandard level of care. If you think that only doctors balk at long hours for low pay, try pitching that deal to nurses. They are just as savvy as physicians about personal economics. Having them take over primary care under the current (or worsening conditions) will burn them out just as quickly and nurses will specialize or quit nursing in droves. There is no magical, “let’s just get someone else to do it for less” model in healthcare when we’re already scraping the bottom of the barrel in terms of ROI for providers of any stripe.

Physician scarcity can be ameliorated by setting doctors free to spend more of their time in patient care, and less of it on distractions (such as excessive documentation for coding and billing purposes). But the solution is not necessarily outsourcing that work to someone else. It’s killing it all together. Radical idea? My practice is doing that now and growing a thriving business to boot.

Primary care doesn’t have to be expensive. Most patients need less than a full hour of a physician’s time per year, an annual cost of about $350. In my practice, we bill for our time and we spend it however it makes best sense for the patient – via phone, email, office visit, or house call. It’s in our interest to see as many patients as possible, and therefore we are increasing access to services. Office wait times are non-existent because many issues can be handled via phone (patients are not required to come to the office for every and any request for the sake of billing).

What’s the catch? We don’t accept insurance. Patients can submit claims to their carrier for reimbursement for our out-of-network services, but we have opted out of public and private insurance plans so that we can spend our time with patients instead of coding, billing, and being beholden to third party documentation requirements and regulations. This system works marvelously for any patient open-minded enough to see that a high deductible health insurance plan (for catastrophic coverage only) saves them thousands per year in premiums, while their primary care “out of pocket” will cost a few hundred or less. The math works for all. Access is improved, costs decrease, quality is maintained.

Now that’s a true win for patients.

Home Visits Reveal How Patients Are Really Doing

A patient was having difficulty swallowing her pills, so her doctor suggested that she might try peanut butter to help the medicine go down. Unbeknownst to the doctor, the patient assumed that this meant that she should mix all her prescription meds into a jar of peanut butter and scoop out a spoonful each day to spread on her toast at breakfast time. This practice was discovered during a home visit by a nurse a few weeks later, who relayed the potential “compliance issue” to the patient’s physician.

Clearly peanut butter is a sub-optimal storage mechanism for prescription medications, and dosing will likely present a challenge in this scenario… However the real message for me is that home visits are critical to understand how (and what) our patients are doing. All the claims data in the world is a poor substitute for the information that can be gathered in a simple house call.

Health insurance companies have gotten this message. Last month I began working for an agency that helps private insurers risk-adjust their Medicare Advantage client pool. In short, private health insurance companies contract with the feds to cover richer benefits for Medicare members who wish to kick in a little extra in premium. The government subsidizes this premium for the members based on their illness severity score (the sicker the patient, the higher the rate paid to private insurers to cover them).

But who knows how sick these members are? Health insurance claims data (diagnosis codes collected over the course of a patient’s lifetime) don’t correlate well with actual illness and current conditions, nor are these codes easy to get one’s hands on in the first place. Multiple previous carriers, incomplete medical records, various specialist physicians with paper charts or EMRs (that don’t talk to one another) all contribute to the poor data quality. So, as expensive a proposition as this is, private insurers are paying independent physicians to make house calls to tease out what’s actually going on with patients.

This process has been eye-opening for me in ways I hadn’t anticipated. First of all, I have a much better sense of how older Americans are actually living their lives by visiting them in their homes. I’ve gotten to know about the importance of family, the value of good caregivers, and the surprising lack of correlation between wealth and happiness. Second, I’ve gotten a sense of primary care quality in rural settings, and how communication break downs occur between patients and physicians. And third, I’ve developed an even deeper appreciation for the complexity of keeping people out of the hospital. Even the most well-intended advice can be “operationalized” in strange and wonderful, peanut-buttery ways.

I thought it might be helpful if I shared my experiences with you via my blog (patient privacy respected always, of course), so that we can explore the intersection between real life scenarios (discovered during house calls) and potential health policy. So stay tuned for more… 😆

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