June, 2021 - Southern Regional AHEC

Resilience

By MICHAEL SHAPIRO, PhD

October 2020

So here we are, almost a year into a debacle that began as an “outbreak,” grew into an epidemic, and was ultimately declared a pandemic back in March…which now feels like an eternity ago. People have been sickened, lives have been lost, economies have tanked, lines have been drawn in the sand, and every facet of life as we know it has been completely disrupted. No one has been spared. Everyone has been impacted, emotionally if not physically.

Unless you’re super-human (or inhuman), there have been moments in which you’ve wondered whether or not the world will ever recover. When will we again get to stand in line impatiently at McDonald’s, push and shove our way through a crowded bar, or glower disdainfully at that guy in the next row at the movie theater who’s making all that noise with his candy? When will we be able to cough or sneeze in a public place without being eyed suspiciously or asked to go home for fourteen days? Will we ever regain the willpower or emotional energy to return to “life-as-it-was”…that is, if “life-as-it-was” ever wants to return to us? I believe that we will. Why? Because of an invariable and inescapably human commodity known as resilience.

Webster (who, as far as I know, is long deceased and did not have the pandemic in mind when he coined this definition) describes resilience as “…the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress.” I believe he was referring to clay, metal, marshmallows, and stuff like that; but I think you get the picture and understand how it can be applied to ourselves and our current situation. The Oxford dictionary defines it as “…the capacity to recover quickly from difficulties; toughness.” The American Psychological Association (my people) describe resilience as “…the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress.” Now we’re getting somewhere!

The point is this: resilience is a thing, and we all have it. For all its seemingly innumerable faults, humankind is—and always has been—resilient. Humanity has endured huge collective struggles, including other pandemics and natural disasters, and has lived to pick up the pieces and go home. World wars have threatened to annihilate both the species and the planet…yet here we are. This is not to minimize the loss and misery these incidents have caused; but it serves as a testimony to our collective resilience that humanity has endured, grown a little wiser (hopefully), and is still here for me to make fun of.

As your psychologist, I wish that I could offer you a pamphlet with quick and easy system for becoming more resilient during this time, maybe of a “10 Steps to Resilience” kind of thing. In the world of psychology, it is known that there are some inborn qualities that contribute to resiliency: a positive outlook, an optimistic personality, and a willingness to use tragedies as opportunities for growth. However, regardless of how much of each of these attributes you might already possess, I can tell you this: you’re already resilient, and you know it!

If you weren’t already resilient, you would have quit school immediately (if they had allowed you to) after getting sent to the principal that time in the second grade (yeah, remember that?). You would have never dated again after that pretty girl or boy rejected you in the seventh grade. You would have never sought employment again after getting fired from your first job after getting caught smoking in the parking lot during your shift (wait…you mean that didn’t happen to everyone?). You’ve been sick, and even if you haven’t recovered completely, you’ve learned to adapt. You learned a “new normal” every time you had another child, moved to a different place, had a financial setback, lost a friendship, or endured the death of someone close to you. Although you may minimize these successes or taken them for granted, you shouldn’t: the fact that you’re still here, reading this blog, means that you’re resilient.

If you’re still not convinced of your own resilience, then take heart in this: resilience can be learned. One of my personal heroes is Dr. Viktor Frankl, who was a psychiatrist and neurologist who survived internment in various Nazi concentration camps for three years, beginning in 1942. Over that three years his father and brother died, and his mother and wife were killed. Frankl himself suffered abuse and starvation. Even so, he survived by finding meaning in what was happening to him. He tried to help despondent prisoners, and in doing so discovered that suffering can be endured if one finds in it a purpose. This culminated in his famous quote about survival (“Those who have a ‘why’ to live can bear with any ‘how’”) and, ultimately, his amazing book, Man’s Search for Meaning (recommended reading for…well, pretty much every person on the planet). His conclusions about finding meaning in suffering have since been borne out in scientific research: according to a study in Health Psychology, people who believed that stress would kill them were 43% more likely to die than those who saw the benefits of stress, or at least believed that they could grow as a result of it! So, to endure stress and be resilient, we need to learn how to re-frame it as beneficial rather than destructive.

Being resilient doesn’t mean being free of struggles…it means that you have the ability to struggle well. If you’re a member of the human race, you’ve certainly learned something about resilience over the past year, and you most certainly deserve a pat on the back for enduring the dumpster fire that is commonly known as “2020”. As we continue to navigate through whatever is to come, I hope that you will learn to find meaning in your trials…and hope fervently for fewer learning opportunities in 2021!

The Masks We Wear (or Don’t)

By MICHAEL SHAPIRO, PhD

July 2020

Masks. Of all the things that we have on our menu of things to get upset about during the pandemic area, we choose masks.

Both the World Health Organization and the Centers of Disease Control and Prevention now strongly recommend wearing face coverings in public, in an effort to “flatten the curve” of the pandemic. Early in the pandemic, this was not so. In fact, both organizations initially suggested just the opposite, mainly because of the relatively low prevalence of the disease at the time, and partly because scientists did not yet understand the degree to which the coronavirus could be spread by asymptomatic carriers. Since then, epidemiological data (showing how death rates have been lower in locations that have mandates in place), case reports, and at least one very interesting high-speed video experiment (showing how respiratory droplets are spread when coughing, sneezing, and talking) have all supported the usefulness and wisdom of simply wearing something over your face. In fact, a recent forecast from the Institute of Health Metrics and Evaluation suggests that if 95% of the population would wear a mask in public, there would be as many as 33,000 fewer deaths in the United States by October 1.

Okay. I get it. It’s not a cure or an ultimate solution, but it’s an incredibly important step in risk reduction. It should be easy. Spiderman does it all the time and has never, as far as we know, transmitted a virus. However, I’d like to take this opportunity to publicly confess that I haven’t been a big fan (of masks, that is. Not Spiderman). Yes, I’m a healthcare provider who is trained in applied science. Yes, I work in a Family Medicine clinic that (wisely) requires all providers and patients to wear masks in the building. Yes, I have a loving wife who carries enough masks in the glove compartment of her car to stage a Wild West-style bank robbery. In the face (no pun intended) of all the supportive scientific evidence, I’m perplexed at my own resistance to this idea, and I’ve had to look deep inside myself to figure out why I feel this way.

