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February/March Newsletter!

February/March Newsletter!

February/March 2022

Welcome to the February/March issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being.

Before we get into the topic for this month, I wanted to share that¬†I had a great response to¬†an article I wrote¬† for the¬†Globe and Mail¬†(Saturday edition) about the pitfalls of the ‚Äėself-improvement‚Äô industry, and had a chance to discuss it on the¬†All Sorts Podcast¬†with the very gracious¬†Desiree Nielsen, RD¬†(whose books you should read, and she has a brand new one as¬†well). It was a wide-ranging interview/discussion, and Desiree’s questions were incredible. Hope you enjoy it. I also realized how much I use the filler words “you know” — will work on that! Consider it a fair warning!


Alright, the topic of this month‚Äôs newsletter,¬† is the idea of ‘value-based care’ in healthcare — one of the most crucial concepts in healthcare today, in both the US and Canada.

But how do we define it? Atul Gawande penned an¬†excellent article in the¬†New Yorker¬†several years ago which hits the main points in a very compelling way. Further, several years ago, the American Board of Internal Medicine (ABIM) Foundation launched the “Choosing Wisely” initiative in part to support value-based care and reduce wasteful procedures/treatments (including that which has little to no evidence of effect).

Value as it relates to ‘value based care’¬†(VBC) is¬†defined as¬†“the measured improvement in a person’s health outcomes for the cost of achieving that improvement.” It’s crucial to note that while reducing costs/waste is related to VBC, it can’t be¬†equated¬†to VBC — they aren’t the same thing.

This brings us to a more philosophical argument: what does ‚Äúvalue‚ÄĚ mean generally, and how does this concept apply to both¬†our health, and the systems that support it (the obvious ‘healthcare system,’ but also the places we work and play and live)?

First we can ponder what value means to ‘health.’ We can probably agree that our ‚Äėhealth‚Äô is inherently valuable, as it’s derivative: without it we‚Äôre limited in actualizing our other needs. As such, we place high value on our health, and are willing to invest in it, though oftentimes it falls by the wayside. Our health is valuable as it links to surviving but also¬†thriving¬†‚ÄĒ without our health, our quality of life suffers (the ‘how’ we live), and at the most extreme, we cease to live (ie we die).

But what about value in healthCARE, i.e. the delivery of services for the purposes of optimizing health/well-being and offsetting/treating morbidities? How might we define that? I think we can conceptualize it in a few different ways.

For one: we can use the Costco example (for my international readers: Costco is described¬†here). Most people would agree that Costco is a place where people seek value for household goods (food, appliances, etc). Why? Because per unit its on average¬†cheaper: the consumer pays less per unit, so Costco remains in business primarily due to this perception of¬†delivering ‘value’ by selling products that themselves deliver ‘value.’¬†Bulk stores are similar: what we save on packaging ends up in our pocket. A good example is¬†shampoo: 20% more for the same price. That‚Äôs value.

Effectively,¬†getting MORE for¬†less¬†money, even if we shell out a bit more money at the outset is ‘value.’ It feels like we got a deal. But it’s more than just monetary. Part of assessing value involves something¬†intrinsic¬†and somewhat intangible. It involves a ‘feeling’ of receiving more than we bargained for (in a good way, to be sure). Think about the last time you went to a cash register and realized a purchase was on sale. Or if your local barista threw in an item (I see you: extra shot of espresso!) for free. Or when searching for a hotel or airline ticket you realize you’ve stumbled upon a deal that’s too good to pass up.¬†That¬†feeling is akin to value. We feel ‘good.’

Can this idea apply to healthcare?

Currently, according to the¬†Centers for Medicare¬†& Medicaid¬†Services (CMS),¬†the US spends just over $12,000 on healthcare per person, per year.¬†COVID has brought this into full focus: spending increased by close to 10% in 2020.¬† The US healthcare system is also one of the¬†least cost-effective¬†systems in the world (meaning more money spent with worse outcomes), especially compared with countries like Canada (where I’ve spent most of my life) and where I was born (United Kingdom). But¬†why?¬†Well¬†a¬†large fraction of spending¬†goes to hospitals (31%) and doctors/primary care clinics (20%), and, as Gawande writes in his New Yorker piece, it’s very likely secondary to how physicians (and insurers, and hospital administrators) are incentivized.¬†Wasteful procedures (and spending) become¬†a byproduct of a mismatch between incentives and value.

Allow me to me share a few stories to illustrate this point.

