Just Read: Professional Identity (Trans)Formation in Medical Education: Reflection, Relationship, Resilience

Just catching on overdue summer reading, this is a piece written by Hedy Wald, PhD (@Hedy_Wald) clinical associate professor of family medicine, Warren Alpert Medical School of Brown University (#FMRevolution 🙂 ).

I was first introduced to Hedy’s work, not through Hedy, but through writing of Danielle Ofri, MD (@danielleofri) (see: Just Read: What Doctors Feel, How Emotions Affect the Practice of Medicine, who was introduced to me by another physician, Dawn Clark, MD (@scpmgmdwellness) (see: Walking and Talking about Physician Wellness with Dawn Clark, MD, Physician Chief Wellness Facilitator.

That’s how this works – as Hedy herself states in the paper:

Relationships influence adoption of professional values within PIF (Professional Identity Formation). Students actively construct PIs through interactions with patients, mentors, and colleagues within complex learning environments…

Professional Identity Formation

[PIF] is the transformative journey through which one integrates the knowledge, skills, values, and behaviors of a competent, humanistic physician with one’s own unique identity and core values …. The education of all medical students is founded on PIF.


identities stabilize in early adulthood, yet transformation continues throughout life

This paper is an introduction to an entire issue in Academic Medicine and interestingly to me, the concepts here are extremely relevant to much of the work I write about (and do) in Washington, DC that I call “helping the world learning to love better” (aka, the reason why we are all here).

Reading the title is reminder of my work with the LGBTQ community and the unstoppable human drive to live in one’s identity – there is transformation to a well adult in this population that occurs (verified by extensive science) which is very similar to transformation to a physician. The journeys are parallel in my mind.


There are many jokes that come to mind when we talk about becoming physicians, which I won’t repeat here. The expression that I like that’s not a joke is “once you get the two letters after your name, they can never be taken away.” I say it not with entitlement, but with responsibility.

The reality is that every physician, regardless of where they work or were trained, always have a commonality of experiences that are unmatched by most humans in any discipline (and the same is true for every profession). To an extent I feel a cohesion/congruity in every conversation, from the simplest to the most intense, with other physicians. After that, it’s what you do with it that matters, and I believe by definition every physician (and really everyone in health care) is exceptional; you have to be to do a job this challenging.

As I review the components discussed with Wald and relate them to my experience, I can recall great moments of supportive identity formation, alongside poor moments – usually as a result of neglect.

I recounted some of these in my post about Jess Jacobs’ death, nearing the one year mark. (see: Remembering Jess Jacobs – by the way the most read post on this blog, ever). However/and I do relate to these components in my own identity formation – here I am writing a blog, after all 🙂 .


I would like to touch on resilience a bit because it is without a doubt the (a) word of the decade. Wald quotes it as “responding to stress in a healthy way with “bouncing back” after challenges and growing stronger.”

I think for me, it’s also the unstoppable drive as a physician to build resilience in others. Again, I feel this is a common experience that physicians have. Regardless of how we get here, we can’t or won’t walk away, even when we walk away, if that makes sense. See the few examples below from just the past month (and note, more reflection).

Yes, we go to dance parties in front of legislators’ homes, candle light vigils, marches, and parades, to help others live their healthy identities, too.

I was taught "you don't have to be perfect as a physician. You just have to be there for your patients." We're here for your long, healthy life. #FMRevolution #WerkForHealth #EqualityEqualsHealth #mostinclusivecity #asdcgoessogoesthenation #LGBTQ artist c
I was taught “you don’t have to be perfect as a physician. You just have to be there for your patients.” We’re here for your long, healthy life. #FMRevolution #WerkForHealth #EqualityEqualsHealth #mostinclusivecity #asdcgoessogoesthenation #LGBTQ artist credit WerkForPeace (View on Flickr.com)

We are your nurses, doctors, therapists, and allied health professionals and we care. Always and in all ways. It's what we came here to do. ✌️💪 #ACA #instaDC #DC Washington, DC USA
We are your nurses, doctors, therapists, and allied health professionals and we care. Always and in all ways. It’s what we came here to do. ✌️💪 #ACA #instaDC #DC Washington, DC USA (View on Flickr.com)

I sometimes experience people who are not physicians ascribe some of what we do to preservation of self, rather than preservation and support of the people we serve, which is a mistake.