Most people have reasonably good reasons to be mask-aversive. They say masks are uncomfortable, especially in the heat of the summer. They say that masks interfere with breathing, or that being “forced” to wear a mask infringes on their rights (specifically, their constitutional right to infect others. It must be in one of those amendments somewhere). I have to admit that my reasons are less rational, and not as well thought-out:

Whenever I think about wearing a mask in public, a small, repressed, macho “tough guy” who resides deep within my psyche makes an appearance and tells me that to do so would be a sign of “weakness”. This little entity in my head (don’t we all have them?) is surprisingly loud, looks a bit like John Wayne, and insists that to wear a mask is just an admission that I’m cowardly, old, and physically frail (whether or not that’s actually true is irrelevant to this discussion). I also assume that people will think I’m somehow antisocial or want nothing to do with them. In other words, I worry about what people will think of me, when in truth, people probably spend a LOT less time thinking about me than I think they do!

Also, as a psychologist, I have to say that I frankly dislike the fact that masks obscure half of my ability to read peoples’ expressions. I can no longer discern what they’re thinking or feeling…at least from the nose down. Conversely, I dislike being unable to use half of my face to express my emotions to others! I’ve always prided myself on my habit of giving a big smile to everyone I see. Anthropologists have shown that monkeys do the same thing in the wild to express their peaceful intentions and not get beat up when entering a potentially hostile jungle situation (I think you can see the analogy). Hence, with a mask, I feel that I’m being deprived of one of the most simple self-defense tools that nature grants freely to less complex mammals who are much farther down the food chain than I am!

As irrational and convoluted as these thoughts may be, they plagued me until the governor of our great state—in a complete inversion of the aforementioned Wild West culture—made it illegal NOT to wear a mask, as of 5:00 p.m. on June 26th of this year. This changed everything! At last, the playing field is completely level. No longer does anyone need to question or consider the motives of anyone else: now we’re all just trying to obey the law and not get fined! This has enabled me to make a complete transition; from being completely insecure about wearing a mask, to now being completely smug and condescending towards people who are not wearing a mask! This, my friends, is true freedom…the freedom to feel superior to lawbreakers!

I can now look with great respect upon my fellow North Carolinians, all of whom are taking this one simple step (sometimes unwillingly…but who cares?) that will do so much to insure the health of others and bring this pandemic to a more abrupt end. Seeing everyone wear a mask in public gives me a warm feeling of camaraderie, as if we are, truly, “all in this together.” It’s supported by science, it’s socially unifying, and it’s good for everyone’s health! So please, in the name of humanity, bear with some discomfort and wear a mask whenever you go outside. With any luck, the type of mask you wear will become a fashion statement…and then you’ll have something else to be insecure about!

Illness Anxiety in the Pandemic Era

By MICHAEL SHAPIRO, PhD

May 2020

I’ve never been a Harry Potter fan. In fact, I’m not even exactly sure what the Harry Potter series is about. My understanding is that it revolves around a bunch of kids who ride broomsticks and play some kind of anti-gravity version of basketball at a private school in some place that looks kind of like the Rocky Mountains, but with fewer Starbucks. Oh, and one of the kids has a scar on his head.

I also know that an important component of the storyline involves a “Book of Spells” or some such thing. Evidently, this book has all the rules or spells (or whatever) that adolescent magicians need to do their job or learn their craft (or whatever).

So, here in the equally magical world of Behavioral Health, we have also have mysterious book known as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (known to you Muggles as “the DSM 5”). This single volume contains a detailed description of every mental disorder anyone has ever had, or could possibly have. These disorders span from the easily recognizable (like depression) to the obscure (like trichotillomania, or compulsive hair-pulling). I’ve often told people that if you look through the DSM 5 long enough, you’ll find some disorder that fits you, no matter how mentally healthy you may feel at the moment.

Anyway, in the DSM 5, there’s a diagnosis called Illness Anxiety Disorder. To qualify for that diagnosis, you have to be obsessively worried about the possibility of acquiring a serious illness. You have to be constantly anxious about your own health, and in an attempt to relieve that anxiety, you have to either engage in excessive health-related behaviors (for example, repeatedly checking your body for signs of illness) or totally avoid healthcare (e.g., staying away from hospitals and doctors’ offices). Interestingly, another requirement is that this preoccupation with your own health has to be “excessive or disproportionate.”

Ah! Therein lies the big philosophical question: in the days of the COVID-19 pandemic, aren’t we all obsessively and disproportionately preoccupied with acquiring a serious illness? Aren’t we all engaging in health-related behaviors and avoiding hospitals and doctors’ offices? In fact, haven’t we been ordered to do these things by our local governments? If so, does this mean that we are all suffering from Illness Anxiety Disorder? More importantly, if we’re all doing these things, then is it really a disorder at all, or are we exhibiting completely normal behavior, just like everyone else?

I’m not exactly sure, but I think my head just imploded while trying to sort this all out. Personally, my hope is that our obsessive preoccupation with the coronavirus can still be considered a “disorder” because that’s good for my business. In fact, I’d like to take this opportunity to thank social media for contributing to my business by fanning the flames of anxiety with an inescapable, constant barrage of false, inflammatory, and often contradictory information. Thanks, Facebook!

But seriously, I have seen many patients over the last two months who are understandably worried and have expressed their anxiety through unanswerable questions and despairing comments like, “Am I going to catch this?”, “Will this ever end?”, “I’m afraid they’re going to lift restrictions too soon!”, and “I feel trapped!” This anxiety has been brought about by a stressful event, sort of like what happens in Posttraumatic Stress Disorder. However, with PTSD, the threat has already passed, and it was probably something very visible (like a tornado or other natural disaster). With the coronavirus, we have an invisible threat, we don’t know when it will end, and we don’t even know if it has touched our lives yet or not. In this respect, a global pandemic is unique amongst stressful events!

So, how can you calm yourself in the midst of so much uncertainty? Before answering that, let me first mention that we here at SR-AHEC are applied scientists–rigorously trained health care providers–who, I’m proud to say, do nothing that isn’t based on solid, verifiable science! We try to rely solely on treatments that have been tested and validated under the cold, dispassionate light of the scientific method! That’s why we don’t bleed patients with leeches anymore (well, except maybe that one time last year. But come on! I couldn’t think of anything else to do, and I made sure that it was covered by insurance first).