First, up:¬†as a patient.¬†In June 2020, a few months into the pandemic, I broke my left wrist ‚ÄĒ¬†a classic FOOSH¬†in my NYC apartment. I was lucky in that it involved my non-dominant hand/wrist. I was also lucky to have a friend who is an ER Doc in the city (hi Dan!) and whom I could call right away as I laid¬†there watching the soft tissues of my wrist¬†swell up (ouch!). Dan kindly¬†organized for me to see his colleague at the emergency department (ED) at¬†a big teaching hospital a few blocks away¬†for an Xray and splint. That was done quickly, and Dan’s colleague kindly allowed me to take a photo of my scans. The orthopedic surgeon resident advised that I’d likely just need a cast, based on the scans alone. Then I was referred, as per protocol in the ED, for a one-week followup with a staff¬†orthopedic surgeon. So, a week later, I dutifully went. The surgeon knew I had a medical background and am a physician myself. What he didn’t know was that I has sent the X-ray images to Dan, my brother (An ER doc in Canada) and a few other friends in ED¬†and Ortho (in Canada and the US)¬†‚ÄĒ¬†every single one said, based on the X-ray and my verbal history of what happened, that¬†the bone alignment was good and a cast alone would suffice.

But what did the surgeon in clinic¬†advise? Surgery. He explained that I would run the risk of arthritis if I didn’t take this option, as an an active woman in her thirties, this may not be ideal.

What‚Äôs the cost difference between a cast for a wrist FOOSH and surgery. ENORMOUS. The ED visit and split, as¬†well¬†as the followup clinic visit amounted to $3,600 USD. Surgery on top would have been at least $10,000 (and that’s being conservative).

And surgery includes risks (of anesthesia, post-surgical infection of the soft tissue/bone, etc).

I was able to explain to the surgeon that I was returning to Canada within days and would prefer to have surgery there if needed. He resigned himself to an ‘ok.’

Back in Canada I was seen quickly and casted, had a great physiotherapist and was about 75% in terms of range of motion and weigh-bearing within 8 weeks, and 100% within 7 months (that last 25% was tricky).

What‚Äôs the lesson here?¬†This was a glaring example of the differences in approach between Canada — which has a universal healthcare system and a different setup of ‘incentives,’¬†and the US.¬† Not assuming ill intent, but was this surgeon aware that surgery would¬†not¬†in fact be better, especially considering the balance of risks and benefits, not to mention costs? Did he know that the risk of arthritis, according to the evidence, is equivocal between a cast and surgery? It’s unclear. But this was an experienced surgeon, so perhaps the incentive to recommend a relatively easy surgical¬†procedure with a high payoff (to him and the hospital system) played a large role.

Now imagine doctors like him making similar recommendations — that is, ones that could be influenced by financial gain, not clinical evidence — to millions of Americans each year, Americans who do not have the privilege of having a medical background or someone they could turn to for an informal opinion before deciding.

This is how the US spends more on healthcare than most other industrialized nations.

Second story: as a doctor.¬†A¬†few years ago as a resident physician in the children’s hospital, I realized that the team was ordering daily ‘lytes’ (short for ‘electrolytes’) for every patient admitted on IV fluids.¬† Allow me a brief digression: our bodies very tightly regulate sodium (Na) and potassium (K), among other things (bicarbonate/HCO3 and chloride/Cl for instance). Intravenous (IV) fluids are a mainstay of supportive care for many patients admitted to the hospital, as hydration is often an issue in we’re sick, due to fluid shifts, insensible losses, etc. IV fluids themselves, as they contain electrolytes, can also lead to ‘too much’ or ‘too little’ electrolytes (specifically K or Na) which can lead to all kinds of issues for the brain and the heart.¬† For an illness like¬†diabetic ketoacidosis (DKA),¬†assessing electrolytes closely and comprehensively is very important¬†for many reasons (more here, note that DKA is managed differently in children vs adults, but the general principle of close electrolyte monitoring remains the same).

But for¬†other¬†illnesses, namely ones that¬†don’t¬†involve massive shifts in electrolytes, and where the main concern is whether the patient could become hypernatremic (high Na) on an NaCl IV fluid, ordering a whole set of ‘lytes’ isn’t usually necessary: checking Na¬†alone¬†should suffice, and potentially, with good kidney function, checking every second day may also be reasonable. So why did the team order¬†daily lytes on everyone on IV fluids? Again: it seemed to be an action that was¬†incentivized, but not due to financial gain per se — it was likely an action incentivized secondary to ‘habit’ (i.e. ‘this is just what we do.’).