Like the other definition of resilience that I have mentioned on this blog, we’ll never completely understand it.

I also strongly identify with what Wald says about studying history

…there is a growing recognition that essential lessons for students and doctors derive from studying history even as medicine remains committed to pushing the frontier of knowledge.

"Don't be trapped by dogma - which is living with the results of other people's thinking". It's what we do with it ....
“Don’t be trapped by dogma – which is living with the results of other people’s thinking”. It’s what we do with it …. (View on Flickr.com)

In some of the work that I do, there’s tension between “heritage” and “the future”. Partially because I am a history geek, I study the people and places who were from the future in their time, and so there’s no tension for me. To know where you came from helps the knowing of where you’re going to, especially if you live in the future. And if you live in the future, that means not living someone else’s life, with the other misfits….


Speaking of living in the future, I finally got to meet Hedy earlier this month. I can’t believe of all the times I didn’t have my camera handy this was the time. In any event, it happened, and I’m delighted to learn that there is a community of experts interested in helping generations of physicians from today and tomorrow establish healthy professional identities. My generation of physicians trained during one of the most profound ethical crises in modern medicine (HIV/AIDS), and as a result we emerged with the goal to change everything. We need all the support we can get, allies need allies.

Just Read: Care and Feeding of Your New Vagina, by Connie Rice; Body Positivity in the era of a world learning to love better

I am gifted (or cursed?) with a photographic memory, and I remember the time in medical school where we were taught, in an innovative new curriculum for its time, that sex and intimacy were not another part of a person’s humanity, they are inextricably linked.

Unfortunately, we weren’t taught about the human drive to live in one’s identity, how it can be more powerful than the will to live, and how health care can undermine both.

I also remember the times that transgender women have told me after vaginoplasty procedures that their surgeon’s guidance on supporting and maintaining the neo-vagina was “ask your friends what to do.” This advice doesn’t work when a person’s friends are all cisgender men (or cisgender women). Not a very humane or respectful way to protect the investment made in a complex procedure by patient and surgeon.

This is why, when friend and community colleague Connie Rice posted her guide, “Care and Feeding of Your New Vagina,” I was immediately interested and decided to post it here.

It shows through humor and frank and direct language, that body positivity, including sex, and intimacy are inextricably linked, for all humans, regardless of identity.

More people with health care = more humans living authentically and able to help the world learn to ❤️ better. Isn't this century great? equalitymarch2017 #EqualityEqualsHealth #dc #WeareDC trans.equalityy
More people with health care = more humans living authentically and able to help the world learn to ❤️ better. Isn’t this century great? @equalitymarch2017 #EqualityEqualsHealth #dc #WeareDC @trans.equalityy (View on Flickr.com)

It also shows the impact of more human beings living in their true identity thanks to broader access to medically supervised transition care. I see this wherever I go now – more humans living, not dying, and now, living healthy. Washington, DC, by the way, has the highest proportion of transgender people in the United States, 500% higher than New York or California.

I don’t know if there are any surgeons still recommending that transgender women learn how to maintain their neo-vaginas by asking their friends or not. If they are, a guide like this is going to be a lot more useful and health promoting.

Care and Feeding of Your New Vagina by Connie Rice on Scribd

Connie began her career as an avionics technician in the US Marine Corps and has been in technology ever since. She’s the proud parent of three Eagle Scout sons. She bikes extensively and rides 5000 miles a year or more. Connie transitioned to female beginning in 2010 and over the next several years.

Connie feels lucky that her education, career, and family allowed her to make this change and felt a strong need to give back to the community. She is a transgender activist and member of Equality Virginia’s Transgender Activist Speakers Bureau where she works to further community understanding of transgender issues.Care and Feeding of Your New Vagina, Connie Rice

What Connie, myself and all of us have in common

Connie, who’s also a leader in technology for a fortune 500 company, also wrote this beautiful essay in 2015: I’m glad I didn’t kill myself – Connie Rice – Medium

By definition, if you’re reading this, you didn’t kill yourself instead of becoming who you are. You weren’t killed because you became who you are.