The practice of employing only scientifically proven medical techniques is known as “Evidence-Based Medicine” (EBM). What does EBM have to say about dealing with our anxieties in this time? Well, it just so happens that the Centre for Evidence-Based Medicine (no, I didn’t misspell a word. This place is located in the UK, where they spell some things rather oddly) has analyzed many scientific articles on the topic and has come up with the following evidence-based suggestions:

Minimize your exposure to the news and other media (I recommend no more than an hour per day to get caught up on the day’s events).
Use trusted sources to access information about the pandemic (as I said in my last blog, you can pretty much trust anything that has been bears the CDC seal of approval).
Stay connected with family and friends, online or via telephone (just don’t lose your temper when you can’t figure out how to turn on the audio).
Provide help and support to other people in the community (like your elderly next-door neighbor, who could use a little help with the groceries).
Practice meditation and mindfulness (this can be as simple as stopping whatever you’re doing, taking a deep breath, observing your own body for signs of tension, and asking yourself what you need to do next).
Look after your body by maintaining a healthy diet and exercising regularly (see our earlier “Guidance to Good Health” blog about exercises you can do at home. Oh, and keep your hand out of the Cheetos).
Avoid unhealthy coping strategies, like drugs and alcohol (interestingly, online sales of alcohol have gone up by 243% during this pandemic! Even sales of Corona beer have, ironically, increased by 50%! How weird is that?).
Keep doing activities you enjoy (preferably not playing video games or watching movies that involve death, destruction, or mayhem. Sesame Street is probably OK…just stay six feet away from Cookie Monster. I question his personal hygiene).

I would add to these a brief three-step cognitive behavior therapy exercise that I do with my patients:

Step 1: Ask yourself, “What is the worst possible thing that could happen to me?” Your answer may be something like, “I’m going to catch this and die.”

Step 2: Force yourself to consider the best possible scenario: for example, “I’m going to be completely OK. The statistics are on my side.”

Step 3: Consider the most likely scenario, and develop a plan for that: for instance, “I may get infected, but for most adults, the symptoms are mild. If I get sick, I’ve figured out exactly where to go for emergency care, and I might actually get caught up on all my Downton Abbey episodes while I’m recovering.”

These steps may all seem fairly self-evident, but once again, they are based in fact and have been verified by research, so I trust them. So, Illness Anxiety Disorder or just a “normal” reaction to a really abnormal situation? Who cares? It’s what all the cool kids are doing. Just do what the science says. Oh, and for social distancing, just use Harry Potter’s “cloak of invisibility.” I think he has one of those.

Lemmings, Toilets, and Reptile Brains: How Should We Respond to COVID-19 Hysteria?

By MICHAEL SHAPIRO, PhD

March 2020

There is a myth with which we’re all familiar. It has to do with lemmings. As you might know, lemmings are adorable little rodents that are typically found in or near the Arctic tundra. They are usually around 6 inches in length, with a cute stubby tail, soft fur, and the appealing little face that is characteristic of some of our most cherished herbivores (like the Easter bunny). They migrate in large herds, and during their migratory season they appear suddenly, en masse, seemingly out of nowhere.

However, the most persistent myth about lemmings is that when their population becomes unsustainably great, they commit mass suicide by following each other off of tall seaside cliffs. This myth is partly based on the fact that every three or four years, a slice of lemmings (no…really! That’s what a group of lemmings is called!) will get so big that they’ll head out and try to migrate elsewhere, where there’s more room, and they assume that their property taxes will be lower. In doing so, they often cross a body of moving water (like a river), and several of them – (the ones who were too arrogant to wear life vests) will drown.

The myth that this was actually a form of suicide took hold in 1958, when Disney filmmakers aired a documentary that showed a bunch of lemmings jumping to their death. However, contrary to our abiding faith in all Disney productions, this was completely staged! Yes, Disney actually pushed the poor creatures off a cliff while the cameras were rolling, in order to perpetuate the myth that lemmings follow each other blindly unto death! Although completely fraudulent, it’s a good thing they did this with lemmings and not mice, or there would be no Mickey to induce vacationers into Disney theme parks, where people blindly follow each other en masse over a financial cliff.

I said all that to say this: the lemming has become a metaphor for someone who blindly follows the crowd, even into the face of a catastrophe. As I’ve listened to the news and have strived (futilely) to find even a single sheet of toilet paper within a 20-mile radius of my home, the lemming metaphor has popped into my mind more than once. We have been inundated with news about the emerging coronavirus pandemic, and very little of that news has been good. Consequently, we watch each other anxiously, waiting to act on any new piece of information with a hair trigger. For example, I’m reasonably certain that the recent run on toilet paper (which future historians will undoubtedly refer to as “The Great Fecal Hygiene Crisis of 2020” or something like that) was started by one guy in one WalMart in one small town who looked at a shelf of TP and said, overly loudly (as people are apt to do in WalMart) something like, “Gosh, I wonder if I should buy some extra?” Cue the lemmings.

At this point, you might want to invoke the misunderstood and sometimes misused term, “mass hysteria.” This term (also known as “mass psychogenic illness” or “mass sociogenic illness”) refers to the rapid spread of symptoms through a population where there is no viral or bacterial agent to account for those symptoms. So, let’s get this straight from the get-go: to attribute the symptoms of covid-19 (the illness caused by the coronavirus) to “mass hysteria” is a misnomer, because it suggests that the symptoms are not real. Nothing could be further from the truth, and we need to take seriously this threat to global health. Instead, it’s our reaction to that threat that bears some scrutiny.

With this in mind, the term “moral panic” is a more accurate description for the phenomenon that has left you without any toilet paper. This term, as it is currently used, links the collective anxiety of a group (in response to some perceived danger or threat) to social media influences. According to sociologist Stanley Cohen, this happens in stages: first, something (or someone) is identified as a threat to community interests. Next, the threat is depicted in symbolic or overly simplified form by the media. This raises public concern, which in turn provokes a response from authorities or policy makers. Then, the ensuing panic over the issue results in some kind of change within the community…and the next thing you know, there you are, left on the potty, searching desperately for any reasonably soft piece of paper (or other material) within easy reach.

In this way, moral panic is a self-perpetuating problem. Panic is contagious. It spreads like proverbial wildfire, as it has following many media revelations that have called to question our way of life. For example, look what happened to Halloween after the New York Times published a 1970 article about people tampering with unwrapped treats (which had actually happened only once, in a small town in upstate New York). As a result of that single article and subsequent panic, we now have Trunk or Treat…and individually wrapped candies that are infuriatingly difficult to open.