Why does this matter? Habits or shortcuts or heuristics save us from additional cognitive load. When we drive a car, we automatically know we need to stop at a red light, and go at the greenlight. We don’t stop to ask ourselves consciously whether we should stop or go (yellow lights on the other hand…).¬†Stopping to think ‘does this patient need this action? Will ordering X change the course of management?’ are important questions, but they take¬†time and effort. It’s often easier, especially in a busy hospital ward, to go into automatic mode and simply order more than what’s actually needed. The idea being: it’s better to be more comprehensive than not.
Except: that assumption is often wrong for patients who are clinically improving.
With this particular example of ‘daily lytes’, out¬†of curiosity, I wondered about two things:

1. What was¬†difference is in terms of volume of blood taken for a patient if we ordered ‘all lytes’¬† compared with just the one we needed (Na) in this case?

2. What was the cost difference between the two?

So, after a hasty lunch one day, I headed down to the lab second floor and asked a technician, who provided me with a list of costs. I also spoke with a phlebotomist to understand the blood volume issue.

Here’s what I found: blood volume wise, the difference was small, but there¬†was¬†still a difference — a few milliliters per tube of blood taken.¬†Iatrogenic (hospital caused) anemia¬†remains an issue in acute care medicine, secondary to taking too much blood from a patient.¬† For a patient in hospital for a week, a few milliliters a day can be significant enough to cause symptoms (fatigue for instance, on top of what may be normal secondary to an illness).

Cost-wise, the difference was about $5. I can’t recall the exact figures, but each electrolyte was roughly $1 dollar (for ease of explanation I’ll assume equivalence between the Canadian and US dollar). A full lytes panel of 6 electrolytes costs $6. What does this mean?¬† Let’s assume that each¬†patient admitted to hospital requires a full lytes panel on admission, but then those that receive IV fluids only need their Na checked each day after. If the¬†average stay is about 4 additional days on the inpatient unit,¬†we’re dealing with a difference per patient of $5 a day — so $20 in total (with the total cost being $26 if we add that day 1 panel cost). Now imagine there are 500 patients admitted per month into the unit who require IV fluids. Thats 500 x $20 (=$10,000) compared with 500 x $4¬†(=$2000). Now multiply that by 12 to get the yearly figures, and then by the number of acute care wards in the country and….well¬†you get the point. The financial difference that results from being more prudent with test-ordering is immense. The consequences of not stopping to think if there could be a¬†better, less wasteful¬†(and potentially¬†less harmful,¬†if we consider the volume of blood lost) way of delivering care results in the¬†opposite¬†of value-based care. Mind you: this is one example, of which there are thousands — as such the it’s not surprising that the waste we’re considering is into the millions if not billions. It’s the price we pay for¬†physician/institutional inertia.

Last example — the everyday patient.¬†In June 2021 I was visiting¬†upstate New York, and had a really interesting chat with a taxi driver (as an aside: some of my most interesting chats about healthcare happen to be with ride-share¬†and taxi drivers). I’ll call him Dale, and the moment I entered his car he launched into a discussion about the American healthcare system. In his 70s, Dale is a blue-collar worker with a grade 10 education. He¬†also served in the military for several years, including in Vietnam. Dale¬†has several chronic health issues, including Type 2 diabetes that’s poorly managed and requires insulin, high blood pressure, and high cholesterol. Recently his Medicare coverage stopped covering his insulin. This led to a very frank discussion with his primary care doctor, and Dale explained to me that he had all but “given up” and accepted that ‘death was around the corner’ (without insulin a patient with uncontrolled diabetes can go into organ failure and die).¬† It was a very tragic example and a story that has stuck with me. Here we¬† have an example of where, despite the high cost of care per patient in the US, we still have millions of people like Dale, who actually¬†need¬†the spending, who fall through the cracks, and adopt¬†an almost resigned/pessimistic view of their longterm healthcare.
All three of these stories help us understand the puzzle pieces behind what we know as “value-based care.” But there is¬†one more story¬†that’s crucial, and particularly topical now: that of physician ‘burnout’ (aka anxiety, depression, etc) secondary to buckling under the pressures of performance,¬†including¬†the expectation to provide¬†‘value based care.’¬†When I mentioned cognitive load and institutional inertia/physician inertia earlier, it was because we¬†must also understand that both of these concepts are in term impacted by the¬†well-being of the physician. A stressed- out, unsupported, demoralized healthcare professional is unlikely to have either the time or the energy to stop to re-evaluate if they are ordering the appropriate test, or more broadly if they are providing the best possible care — one that maximizes outcomes for the patient and minimizes costs (not to mention makes the physician ‘feel’ like they’re making a difference).

Value-based care, in other words, must also, as it’s core assumption, place ‘value’ on physician health and¬†well-being. It should be¬†easier¬†to provide value-based patient care, not more difficult, and there is value inherent in ensuring the physician feels good, remains healthy and thriving before/during/after delivering patient care.