I wrote this after the murder of 49 people in Orlando who were killed because they were living in their true identities:

I survived. I didn’t kill myself. I didn’t get killed. I hoped to become a doctor. Then I became a doctor. And then I found other doctors and nurses who also survived. We came to health care to change everything. We’re working to be great allies. Thank you for being ours. Every human deserves a long healthy life, and we’re going to help you live one.Photo Friday: This doctor is here for you during LGBTQ pride, and for your long, healthy life – Ted Eytan, MD

Enjoy the guide, feel free to share. Connie’s contact information is within.

Just Read: Always Hungry, by David Ludwig, MD

I actually didn’t just read this book, I read it awhile ago, but haven’t posted on it, until now (thanks for the nudge @ePatientDave).

I recommend this book as a companion to the others I have reviewed here (Why We Get Fat, Big Fat Surprise, The Case Against Sugar) because it’s more practical, written for a non-clinician audience by an experienced physician expert in the field, David Ludwig, MD (@davidludwig).

(Editorial comment, unlike other heath-oriented movements I have interacted with, I am pleased to see so many in the nutrition movement to be using social media to communicate their ideas. This is not the case among other physician-involved health movements I have seen, and it’s a loss for them, because there’s nowhere to go to ask questions.)

The Science

David covers just enough of the science to be useful for someone to understand the why of this approach:

So, in the 1970s, prominent nutrition experts began recommending that everyone follow a low-fat diet, in the belief that eating less fat would automatically help lower calorie intake and prevent obesity. Thus began the biggest public health experiment in history. Over the next few decades, the U.S. government spent many millions of dollars in a campaign to convince Americans to cut back on fat, culminating in the creation of the original Food Guide Pyramid…

Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently (p. 18). Grand Central Publishing. Kindle Edition.

And one example of the answer to whether this approach worked (the Look Ahead Study):

The study, conducted in sixteen clinical centers in the United States, assigned about five thousand adults with type 2 diabetes to either a low-fat diet with intensive lifestyle modification or to usual care. The study, published in the New England Journal of Medicine in 2013,33 was terminated prematurely for “futility.” Analysis by independent statisticians found no reduction of heart disease among participants assigned to the intensive low-fat diet, and no prospect of ever seeing such a benefit emerge.

Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently (p. 59). Grand Central Publishing. Kindle Edition.

There’s tons of published information about these findings, though, this book is more directed at successful behaviors.

The Behavior

The book is really designed as a plan to change dietary habits to ones that are more consistent with maintaining a healthy weight. Ludwig appropriately diminishes the argument that being overweight is about lack of self-control or too-large portion sizes or calories-in vs calories-out.

Although the focus on calorie balance rarely produces weight loss, it regularly causes suffering. If all calories are alike, then there are no “bad foods,” and the onus is on us to exert self-control. This view blames people with excess weight (who are presumed to lack knowledge, discipline, or willpower)—absolving the food industry of responsibility for aggressively marketing junk food and the government for ineffective dietary guidance.

Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently. Grand Central Publishing. Kindle Edition.

As I have mentioned previously, I am a former-fat person, and even before I went to medical school, I felt the medicalization of obesity had serious shortcomings from my own personal experience – it appeared to me that the creators of this approach had never experienced being overweight, like so many other things in medicine that have been designed TO people and not WITH people.

One of the challenges of moving away from a low-fat diet, though, is that there are extreme versions of the opposite, such as ketogenic diets. These may be successful for some, however, they require a level of commitment and medical supervision that’s not feasible for everyone.

From my read, Ludwig takes a very reasonable patient-centered approach (since he’s a physician, after all :)), and steers away from extremes into a slow modification approach that a person could follow if they were thusly motivated (and that’s the caveat, see below). He does not permanently forbid foods and the book is obviously written with enough guardrails (he is a physician after all…) that it appears safe relative to other guides I have seen.