So, how do we avoid contributing to moral panic? How do we keep from making matters worse by panicking over every new piece of information? Well, let’s start with this: don’t panic over every new piece of information. With few exceptions, panic is an irrational response to some stimulus, or a disproportional response to a perceived threat. Jumping to irrational conclusions (often based on erroneous information) propels panic; not the other way around. The panic response is governed by the instinctive, primitive part of your brain, which is often referred to by neuroscientists as the mesencephalon or “reptilian brain.” To avoid panic, one must tame the reptile by engaging the telencephalon, or “thinking” part of the brain. How do we do that?

First, choose not to accept your first instinctive reaction to something fearful. Suppress the primitive part of your brain. After all, it’s that part of your brain that tries to get you to eat with your hands when you’re at a fancy restaurant or pee off your porch when you feel the call of nature (um…okay, maybe that’s just me). Instead, gather more information before deciding how to react. To do that—and this is vitally important—seek out sources of information that the “thinking” part of your brain tells you are trustworthy! For example, when it comes to new information about covid-19, I think we can have total confidence in the CDC. It is an established public health institute that’s been around since 1946 and is crammed full of really, really, really smart people who have built entire careers out of studying the propagation of infectious diseases. Unlike us, they spend every day knee-deep in pathogens, applying their big brains to solving problems just like this one. Yeah, I think we can be absolutely OK with doing whatever they tell us to do. They’re not lemmings, they’re scientists.

In contrast, look with a very skeptical eye on any post or sound bite that is launched by a partisan political group, a corporation that stands to capitalize on the crisis (including popular media), or the guy in your neighborhood that bought all that Purell to re-sell at $75.00 a bottle. They’re not scientists, they’re the Disney filmmakers who are pushing the lemmings over the edge.

Even less trustworthy is your cousin, uncle, brother-in-law, or cousin’s uncle’s brother-in-law who posts on Facebook and considers the shortage of toilet paper to be the prelude to the collapse of civilization which, as he’ll remind you, he has been predicting since the beginning of civilization. As far as modern science can determine, having no TP has a mortality rate of zero. It may be a temporary inconvenience, but it is not the end of the world (in fact, if you own the Charmin company, things are looking pretty good from your perspective, aren’t they?). Let’s keep things in perspective.

Once you’ve decided not to listen to biased, partisan, or un-scientific sources, now do this: don’t listen to anything. Take a break. No, I’m not urging you to ignore reality, repress your feelings, wear rose-colored glasses, or minimize this threat to our collective health. I’m not going to try to pacify you with a cliché (“Don’t worry. We’ve been through all this before. Look at the bubonic plague of the 14th century! We’re still here, aren’t we?”); I’m urging you to momentarily stop the barrage of inflammatory, often conflicting information. Stuck at home? Don’t watch the news, watch SpongeBob. Listen to music (just not the soundtrack to Outbreak). Read a fiction or fantasy novel, for cryin’ out loud…it’s one of those leafy paper things over there on your shelf. Once again, I’m not advocating burying your head in the sand (after all, there are germs there, too!). I’m just urging you to give it a rest and put it in neutral for a little while. Afterwards, you’ll feel energized, refreshed, and ready to think rationally.

Lastly, don’t contribute to the panic by becoming a virus yourself. How do you think they came up with the term “going viral”? Like a virus, information (everything from cute puppy videos to hate speech) gets disseminated when one “host” (electronics consumer) shares with several others who, in turn, share with others…thereby spreading the information (or dis-information) exponentially. This kind of indiscriminate sharing has an almost magical ability to magnify disproportionally the importance of whatever it is you’re sharing. I mean, come on; was “Gangnam Style” really that fascinating? Would it ever have lived for more than a few seconds outside of the petri dish of social media? Yeah, I don’t think so either.

So, when your aforementioned cousin’s uncle’s brother-in-law posts his perception of the impending world cataclysm, please don’t respond, and please don’t “share” with others. Let’s practice some electronic “social distancing.” Don’t contribute to moral panic, and don’t be a lemming or a reptile or a host to an electronic virus. The very fact that you’re reading this blog is proof that you are an intelligent, rational, thinking human being with excellent taste and a critical eye. Time to start acting like one. Meanwhile, I’ll continue to stand here in the grocery store, staring at this shelf of duct tape and brown lunch bags, wondering if they would make an acceptable proxy for toilet tissue.

Relationships. Who needs ‘em?

By MICHAEL SHAPIRO, PhD

February 2020

A quick peek at my calendar reveals that it’s February. Ah, February…the month that hosts the most famous holiday that isn’t really a holiday: Valentine’s Day. As of the time of this writing, we’re now about a week past this annual high-pressure reminder to do some nice stuff for (or to) someone you love. I believe I’ve dodged marital suicide for one more year by making sure I took my wife out for an extravagant and lavish dinner. Fortunately, Applebee’s never disappoints.

As the number of Valentine’s Days that are left to me slowly dwindles, it has caused me to contemplate the value and importance of relationships (not just romantic ones). According to Harvard Health Publishing, positive connections with others yield benefits for both physical and emotional health. Numerous studies have shown that people who have social support from family, friends, and the community have fewer health problems and actually live longer than people who are solitary or socially withdrawn. Evidently, this is because positive relationships reduce stress; and stress is known to interfere with cardiac functioning, the immune system, and even the health of your gut. Engaging in “caring behaviors” has even been found to trigger stress-reducing hormones (and, it’s far cheaper than a spa day)!

This all makes sense if consider the fact that humans are extremely social animals. We depend on each other. We have to. We’ve always had to. Think about it from the standpoint of evolution: unlike lions and wooly mammoths and alligators and such, primitive man was not blessed with tremendous strength or speed or stealth. However, we “aced” it in the brain department. Man quickly figured out that if we worked together, we had a better chance of survival and reproduction (especially the reproduction part, which doesn’t work particularly well when you’re alone). As a result, in order to encourage mutual survival, man developed a highly social brain that actually allows us to feel good when we experience social interactions, and to feel a kind of pain when we are socially rejected or marginalized. Even the emotion of sympathy (feeling sorrow or pity over someone else’s misfortune) served an evolutionary function by making sure that we were motivated to work cooperatively to help each other survive.