Now that I’ve [hopefully] painted the problem clearly, we can agree that the *system* has to change. But for it to change in a sustainable way, the tweaks¬†can’t just be topdown¬†— from government or insurers for instance. We need to be thinking more creatively, like an entrepreneur. We need to ask how, to paraphrase Buckminster Fuller, of ways in which we can make the old system of how physicians are incentivized to deliver care,¬†obsolete. The only way to do that is to create a better system, one that¬†provides¬†incentives that align with what doctors value.

Is there a way to provide value-based care while optimizing physician health/well-being and cutting down on unnecessary time wasted on administrative tasks? Yes.

Is there a way to improve patient outcomes while lowering costs, saving the most money on complex procedures that are actually needed.  Yes.

Could this also involve taking a more whole-person/patient approach to healthcare? Yes.

So what might this potentially ‘better system’ look like? That‚Äôs the topic of the next newsletter, and an exciting announcement I have about a pivot in my own professional focus.

 

Have a healthy, joyful, and safe month,


Amitha Kalaichandran, M.D., M.H.S.

 

December/January Newsletter!

December/January Newsletter!

December 2021/January 2022

Welcome to the December/January issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being.

This edition is a bit different from the previous one (and it’s a long one, so brace yourself!), because it’s focused on ONE big topic, which is: what do we ‘attend’ (pay attention) to? I’ve written briefly about this before, after reading a book I often recommend: Attending by Ronald Epstein.

This photo will make sense shortly.

 

so will this!

While I was in London for 6 weeks recently, for personal¬†and professional reasons, I met a lot of fascinating people (maybe there was something in the air…besides the obvious SARS-CoV-2?), but¬†one¬†person, whom I’ll dub for dispositional reasons “Mr Darcy“, stood out for one reason: he paid attention to to the *right* things.

Mr Darcy is unique for many reasons: an academic surgeon but someone who grew up with a strong literary background,¬†being¬†diasporic but born in the UK, and having several¬†unusual obsessions outside of work, all of which has allowed his mind to adapt and see connections between disparate things and experience the world differently.¬†This same tendency has undoubtedly also led him to pursue the right questions in his research (think: senior authorship on several¬†Nature¬†papers, even though he’s technically an early career physician and researcher) and numerous professional opportunities.

Mr Darcy also happens to be an excellent¬†cook, namely because he’s a bit of an obsessive. Once he made squid ink breadsticks (with a complicated dip recipe)¬†for a party we attended, because¬†at some point he realized regular breadsticks were not good enough. The extra¬†few minutes to add squid ink paid off for the guests, mostly in ‘awe’ and joy, and even though the dish itself was tasty — that tiny tweak moved it from good to “extraordinary.”

But all of these things aside, Mr Darcy also left an impression on me personally because¬†he paid attention to the *right* things.¬†To be sure, it wasn’t an *excess* of attention — but an investment and calibration towards the things¬†that matter.

It’s quite easy, when we think about it, to give anyone or anything a *lot* of generic attention: spend¬†more money¬†to impress someone,¬†spend¬†more time¬†on¬†one thing (this¬†grit/slogging¬†isn’t always ideal) or person¬†to show ‘effort’ or ‘commitment.’¬†But the impact tends to be low, over time especially, if that’s the only dimension we focus on.¬†Investing in the¬†correct¬†things, things that lead to the biggest payoff, is often a better, or at least complementary,¬†strategy.

This idea led me to think about how often I pay a *lot* of attention, when I should really be spending the *right* type of specific attention. One big area is cooking.

I’m a relatively good cook: I’ve been cooking for many years. Overall, when I cook for loved ones, they enjoy the meal. But am I a¬†great¬†cook?¬†Definitely not, if we define ‘great’ as ‘exceptional’ or ‘extraordinary’ — I can’t recall one time when a loved one brought up a meal I’ve made as specifically memorable, which is a good marker for ‘extraordinary.’ We know this because we often remember the moments that stand out as well above average — specific meals at restaurants are a big one.

So, for 2 weeks, mid November to December 1st,¬†effectively just as I returned from London, I challenged myself to apply¬†the principle of ‘paying the¬†right¬†attention,’ towards becoming closer to ‘extraordinary’ with cooking. My goal wasn’t to cosplay as a professional chef, in as much as a layperson can’t just put a white coat on and be a doctor, but I wanted to refine my thinking and approach enough¬†to get closer to ‘extraordinary’ — to change up my ‘process’, and iterate to lead to a¬†better outcome and experience.

I decided to¬†experiment with a new dinner dish, or refine one I’d¬†made before, daily, as this¬†seemed the most efficient way to establish a habit, and enter into a learning curve where I could build upon skills each day (so total immersion!).