The Motivation

The book is great for those who are motivated and want to make a change. At the same time, it’s also very well known from studies that giving people information is not sufficient for them to change their behavior (see this review from the American Heart Association – the smartphone app graveyard continues to grow in size: Just Read: Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention).

I have recommended this book to some people, and my assessment of the uptake is “marginal,” not because of the book, because of where people are in their journey. Which is fine, that’s where information fits in, for the times that support is there and people are ready.

As Ludwig states, we’re in the middle (maybe the end?) of a 40-year failed experiment in changing the nutrition habits of the world. The data shows that people did in fact listen to the advice given and changed their habits (yet another perpetuated myth – “if people would just do as they were told”). It’s going to be an exciting next 40 years….

Just Read: “Why We Get Fat,” by Gary Taubes

I actually read this book some time ago and didn’t post on it until now.

This book would be a companion to 2017’s “The Case Against Sugar” also by Gary Taubes (see my review of that book here) (@GaryTaubes). Written in 2010, it explores the causes of obesity, and makes the case away from a “calories in-calories out” approach to an endocrine (hormonal) mediated one.

The reason I am interested in exploring this is because of the potential harm I see in blaming culture around obesity. What if the medical profession is telling people to do the wrong things, and then blaming them when their biology achieves the goals of their physician-directed behavior?

A recent (2012) study of medical students has shown that the explicit biases (ones they are willing to endorse) are:

  • Bias against lesbian, gay, bisexual, and transgender (LGBTQ) human beings
  • Bias against human beings who are obese

In fact, the bias against obese people is stronger than that against LGBTQ:

Explicit attitudes among medical students 54441
Explicit attitudes among medical students 54441 (View on Flickr.com)

Of all the dangerous ideas that health officials could have embraced while trying to understand why we get fat, they would have been hard-pressed to find one ultimately more damaging than calories-in/ calories-out. That it reinforces what appears to be so obvious— obesity as the penalty for gluttony and sloth— is what makes it so alluring. But it’s misleading and misconceived on so many levels that it’s hard to imagine how it survived unscathed and virtually unchallenged for the last fifty years. It has done incalculable harm.

Taubes, Gary (2010-12-28). Why We Get Fat: And What to Do About It (Kindle Locations 1187-1191). Knopf Doubleday Publishing Group. Kindle Edition.

This book is clearly not intended to guide a person on how to alter their diet in a step by step method – it is aimed more at a scientific explanation around the causes of obesity. There are other books to guide a person through a different dietary approach, most notably “Always Hungry,” by David Ludwig, MD (@DavidLudWigMD), which I’ll post on separately.

Just Read: Peter Drucker, The Effective Executive: The Definitive Guide to Getting the Right Things Done

This book was written 50 years ago, well read and reviewed, so I’m not going to add whole lot of insight to Peter’s work. It reads like it was written yesterday, and I’ll say there are few works that I have highlighted as much as this one. It’s the frankness and interest in the development of the reader that comes across.

The book is a lot about the 20th Century knowledge worker, with some hints about the 21st Century. One of my favorite 21st Century quotes relevant to this is at the bottom of the post.

First, a few quotes I relished, below.

On Being Future Focused (or as I say, the need to live in the future)

“There’ll always be a market for an efficient buggy-whip plant,” and, “This product built this company and it’s our duty to maintain for it the market it deserves.” It’s those other companies, however, which send their executives to seminars on creativity and which complain about the absence of new products. The need to slough off the outworn old to make possible the productive new is universal. It is reasonably certain that we would still have stagecoaches— nationalized, to be sure, heavily subsidized, and with a fantastic research program to “retrain the horse”— had there been ministries of transportation around 1825.
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 120). HarperCollins. Kindle Edition.


Outside of Victorian novels, happiness does not come to the marriage of two people who almost got married at age 21 and who then, at age 38, both widowed, find each other again. If married at age 21, these people might have had an opportunity to grow up together. But in seventeen years both have changed, grown apart, and developed their own ways.The man who wanted to become a doctor as a youth but was forced to go into business instead, and who now, at age fifty and successful, goes back to his first love and enrolls in medical school is not likely to finish, let alone to become a successful physician.

Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 122). HarperCollins. Kindle Edition.

The lesson doctors also learn in the journey to leadership

When General Eisenhower was elected president, his predecessor, Harry S. Truman, said: “Poor Ike; when he was a general, he gave an order and it was carried out. Now he is going to sit in that big office and he’ll give an order and not a damn thing is going to happen.”
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 158). HarperCollins. Kindle Edition.

On the need to actually see what’s happening

With the coming of the computer this will become even more important, for the decision-maker will, in all likelihood, be even further removed from the scene of action. Unless he accepts, as a matter of course, that he had better go out and look at the scene of action, he will be increasingly divorced from reality. All a computer can handle are abstractions. And abstractions can be relied on only if they are constantly checked against the concrete. Otherwise, they are certain to mislead us. To go and look for oneself is also the best, if not the only, way to test whether the assumptions on which a decision had been made are still valid or whether they are becoming obsolete and need to be thought through again. And one always has to expect the assumptions to become obsolete sooner or later. Reality never stands still very long. Failure to go out and look is the typical reason for persisting in a course of action long after it has ceased to be appropriate or even rational.
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 159). HarperCollins. Kindle Edition.

The tragic, and shining example of this is the National Health Service’ Mid Staffordshire Hospital scandal – an estimated 400-1,200 deaths, in a place awash with data but not people seeing what was actually happening.

Being present saves lives.

Effectiveness in the 21st Century

…there is no inherent reason why decisions should be distasteful— but most effective ones are.
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 176). HarperCollins. Kindle Edition.

Peter Drucker operated in a (cis-gender, heterosexual, white) male-dominated business world, which we now understand brought with it tremendous limitations in terms of growth, profitability, and success of the organizations so led.

Equality equals health. It equals effectiveness also. Diversity also allows the human species to survive 🙂 .

The social movements of our time have demonstrated the additional creativity, courage, and effectiveness that comes from the non-traditional, out-of-the way places. Everyone is necessary, and the computer as described accurately 50 years ago, has limitations. (My favorite quote about that, from 1966, is at the bottom of this post)

Drucker presages that reality:

We will have to satisfy both the objective needs of society for performance by the organization, and the needs of the person for achievement and fulfillment.

Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 192). HarperCollins. Kindle Edition.

And the leaders of our time exemplify it

You know one thing for sure: If you’re a woman and you’re effective, you will be a target,” Pelosi said. “It isn’t a problem for me, because I care more about being effective than I care about being a target.”Congresswoman Nancy Pelosi (2013)

Just Read: The Case Against Sugar

One of my earliest memories was the rush to the grocery store by my family to stock up on saccharin sweetened beverages when it was feared they would be pulled off the market, in 1977. The shelves were bare (it was as much an emergency as any I remember in the household)…

This was the headline (behind paywal, if you have library access):

By, Tom Shales. 1977. “Tears & Fears: Threat to Saccharin Spurs New Hoarding! Diet-Rite Dementia, Tab Teetotaling in the Offing?” The Washington Post (1974-Current File), Mar 15, 2..

I looked this piece of history up online after I read Gary Taubes’ The Case Against Sugar, and amazingly, in this piece from March, 1977, they seemed to express some of the wisdom that’s now being discussed 40 years later (almost to the day):

From Pending FDA Saccharin Ban A Bitter Dose for Many in U.S. – The Washington Post, April 4, 1977

There are various problems with the high current levels of consomption, according to food experts. Measured in calories, sugar and other sweeteners – the main other sweetener is corn syrup – now provide about a fifth of the average American’s daily diet. But sweeteners contain none of the protein, vitamins and minerals the average person needs. These things must come from the other four-fifths of the diet: in this sense, the sugar fifth is wasted.

A second problem is the more familiar and simpler one, that sweetened foods are fattening. A third, related problem is the pervasiveness of sweeteners. A high percentage of our food today is processed, as opposed to fresh, and a high percentage of processed food is sweetened.