I once read a study that was conducted by the Gallup organization, which (as you may know) is an analytics company based in Washington, DC. In this study, when people were asked why they became homeless, why their marriage failed, or why they overeat; they often attributed these problems to the poor quality (or complete lack) of friendships. A subsequent study on friendship yielded some surprising findings. For example, a majority of married people indicated that friendship is more than five times as important to them as physical intimacy within the marriage (okay, I presume these weren’t newlyweds). Similarly, it was found that if you have a “best friend” at work, you are seven times more likely to feel engaged in your job! If this is true, your office should sink some money into a nice water cooler (which is the traditional hub of gossiping, lollygagging, and other “friendship at work” activities).

So, now that we know how important it is to have close relationships (both family and friends), why doesn’t everyone have them? Because, like a high-performance sports car, they are often difficult (and expensive, both economically and emotionally) to maintain. They require work, time, commitment, and even money. If such a high level of effort seems repulsive or exhausting to you…just look around you. This may be why you’re alone right now, sitting alone in your grandmother’s basement, eating Cheetos and playing World of Warcraft (is that still a thing?). In contrast, if you’re willing to make the effort in the interest of enriching your life with positive relationships, here are some steps to take:

Be intentional. I’m no farmer (in fact, I’m notorious for my “brown thumb”), but from what I understand, a domesticated plant is unlikely to grow on its own. It has to be made secure in the soil and then nurtured, pruned, fed, and watered. Like growing a plant, one must be intentional about cultivating a friendship. Don’t wait for it to happen; take the initiative. Call a friend and make that appointment for a cup of coffee, or to go to that movie you’ve both wanted to see. However, remember this: friendships are built around common interests. Just because you’ve been dying to see that Monster Truck Jam, it’s entirely possible that your companion may find all that noise and mechanical mayhem to be a little, shall we say, “off-putting.” Also, as I mentioned in a previous blog, men and women tend to cultivate friendships differently: men bond “side by side” (i.e., by participating in a common activity, like playing golf or fixing a car); while women value “face to face” activities (like talking over a cup of tea). Make a plan, then take some initiative!

Communicate. Those of us who are married know that unspoken feelings and hidden secrets are like flesh-eating bacteria to a long-term relationship. Unspoken feelings burrow, fester, and eventually begin to erode the framework of the relationship that you’ve taken so much time and effort to build. If you harbor unresolved anger over a past offense but don’t want to undergo the aggravation and effort of “fighting it out” until it’s resolved, it will grow and become distorted. What actually happened will soon become your perception of what happened…which, with so many feelings behind it, gets magnified and ends up looking very little like the truth. So, before things get out of hand, voice your feelings in a non-confrontational way. Marriage therapists are big on the “I message.” This is a technique wherein you express a complaint from the perspective of how you feel, rather than accusing or blaming the other person. For example, instead of, “You’re always late! You’re never on time!”, you might try, “When you’re late, I feel like I’m low on your priority list.” Another good prelude is, “Help me understand.” Using this helpful technique, “You went out motorcycle riding with your buddies instead of taking me out for Valentine’s Day?” becomes “Help me understand how you thought that going out with your friends would be a good idea” (just a random example, of course. Not like this has ever happened to me). As I tell my patients, when it comes to having an emotional discussion with someone, it’s all about paving the road first (in case the metaphor eludes you, I’m talking about carefully choosing your words to smooth out the bumpy hazards ahead).

Forgive. The way I see it, each offense that hasn’t been talked-through or forgiven becomes like a nuclear warhead, waiting to explode. Over the years, each of these armed missiles gets “stockpiled” in the back of your mind. If you know anything about nuclear physics (and I sure don’t), you know that there is only a limited amount of fissionable material that can be stored together before the whole pile reaches critical mass, resulting in an explosion of tremendous magnitude. I’ve seen this happen with couples who have been married for many years. Rather than putting the work into dealing with resentments, they amass these nuclear weapons until they’re finally ignited by something that, on the front end, seems very trivial (like leaving your underwear on the floor. Once again, not a personal example). The spouse is left to wonder, “What the heck brought that on?”

Believe it or not, there is a significant amount of scientific literature that cites the actual health benefits of forgiveness. Research from Stanford University’s Forgiveness Project and Clinic (yeah, there’s really such a thing!) has shown that forgiveness not only benefits the other person, but it’s critical for our own physical and mental health. Studies have revealed that people who are more “forgiving” have fewer health problems, less depression, and fewer symptoms of emotional stress. In contrast, failure to forgive increases the risk of a number of illnesses, including cardiovascular disease and even certain forms of cancer. Even the risk of injury by accident is higher in people who do not forgive! In the laboratory, people who were merely asked to imagine not forgiving someone showed unhealthy changes in blood pressure, muscle tension, and immune response. The exact opposite happened when people were asked to imagine a “forgiveness” scenario.

So, it’s important to forgive when we believe we’ve been mistreated or misunderstood. Of course, easier said than done, right? In an effort to forgive someone, it might first help to understand what forgiveness is not. It does not mean what we condone hurtful actions (like abuse). It does not mean that we forget what happened (“forgive AND forget” is a poetic but often impossible standard). Most importantly, it does not always mean that we completely repair the relationship or reconcile with the offender (especially when the offender has no interest in fixing things). Instead, forgiveness is a choice; an action that we decide to take, regardless of how the other person feels or responds. It’s a decision—often difficult to make and subsequently stick to—to not hold the other person’s offence against them. It often takes time, and it’s often a decision that has to be renewed every day! It will become easier over time, although everyone’s timeline is different.

So there it is. If you understand the importance of relationships and want to help them thrive, you can be intentional, communicate, and forgive. Takes some work? Yes. Sometimes confusing? Certainly. However, here in the 21st century, when relationships are becoming progressively more remote and toxic (thanks again, social media!), there is no single more valuable pursuit when it comes to ensuring our own health and survival! Now…it’s almost March. Where did I store those chocolate Easter eggs from last year?

New Year’s Reservations…I Mean, Resolutions

By MICHAEL SHAPIRO, PhD

January 2020

It occurred to me this week that I had not written a blog entry for the month of December, 2019. For the year 2020, I will resolve to pay better attention to deadlines…and then to not make any more resolutions!

Speaking of which…what is the deal with New Year’s resolutions? We’ve all made them; and we’ve all failed to keep them. When we fail, most of us feel guilty. We then resolve to stop beating ourselves up about it…which ends up being the only resolution we keep, at least until next year, when the cycle starts all over again!