Instead of focusing solely on one sense (taste), I wanted to explore the other senses as well: aroma (the feeling that hits you just before you take a bite, or when a plate arrives), visual (how are things plated/the art element to the presentation), sound and texture (how do elements pair together and ‘sound’ e.g. a crunch). Flavor/taste was also important, but I wanted to dive into pairing things that we don’t typically see together, or explore ingredients I haven’t used before.

The way I cook is probably how I approach many things, including my writing: I begin with an idea, and build around it. With cooking, I’ve always followed the taste principle of balancing at least four of: sweet/sour/bitter/salt/fat in some way.¬† If I wanted to make one element the center — a cut of fish or meat, tofu, grain, or vegetable — I’d begin there, and then see how the other puzzle pieces fit together, according to the framework of¬†flavor, visual, texture, etc. What worked best was creating a list of several potential dishes, and moving elements around over time.

The biggest gap was around technique: where I asked myself ‘if my goal is X, what cooking technique would be best?’ And in those instances, a quick google search or Youtube video sufficed to fill in that gap. This is all to say that I didn’t follow any preset recipes for most dishes (Dishoom’s black dal¬†being one big¬†exception!), and don’t tend to write out my recipes, because I simply don’t see cooking as prescriptive: and reversing my exact steps¬† seemed cumbersome.

Adventure was also key: having¬†‘beginners mind‘ conversations with people at niche grocery stores and asking for advice or ingredient recommendations, for instance.

Part of intentionally gaining any new skill¬†is accepting that failure and risk are¬†part of it. As such, I set an ‘error rate’ of 10%, meaning that if 10% of my dishes ended up inedible, I’d be ok with it. Setting this meant I was free to explore weird combinations, or plate things without the expectation of perfection.

I also wanted to ensure that, unlike when I typically cook, I wouldn’t multitask. This meant that music was fine, but no podcasts/audiobooks or phone calls — I wanted to cultivate a¬†flow state¬†and focus my attention to each step of the ‘cooking experiment.’ It thus became a form of ‘mindfulness’ in action, and allowed¬†for ‘deep work.’

Last: I wanted to set a few boundaries — namely¬†time¬†(the daily experiments had an end date so I wouldn’t totally fall into a rabbit hole but could also spend the time cultivating this new skill; also that most dishes should take about an hour, even if prep involved a few minutes overnight) and ‘gadgets‘: often when we get excited about a new hobby we can be impulsive with getting all the gear, even before we know whether we actually need it. I¬†did¬†change my mind¬†on a sous vide machine: I settled on a basic one that saved a lot of time and effort after I understood the manual investment (because I made the manual investment for one dish!), and because¬†my perspective changed on Black Friday! But I didn’t purchase a blowtorch (which would have allowed me to cook pieces of fish directly on a plate).

Overall, the process was enjoyable, and a fun self-directed learning activity that allowed me to follow my curiosity, take risks, and improve in a tangible¬†way. Now I’m inspired to offer this skill to loved ones as a way to change up the typical ‘ordering takeout’ or cooking something basic. Cooking for someone is, indeed, an under-appreciated love language and expression of care — why¬†not¬†make it extraordinary then?

It also¬†made me realize that, when we often discuss ‘wellness’ strategies and approaches, we focus heavily on things like nutrition, sleep, connection, mindfulness (all things I’ve written about, are described on my website)¬†but we pay less attention to the human need to¬†explore and discover, and the unique¬†benefit¬†it poses to well-being that most other ‘self improvement’/wellness/self-help things don’t. For instance: when is the last time you took a ‘field trip’ to learn about something (eg an industry) that you’ve been curious about, without a professional payoff (eg¬†as part of a job)? And why are¬†adult field trips not more common?

So, as a small step up¬†from¬†Instagram,¬†I’ve¬†added a tab¬†to my website as a nudge to inspire us all to do more curiosity-led experiments in the future, even if it isn’t daily (or even weekly), as part of our wellness.¬† Why ‘peaceful pescetarian’? That was a [now defunct] food blog I had several years ago to document seafood-y things I ate (and a few things I made). Needless to say it didn’t last, but I love the name (though if I could rename it, it would be ‘the peaceful pescetarian and the vegetarian hedonist’ ūüôā¬†).