More than two-thirds of our daily sugar and other sweeteners comes to us in processed foods, including soft drinks and other processed beverages.

The wisdom they may have not had, at least in popular thought, was that sugar is more than wasted calories. There’s evidence that it is a metabolically active distinct subtance that changes the chemistry of our bodies in ways other forms of calories do not.

And actually, many scientists already knew that, however that science wasn’t promoted or supported by various interests….

Exonerating Fat, Arguing Against Sugar

This book continues a series of works by Taubes and others calling into question a 40 year experiment (see: Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise) in changing American (and global) eating habits to banish fat, which by definition means promoting carbohydrates (you have to eat something).

And promote they did, according to the record –

et tu, Consumer reports? American Heart Association?

In our lifetimes…

The magazine Consumer Reports may have captured this logic perfectly (of creating sugar sweetened cereals) in 1986 when it claimed, “Eating any of the cereals would certainly provide better nutrition than eating no breakfast at all.”

(By the mid-1990s, even the American Heart Association was recommending we have sugar candies for snacks, rather than foods that contained saturated fat.)

Bringing Occam’s Razor

The book adopts a philosophy that is used in medicine widely – Among competing hypotheses, the one with the fewest assumptions should be selected. Otherwise quoted as “if it swims like a duck, sounds like a horse, etc etc.”

In doing so, the possible causes of what are known as “Western Diseases” (read location 3729 on kindle to see the list) are reviewed through a lens that involves insulin metabolism, and specifically insulin resistance, which is known to be central to diabetes and probably a requirement for obesity. The counter-discussion is that obesity is a cause of insulin resistance, this is what we were taught in medical school, and this is extensively reviewed in the book.

In any event, everything from gout to hypertension is recast in an Occam’s mindset, in that the things we’ve been taught about what causes these diseases (purines for gout, salt for hypertension) may actually link back to insulin resistance as causing the causes we were taught about.

Which happens to track the increase in consumption of sugar in society.

In fact, a review of my own postings from social media in 2012 reveals that I was unsure about the causes of hypertension, based on my own medical training and extensive review of the literature. That says something: (7) Ted Eytan’s answer to Does weight loss cause blood pressure to go down, or are both the result of something else (like more physical activity)? – Quora

The People and the Science

As with Nina Teicholz’ book, there’s a discussion of the people and personalities involved in the science and sociology of our diet, and like most humans, they are fallible, imperfect beings. It is true now that when I read a paper involving nutrition, I now have to study who the authors are and which institution they are from so that I can track back to the potential conflicts they may have. We always have done that with medical literature (review the science and relate it to the person doing the science), this book just gives a roadmap (along with Teicholz’) to the nutritional science community.

Where we came from

I have always believed that we have to know where we came from to know where we’re going, and there’s a ton of history in here. It’s a marvel to think about what was going on in Washington, DC, and even my home state of Arizona, when I was growing up, that would shape our country’s health destiny.

(side story: while I was an undergrad in Tucson, Arizona, I did some data entry on a nutritional study to get research experience, and I remember that the software that we were using didn’t have entries for the new “fat free” foods being marketed. My faculty sponsor told me, “Fat free salad dressing is really just sugar and water, so code it like that”)

The question of whether artificial sweeteners are healthy or not is not fully addressed in the book, because it’s not fully addressed in the science. What they (sweeteners) did, though, was raise the cry for a healthier life and a freedom from obesity and diabetes. Just read the quotes from the above Washington Post article:

“Please . . .” a woman from Dallas implores. “I don’t know what we would do for grandma if saccharin is banned.”

“I am . . . a former fat person!” another woman, from Huntington Beach, Calif., exclaim. “I use saccharin every day in cooking.”

“As the mother of a 12-year-old diabetic child, I appeal to you . . .” writes a third petitioner, from Dunwoody, Ga.

And this commercial from 1979, when a calorie was a calorie, and people were so…thin*.

*As a former fat person, the intent of sharing this bit of history is not to fat shame, it’s to explore the history of obesity and causes that might be reversible or preventable in the interest of health, with the recognition that health is multi-dimensional and factorial 🙂