Are we really so weak-willed? Do our best intentions always have to go bad? Is the custom of setting New Year’s resolutions just another yearly process to set ourselves up for humiliation and failure? Good questions! Let’s make a resolution to get to the bottom of this!

According to one of my most trusted scientific sources (the History Channel), the first New Year’s resolutions were probably made about 4,000 years ago in ancient Babylon. Each year, after spending 12 days crowning a new king (or pledging loyalty to the reigning king), these ancient partiers would make a promise to pay all debts and return all borrowed objects (like CDs, power tools, and stuff like that), in the hope that the gods would bless them with prosperity during the ensuing year. Later, the ancient Romans (who actually invented “January”) would begin each year by offering sacrifices and making a promise to behave themselves for the rest of the year. We all know how that turned out. At some point, making New Year’s resolutions became a secular (rather than religious) practice. Instead of resolving to improve ourselves as a community, we decided to look inward and make personal goals for self-improvement. Unfortunately, statistics show that although around 45 percent of Americans make New Year’s resolutions, only about 8 percent keep them. Where do you fall in that statistic? Yeah, I thought so.

So, should we throw the New Year’s baby (the cute one with the sash) out with the bathwater? I don’t think so. Setting goals is an admirable and commendable practice! Doing so prevents us from becoming stagnant. A resolution is a promise to ourselves to keep growing, improving, and changing for the better! As a psychologist who works with patients who suffer from medical disorders that are mediated by lifestyle (for example, obesity, diabetes, and hypertension), I’ve seen that goal-setting can be a lifesaver…as long as those goals are set properly! To this end, we health care professionals (or was it the ancient Babylonians?) have come up with an acronym for goal-setting that can easily be applied to New Year’s resolutions: SMART. Specifically, make resolutions that are Specific, Measurable, Attainable, Realistic, and Time-based. Let’s look at each of these individually:

A “specific” goal is one that is, well, specific rather than vague or overly general. For example, rather than resolving to “look better in 2020” or “lose this gut” (yeah, that’s one of my favorites); one might say, “I resolve to lose 10 pounds.” This places the goal in clear view, thereby making it more realistic and attainable (more on that in a minute).

A goal also has to be “measurable,” mainly to help you know when you’ve achieved it! After all, to “look better in 2020” is pretty subjective: my idea of “looking better” probably differs from yours (personally, if I leave home with my hair combed and my underwear on the inside of my pants, I’m looking pretty good!). Whether your goal involves weight loss, exercise, or something else; it’s helpful to have a numerical way to measure your progress, be it in pounds, inches, days, HbA1c levels (for you diabetics), calories, school grades, blood pressure values, or number of good deeds done.

An “attainable” goal is one that is not so far from where you are now, just a small “bump” up or down, thereby making it more easily reached. For example, a weight loss goal of one pound per week is much more manageable than 20 pounds per week…which brings us to the next part of the acronym: a “realistic” goal is one that is reasonable for your body type, your resources, and your circumstances.

I’ll confess that I’ve always held on to two important personal goals: to become an astronaut, and to invent teleportation (you know, like on Star Trek). Unfortunately, now that I’m in my 60’s and have established a fairly stable career path (oh, and don’t have a sufficiently high IQ or even a decent understanding of subatomic physics), I’m beginning to think that these goals may be slightly—and I mean just slightly—unrealistic. Similarly, if your goal is to become a millionaire this year; or to diet and exercise until you look like Natalie Portman or David Gandy (who, according to a study performed in the UK, are the most beautiful people in the world, based on what are considered to be the most universally attractive physical traits); you might want first want to take a look at your bank account, your investment portfolio, and your image in a full-length mirror.

Lastly, a “time-based” goal has a specific expiration date. This will ensure that you stay motivated, which is more likely when you set a definite time limit. When your timeframe is vague or non-existent (“I need to lose weight this year,” “I gotta get around to fixing the house,” “I’m finally going to clean out the basement”), it only give you an excuse to put it off. Besides, time limits provide a “checkpoint” for you to assess your progress. If you haven’t lost that one pound by the end of the week, you can stop and re-assess whether or not that goal was realistic and attainable. If you did meet your goal, you can pat yourself on the back, and then set a new goal that’s even more challenging (“Now that I know I can handle walking one mile a day, I’ll set a new goal for a mile-and-a-half!”).

So, if you’re looking back on all the resolutions you didn’t keep in 2019 but are not yet ready to completely give up on the grand old tradition of making New Year’s resolutions; try making some using the SMART goal paradigm. However, as of the day of this writing, it’s already January 3…so you’d better hurry up and get started. Personally, I think I’m actually only a few days away from finally nailing the whole teleportation thing…

Guidance to Good Health Blogs

Now is the Time: Catch-up to Get Ahead on Childhood Immunizations

By Adm. Brett P. Giroir, M.D.,Assistant Secretary for Health

August 2020

During National Immunization Awareness Month, the U.S. Department of Health and Human Services (HHS) is urging healthcare providers and parents to “catch-up to get ahead” on childhood immunizations.

The COVID-19 pandemic has led to worrisome declines in well-child visits and routine immunization rates. Although we have made progress to reverse this trend, without high vaccination rates there is a risk for outbreaks and further strain on our nation’s healthcare system.

As a pediatric critical care physician, I know all too well the devastating consequences that diseases, like whooping cough and measles, can have on children and their families. It is tragic to see a child become sick, or even die, from a disease that we can prevent with safe and effective vaccines. In our fight against the COVID-19 pandemic, we cannot let down our guard against preventable childhood diseases. Now is the time to get every child back on track with recommended vaccines.

To increase childhood immunization rates and reduce potential outbreaks of vaccine-preventable diseases before flu season, HHS is coordinating the “Catch-up to Get Ahead” effort. Together a number of government and private sector partners will enhance access to essential immunization services by:

Increasing immunization opportunities by encouraging extended office and clinic hours for the administration of catch-up vaccines;
Informing parents about COVID-19 safety precautions and practices in place in healthcare settings and encouraging them to take their children to get vaccinated; and
Catching children up on their immunizations to mitigate pressures on our healthcare system when the influenza and SARS-CoV-2 viruses begin co-circulating in the coming months.
Promoting the importance of childhood immunizations.

It’s imperative to make sure our children are vaccinated on time throughout their childhood before they are exposed to potentially life-threatening diseases. Vaccines are a safe and effective way to guard our children against 16 serious diseases, such as rubella, polio, and cancers caused by HPV.