We’re nearing the end of this rather long, hopefully not *too rambling*, letter¬†but my hope is to¬†inspire you to consider adding something to your wellness repertoire this holiday season, that perhaps you might carry forward into 2022,¬†that goes beyond what we typically associated with ‘wellness;’¬†something that challenges you to¬†learn something/get better at something you’ve perhaps been curious about¬†for a long while; something that doesn’t necessarily need to be tied to your professional goals, but has the potential to expand your sense of joy and well-being. Part of this may involve¬†exploring¬†where you might have been paying *excess* attention, and where instead,¬†you might get a better outcome from paying the *right* attention instead. Consider it an experiment that provides meaningful data to help you make better decisions, and re-evaluate how/where/when you spend your energy and time.

In other words, we can all benefit from¬†Mr Darcy’s insight, especially as our well-being may be further challenged this winter due to the new variant: a reminder that we’re in a pandemic¬†marathon, one that’s approaching almost two years, where it might be helpful to expand our toolbox of things that keep us calibrated towards more joy, peace, and wonder during these uncertain and troubling times.¬† And if you *do* try something new, shoot me an email or tweet it to me!
 

Have a healthy, joyful, and safe Holiday season, 


Amitha Kalaichandran, M.D., M.H.S.

 

ps and on an unrelated note, I’m¬†re-sharing the link¬†to a very worthwhile fund to consider during this season of ‘giving’. I’ll have more to say in the next newsletter.¬†

 

Introducing…edible art (wellness as creative curiosity)

Introducing…edible art (wellness as creative curiosity)

Roasted artichoke with olive-pomegranate tapenade. Beurre Blanc. Pickled Radish.

Coconut flour battered haddock. Spicy mint peas. Homemade red potato ‘chips.’

Harissa–backed mackerel. Roasted persimmon. Golden beet labneh.

Zaatar seared mackerel. Egg-free gribiche. Guajillo chilli oil.

Butter seared scallop on roasted lotus root. Coconut milk romesco sauce. Poached bamboo shoot/roasted golden beet/radicchio salad.

Sage and shio koji Enoki with kiwi kimchi.

Arctic char mi cuit. Yuzukosho. Karashi green beans. Yellow summer squash.

Mafalde ai funghi (morel & black trumpet). Black garlic. Wild asparagus.

Roasted eggplant with shiso, coriander. Enoki-fig confit.

Poached Nashi pear with maple syrup and feta. Farro/mushroom/roasted chickpea stuffed harissa grape leaves. Chickpea aioli. Fried pumpkin flowers.

Turkey sous vide. Sumac. Umeboshi. Celeriac mash. Sangack-pomegranate-date stuffing. Patti cake roasted squash. Wild mushroom gravy.

Mango butter poached lobster tail. Pea-green chilli relish.

Fried tofu umeboshi with morel veloute. Fresh fig. Shiso. Black garlic. Candied walnut.

Tandoori prawns. Remixed cucumber raita. Papadam.

Dosa. Dishoom black dal. Sunchoke-tomato curry.

Seared cactus with hearts of palm/orange bell pepper/pumpkin flower/prickly pear salsa. Ancho.

Lavender-honey-glazed duck with persimmon and fennel. Roasted purple brussel sprouts. Black truffle pomme puree. (my adapted version of Daniel Humm’s creation).

Tuna crispy rice with yuzu avocado and lumpfish caviar. Yukari salt. Ponzu. Shiso. Served with miso bagna cauda, pickled watermelon radish, bamboo shoot.

Sesame and quinoa crusted tuna tataki with ponzu. Pickled watermelon radish. Bamboo shoot. Carrot. Fermented ginger.

Panseared half seabream with roasted marcona almond scales. Broccolini. Pickled baby radish. Purple brussel spout. Yellow carrot.

Roasted bream. Broccolini/leek/fennel/black garlic/coconut milk puree.

Morel ragu/bolognese. Squid ink tagliatelle. Crushed chilli.

Mushroom vegetarian carbonara meets spaghetti alla nerano.

Jerk fish “grounded” with fried plantain, okra, and heirloom carrots.

Jerk fish “refined” with plantain-banana pur√©e, jerk ‘gel√©e’ & steamed okra.

Nasi Lemak

 

Gambas a la Clem (spot prawns with yuzu/sumac/clementine glaze, poached in ghee)

 

Roasted squash with olive pistou. Pickled kohlrabi.

 

Gambas al ajillo (spot prawns with garlic, shallot, black garlic, guaijllo chilli, parsley olive oil)

 

November Newsletter!

 

 

 

**note: photos will no longer be reposted from the newsletter for privacy purposes (subscribe for access to full newsletter)

November 2021

Welcome to the November issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being. 

Some things that had me wondering last month:
 

1. COVID and…
Counterfeit:¬†¬†from¬†STATNews¬†— the frightening¬†burgeoning secondary industry of fake vaccines and COVID medicines.¬†

Children: in the NYT, preparing them for the trauma of COVID, and (an oped from the American Academy of Pediatrics) preparing ourselves for their vaccines  in the NYT

What it will take to end the pandemic: A smart, and pragmatic, take from Leana Wen, in the WashPo.

Rapid tests:¬†First read this eye-opening¬†tweet thread¬†by David Leonhardt (of the NYT) about issues with accessing rapid tests in the US (also applies to Canada), then read this profile of Michael Mina, an early proponent of these tests, in¬†Bloomberg.¬†For what it’s worth, it does seem that access to free rapid tests is around the corner for North America (below, an example from London, where the NHS provides them for free).

2. Podcasts (& shows/books) worth listening to/watching 
Not a podcast or show or book (Sadly I have started nothing new this month…) but I did really love¬†Ryan Holiday’s newsletter¬†(a yearly one he puts out for his birthday).¬†¬†

This is from the archive but it made me think and re-think.

Lastly, I was very late to this viral piece, “The Bad Art Friend,”¬†but finally listened to it on The Daily, and it was immensely horrifying and sad. In my view, there’s no question who the person in the wrong was: Dawn Dorland was gaslit and tormented for years — make no mistake: this was not an impulsive petty comment or bit of gossip. It was an orchestrated campaign over years to take her story, and associated themes around it (including perhaps the question of altruism vs validation — a great¬†film¬†about this theme is underway), her own words, with the goal of profiting off of it and dehumanizing her. Brene Brown discusses the idea of “common enemy intimacy”¬†— this was certainly at play here: a group of very insecure writers, or perhaps a group of neutral writers, who were swayed (groupthink/social psychology stuff) by an individual with sociopathic and/or Machiavellian tendencies to partake in this abuse and gaslighting. It’s all made worse by two things: that Dawn had openly disclosed her trauma and mistrust (and they did it anyway, to re-traumatize her) and that the perpetrator used the excuse of being a woman of color as a way to paint Dawn as a person abusing her ‘white privilege’ (which only does harm to legitimate claims of bias and systemic racism in writing and beyond).¬†

I’m hopeful Dawn will find justice, and more importantly, healing. I also hope this experience might plant the seed for her own memoir — could this just be a turning point in a fascinating story about altruism, kidney donation, and healing from trauma? I hope so.

3.On…when to quit (not grit)
In the¬†NYT Opinion¬†section, an incredible ‘video oped’ from Lindsay Crouse, on¬†¬†video when to quit (over grit).

4.Sound (and wise) reflections
This is very old (if May 2021 is old), and sadly I just found it a few weeks ago, but it’s one of the best ‘think pieces’ about the pandemic, in the¬†Tyee¬†(which is Canadian!).¬†

5.Miscellany
Dr Eric Warm’s¬†paper¬†on game theory and the Match is well worth the time and introspection. The only thing that might have made it a bit better: incorporating the “Secretary Problem,” which someone told me about a month ago, and I can’t get enough out of my head (it’s brilliant…and applicable to many things).

Somewhat unrelated to this, is the “Avocado Problem” (which I¬†believe¬†I just made up…but I’m anxious to google it, in case it isn’t exactly original). It began with this….(M & S is a fine food shop, part of Marks & Spencers)…..read on and tell me if there’s anything to this…(by the way — it’s great that they specify that the ‘eat now’ avocado and the ‘eat later’ one are from two different places…)

It begins with a question: is there an optimum number of avocados that one (a buyer) can purchase in order to maximize satisfaction (having a ripe¬†avocado to eat relatively soon) and minimize distress (buying an overripe one accidentally, buying an underripe one that needs time…i.e. cannot be eaten when the buyer wants)? I believe M+S has solved this. The optimum number is exactly 2, but one must be ‘ready to eat’ and the other slightly unripe. Why?¬† Let us assume that most people who buy avocados imagine themselves eating it later that day (guac, snack)¬†or the following morning (avocado toast, huevos rancheros). That leaves a window of 8-12 hours for pleasant consumption.¬† Let’s also assume that most people who buy avocados dont like to go shopping for them daily. We rarely buy apples one at a time, right? But apples are not avocados (forget oranges)…more on that later.¬†

Ok so now we have a person who wants to buy an avocado for¬†imminent¬†consumption but *also* has planned to eat another one¬†within the next few days. Placing household size aside for a moment (but we would¬†multiply the stable answer by the number in a household), the stable answer is 2: one ripe, one unripe (preferably not in the wasteful/plastic package as above, but individually).¬† So why do grocery stories sell them as 5-7 in that green netting? Everytime I’ve given in to ‘buy more to save more’ idea, with avocados only (not apples!) I’ve regretted it. Why? Because avocados ripen more or less at the same time when they are sold like that — it’s the ethylene gas they give off to one another. So while we *think* buying more is better, the net outcome is roughly 3 edible avocados, with 3-4 going to waste. (again: not the same for apples, oranges, etc…avocados are among the most temperamental and unforgiving of fruits!).