Getting children back on track with recommended vaccines is safe, but there may be delays, as many children need to catch-up during this time. Additional precautions are in place in healthcare settings to prevent the spread of SARS-CoV-2, the virus that causes COVID-19. Most vaccines are also available at no or low cost to the parent. Parents should talk to their healthcare provider if they feel that cost is a barrier to getting their children vaccinated.

To learn more about vaccines and vaccine-preventable diseases, visit vaccines.gov.

Why Do Some People Develop Diabetes and Others Don’t?

By Lenny Salzberg, M.D.

May 2020

Risk factors for type 2 diabetes

Why do some people develop diabetes, and others don’t? Lifestyle and environmental factors account for the majority of the diabetes epidemic. We know that an energy-dense Western-style diet (food trucks, anyone?) and a sedentary lifestyle (thanks, COVID-19 L) are responsible for the epidemic of obesity, and that obesity often leads to diabetes. But not everyone who is obese gets diabetes, and not everyone with diabetes is obese! Why???

Genetics! Scientists have already identified 500 genes that are associated with type 2 diabetes, which together account for 20% of the predisposition to type 2 diabetes. But genes don’t explain everything. In addition to genetic factors, there are “epigenetic” factors, which are influences outside the DNA. These include things like aging, the environment, and exposure to substances during gestation. For example, prenatal exposure to famine has been associated with a higher risk of developing type 2 diabetes. Also, the children of women who have gestational diabetes are eight times more likely to develop diabetes themselves! So, if you don’t want your baby to grow up to have diabetes, don’t get pregnant during a famine, but if you must, don’t get diabetes while you are pregnant!

What are some surprising risk factors for diabetes? Many of us know about the risks incurred by lack of exercise and by drinking Mountain Dew and other sugar-sweetened beverages (e.g. sweet tea). But did you know that eating a low fiber diet, not sleeping enough, and even exposure to loud road noise are all independent risk factors for diabetes? Did you know that drinking 3 or more cups of coffee (either caffeinated or decaffeinated) is associated with a lower risk of diabetes?

The Microbiome

One of the frontiers in diabetes risk management involves our complex intestinal ecosystem: the “gut microbiome.” The gut is nearly sterile at birth. However, by age three, the gut has acquired most of the microbes that will be present through adulthood. These microscopic organisms (certain types of bacteria, fungi, and viruses) share a symbiotic relationship with the lining of the gut.

The two main types of bacteria in the gut are called Firmicutes and Bacteroidetes. Firmicutes are found predominantly in the small intestines, while Bacteroidetes reside mostly in the colon. These bacteria are involved in nutrient metabolism, drug metabolism, maintenance of the gut lining, and protection against pathogens. Dysbiosis (an imbalance of gut microbes) occurs as a result of an unhealthy diet, antibiotic treatment, or chronic infection. In one study, four days of a meat-based diet rapidly decreased the abundance of Firmicutes in the gut. Who would have thought that eating meat was bad for us? Also, it has been shown that the guts of patients with diabetes and prediabetes have fewer of the type of bacteria that change carbohydrates into short-chain fatty acids (SCFAs). SCFAs affect metabolism, energy balance, and the stability of the immune system.

Strategies to prevent and treat diabetes through manipulation of the gut microbiome are being developed. We know that you can help your own microbiome by consuming “prebiotics”, like vegetables and fruit. Probiotics, like kefir and yogurt, may also improve your gut microbiome! In the meantime, pick your parents well, eat a high fiber diet, avoid meat, drink a lot of coffee AND get enough sleep, and try not to live next to a highway! Good luck!

Corona, No Lime

By Ebaad Malick, M.D.

March 2020

For most of us, these past few weeks have been full of fear, news reports, memes on social media, and thoughts about finally getting that modern Japanese toilet installed (look it up). Of course, I am talking about Coronavirus, or, more specifically, COVID-19. At the end of this article I will include helpful links to some of the world’s top health organizations with easy-to-digest information about the virus and how to manage this developing pandemic. For now, I think we should all take a step back and think about a few things.

COVID-19 has engulfed all of the world on one key issue, thereby uniting us all against it. People are packing grocery stores to stock up on food and cleaning supplies. Around the globe, there have been cancellations of major sporting events and public gatherings. Even celebrities and politicians are being tested (or finally deciding to get tested), and there are a few instances of leading doctors and healthcare workers who have tragically passed away due to the disease.

At times like these, I hope we can at least feel more empathetic to those in our society who everyday can’t get the supplies they need, or who live in constant fear of opportunistic diseases due to their socioeconomic status. Hopefully, we can now better understand why so many people act out of fear and try everything they can to migrate to a safer area for their family.

All of a sudden, we are all injected with our own fears, and we begin to act out of that fear. Some of the pettier issues in our lives seem smaller. Our fragile humanity has been exposed. Viruses do not discriminate the same way we humans do. They don’t care if you are black or white. They don’t care if you’re rich or poor. They even don’t care if you’re one of those people that put pineapples on pizza (why, though?). A virus can infect almost anyone who is exposed to it; even with certain genetic factors and risk factors at play.

At this time, I would like to thank all physicians, nurses, and other healthcare workers who are putting themselves at risk by being the first to respond to people with symptoms of COVID-19. When a patient comes into the clinic coughing up a storm, it is the person working the front desk that is exposed first; even before the patient gets a mask or further precautions. Nurses are still taking vital signs and touching the patients more than anyone. In major sporting leagues, they have suspended the season to help control the spread of the virus and protect players, spectators, and their families. However, there is no suspending hospitals, clinics, and laboratory testing.

COVID-19 belongs to a class of viruses called Coronaviridae. So far, it has been shown to mainly affect people over 60 who have heart failure, diabetes, and immunosuppression (weakened immune system). Nevertheless, it is important to note that new information comes in every day, and there are still some cases showing up in all age groups. Leading scientists and medical professionals caution us to understand that everyone is still at risk, even if the first wave of reported deaths and hospitalizations are in older populations with comorbid medical conditions. So far, it appears that the virus is transferred via respiratory droplets, similar to the flu. This is why social distancing is important to reduce the amount of time you are within 6 feet of another person. We should also understand that touching our noses and mouths can transmit the virus if we touch an infected surface (like metals and fabrics). By washing our hands we can decrease the chance of transmitting the virus to ourselves or someone else.