Now you might be wondering…what does this have to do with a newsletter about well-being and health? Everything! Because so much of our well-being deals with *how* we make decisions. Not the *what* (outcome isn’t relevant here) but the process. Good decisions heighten our well-being (regardless of the outcome) because we minimize regret around the counterfactual. Bad decisions:¬†the opposite. We weigh¬†a variety of factors differently when we make decisions, and there’s also an element of¬†chance¬†(read anything by Annie Duke, like¬†this¬†or¬†this, to get more insight into this — her work has shifted my perspective¬†immensely¬†over the last 18 months).¬† Apples, you’ll recall,¬†are not avocados. Apples are one of the most forgiving and stable of fruits — the time window to consume them is relatively long (a week or more) as opposed to short (avocados: hours !). That’s why buying apples in bulk makes sense: you can trust there’s one available for immediate consumption,¬†and¬†one (or many) for later. It doesn’t become a frantic exercise in planning and calculating….as it does for avocados. When we make decisions: about picking the right professional opportunity, business/romantic partner, etc, we weigh some of these same factors. And a big one, beyond compatibility around values etc is *timing*. The problem is that we often presume that these opportunities are like apples: ready when we are, and if we aren’t ready they will still be around when we are; as humans we tend to over-emphasize our own sense of timing and time more generally. This is, obviously, wrong.

Most things (opportunities, people we may want to partner with) are like avocados: If we’re ready (timing wise), we ‘match’ to the right opportunity that¬†might¬†be ready (ripe) as well, except that there’s also the element of uncertainty and chance: that ripe opportunity may not be all it that it seems (the ripe opportunity may end up being overripe/rotten when we finally dig in…which we perhaps didn’t judge well beforehand) OR, since we dont function in isolation¬†but with other people, others may jump at that ripe opportunity before us.¬†As such, the most stable solution is to pursue the ‘ripe’ one, but have a somewhat ‘unripe’ one in the wings. Note: this¬†isn’t¬†the same as having a¬†backup plan: a backup plan is effectively like lining up two ripe things one after another — having something in the wings that isn’t totally ‘ripe’ (either the opportunity is still in flux, or you are still somewhat unsure), but could be sorted out over¬†a period of time is better (this means that we also¬†avoid the competition element).¬†

Thanks¬†M&S Simply Food¬†for sponsoring this not-so-simple digression¬†(kidding). And yes, I know avocados are¬†not¬†the most sustainable fruit…but let’s park that for now, for the sake of this thought experiment.¬†

6.Best tweets¬†of the month goes to…
Adam Grant on prestige and jobs
Sahil Bloom on following your curiosity 
Maria Popova on living just the one life
Amy Edmondson¬†on…cookies ūüôā

7.Products/Services that have made a meaningful difference during the pandemic:
This newsletter is not sponsored, but I love sharing products that have made a meaningful difference in my day to day (increased productivity, more joy, etc).¬† This month I’m sharing my absolute favorite tea:¬†Marco Polo¬†by Mariage Freres.

I discovered it at a friend’s house in 2016, in Cabbagetown Toronto — the teabags are just sublime and a bit over the top (think: linen). I managed to find the loose tea version at Pottery Barn of all places, but paid a visit to the Covent Garden location recently and picked up some more teabags, and have made a few cups for friends here. It’s a black tea with a fruity essence, and is simply delicious with or without honey/milk — perfect post dinner, pre conversation tincture ūüė欆

In My Own Words…

I just completed my reporting for a longform piece I’m working on for Wired (now the writing begins), and gave keynote talk for the National Partnership for Hospital and Hospice Innovation (their Summit is underway), on the topic of burnout and healthcare revolutions (I’ll share the video next month). Funny enough, my mother sent me a photo from London (where I am for another 10 days) from the late 1980s — my first ever keynote! Thankfully my audience was slightly larger this time around, and I found a nicer bookshelf.ūüėú

I also had a chance to visit my old house (where I lived from about 2 to 6 years old), a duplex in Welling, Kent: 24 Clifton Road. It was really fun to chat with one of the neighbours and get all caught up on the neighbourhood happenings over the last couple of decades! I also retraced my walk to primary school — I’m a bit dumbfounded at how long it was (about 20 min for an adult, so 35¬†min for a 6 year old?)¬†¬†

Have a healthy, joyful, and safe November,


Amitha Kalaichandran, M.D., M.H.S.