For more information about the Coronavirus please use one of the following links:

Center for Disease Control (CDC)

World Health Organization (WHO)

The Best Diet? No Diet at All.

By Kristina Kurkimilis, DO

February 2020

My (not so formal) formal disclosure: the following represents the opinion of a second-year family practice resident, fitness enthusiast, and nutrition dabbler…namely, myself.

“Diet” is defined as, “…the kinds of food that a person, animal, or community habitually eats”; or “…to restrict oneself to small amounts or special kinds of food in order to lose weight.” Nowhere in this definition are you told how to eat; you’re only told that dieting involves restricting food. However, how do you know what you’re supposed to restrict? Also, how can the restriction of any kind of food be completely sustainable?

This brings me to my next definition, “fad diet.” This term refers to “…a popular diet used to lose as much weight as possible in a short amount of time.” For example, some fad diets (like the South Beach Diet, the Lemon Diet, and “juice cleanses”) call for the complete elimination of entire food groups. I have a lot of issues with these fad diets! For one, the goal should never be to lose as much weight as possible, but instead to lose weight in a healthy way. Second, losing weight in a short amount of time only leads to “yo-yoing” (sudden weight loss followed by sudden weight gain).

Why do I sound like such a diet hater? Because I believe that if you’ve decided to make a commitment to your health by losing weight and eating better, then you should do yourself the favor of creating sustainable new lifestyle habits that will last a lifetime, rather than dieting for just a few weeks so that you can fit into that dress or that pair of pants. Instead of crash diets or fad diets, I recommend small, sustainable changes that will eventually evolve into lifetimes habits.

When it comes to dieting, small changes will be much more productive than the drastic changes demanded by a fad diet. For example, let’s take a diet that promises that you will “…lose 15 pounds in a week if you eat zero carbohydrates.” You may be able to do this for a few days, or until you’re tempted by cake at your best friend’s birthday party. At that point, you might think, “I can cheat with one piece of cake today, and then jump right back to my diet tomorrow!” Unfortunately, that one piece turns into a few pieces, or you add some pizza and fries! This is a common story that I hear pretty frequently in my office. The intent to eat better and lose weight always starts off strong, when the motivation is high and there is a “newness” to the whole process. But then you start to crave what you can’t have, you want to be able to enjoy a drink or a meal with your friends, or you have a tough day at work and just need that ONE thing you’ve sworn off of to feel better. This is no way to live your best life! Instead, you’ve created a life full of deprivation, guilt, and shame.

Instead, I think you should adopt an “80/20 lifestyle.” This means that instead of eliminating something completely, you try to abstain from it 80% of the time. Then, following the rules below, you can spend the remaining 20% enjoying live and giving yourself some grace!

More generally, try to follow the following rules, which I give to all patients who are seeking out a healthier diet:

Eat whole foods (foods as close as possible to the way nature made them). Try to avoid frozen, processed, or packages foods.
To make rule #1 easier, shop the perimeter of the grocery store, because the shelves in the middle of the store are usually reserved for less healthy items, like packaged and frozen foods.
Limit foods that have white grains, added sugar, and added salt. You can still eat foods with natural sugar in them (like fruit), but for a zero on the “added sugar” part of the label. Replace white bread and white pasta with their whole-grain counterparts, and don’t keep a salt shaker on your table at home!

So, if it’s your best friend’s birthday, go ahead and have a piece a cake. If you keep up with the “80/20 rule,” you won’t feel like it’s “cheating,” and you’ll avoid the temptation to binge later on. For some people, the word “diet” is enough to make them feel restricted. Instead, I challenge you to create new habits and change your lifestyle rather than trying a fad diet, failing, and regaining the weight you were trying to lose. You may feel like the tortoise in the race against the hare, but who wins the race? Slow and steady.

Nutrition, Simply Put.

By Kristina Kurkimilis, DO

July 2019

Whether you follow doctor’s orders or follow the latest fad diets, it’s so easy to quickly become overwhelmed by what is good or bad, healthy or unhealthy, right or wrong when it comes to food choices. We doctors always tell patients to “improve their diet,” or we write “Discussed diet with patient” in our clinic notes…but really, what does that mean? If you’re a middle aged patient with diabetes, hypertension, and high cholesterol, there are different recommended diets for each of these chronic illnesses, so what foods would be good to eat for all of them? Where is the best place to start on your lifelong journey of better eating?

The very first step I recommend to anyone looking to change their diet it to keep a food diary. Or, for the technologically inclined, download the free food tracking app called MyFitnessPal. For a month, track everything you eat or drink and, most importantly, how you feel. Note if you were really stressed before you picked up that donut in the breakroom, or write it down if you had bad diarrhea after the burger and fries you ate for lunch. Especially if you are plagued with a diagnosis like diabetes or hypertension, I urge you to also keep a diary of your sugars and/or your blood pressure to see how those are affected by the food you eat. You can learn so much by simply tracking (without judgment) what goes in your body. The reason I recommend tracking for a month (rather than a week, as some people suggest) is because you can start to see trends and patterns over a month; whereas tracking for only a week may tempt you to make different choices just so you “look good on paper.” A month is also enough time to create a habit, and the goal with nutrition should be to form good habits that are sustainable over a lifetime (not just to lose a few pounds).

Once you have tracked for a month or so, make small changes in your diet that are sustainable. For example, switch those sodas with bottled water. Instead of a sugary dessert every night, try something that’s naturally sweet, like fruit. If you’re always super-sizing your meal when you eat out, try to get the regular size; or instead of getting fries, try the salad for your side.

If you aren’t sure where to start with these decisions, your doctor is here to help! Don’t be afraid to bring your food logs to your next doctor’s visit. By that point, you will have already shown great commitment to change, and your doctor will be more than willing to help you figure out the next steps towards a sustainable diet. It is imperative to remember that your doctor is not only here to treat sickness, but to provide guidance to prevent sickness!

Grab your notebook or grab your smartphone and commit to 1 month of logging your food choices. The first step to better nutrition is to personalize your diet and eating habits, and what is more personal than keeping a “diary” of the factors that cause you to overeat, or the things that raise your blood sugar or blood pressure? Most “fad” diets will work for a short period of time. In contrast, a complete change of lifestyle may take longer but will be sustainable for an entire lifetime. If you are willing to put in the legwork in on the front end, then you will reap the results for a long time to come!