How to Do No Harm

How leaders can minimize harm in health care, in other industries, and in all areas of life.

“How can we change this process to prevent this error from happening again?” the senior ward nurse asked the group. It is a common question, one that I have heard thousands of times from experienced and dedicated health care professionals of all stripes.

I have worked in health care for many years, serving in positions from volunteer to emergency medical technician to senior attending physician to chief of staff at a hospital to chief medical officer of a large network. In every position, “do no harm” is a fundamental theme. This famous statement from the writings of Hippocrates encapsulates quality improvement, patient safety, access to care, and many other goals in modern medicine.

“Do no harm” can be thought of as eliminating risks that could lead to a bad outcome, such as injury or death. Occupational and Environmental Medicine physicians learn that there are four ways to decrease risk in the workplace and in the environment:

  1. Eliminate the risk entirely. We have two inverter generators to use at home and church rather than traditional ones. They are quieter and generate less carbon monoxide, thus eliminating two risks. Taking the lead out of gasoline and paint decreases the chance of lead poisoning, and using nitrile rather than latex gloves helps avoid latex allergies.
  2. Separate the risk from the people. Modern automotive engineers have designed and built cars which nearly the whole car can be destroyed in a crash, but the passenger compartment can stay nearly intact, thus saving the people inside. Hospitals sometimes use devices that automatically retract used needles to avoid needlestick injuries.
  3. Develop administrative controls; processes to minimize risk. “Tickets to ride” ensure the patients are protected before patient transport and “time outs” before procedures minimize the chance of operating on the wrong site, or even on the wrong patient.  
  4. Use personal protective equipment (PPE). Lead aprons in radiology protect patients and staff from radiation exposure. Gloves and mask decrease the chance of infections. In the fire fighting world, bunker gear enables humans to survive and even work in otherwise fatal environments.

The surest way to “do not harm” is to engineer the risk out, and second is to separate people from risk. Neither of these methods require people to do anything, and therefore remove the single biggest point of failure in many safety processes…human error. Techniques 3 and 4 are less reliable precisely because people have to be trained to follow administrative controls and use PPE. Further, people have to follow these controls and use these practices every time and under every condition.

Manufacturing is far more amenable to engineering controls than health care. Producing tires or peanut butter can be broken down into a discrete series of steps which must be done in sequence and in which the production machinery, the rubber, the peanuts, and the other parts of the process can be trusted to behave in reliable ways. In health care, neither the staff nor the treatments nor the patients are equally predictable. That is why health care relies on administrative controls and personal protective equipment, and why we have so many failures…so much risk to patients and staff.

There is, however, another way to minimize the risk of harm, and that is to improve the people. If hazard is thought of as having three components – danger (what can do the damage, like a hepatitis A virus), person (who is at risk), and vector (food and water contaminated with hepatitis A), those who wish to minimize the risk of hepatitis A can attack at any of these points. The Smallpox Eradication Program of the World Health Organization in the 1960s and 1970s, and the modern polio eradication program are examples of attacking the pathogen directly. Purifying the food and water, which commonly transmit hepatitis A, eliminates the vector. Immunization strengthens the person, making them immune to the disease. Simple interventions such as improving diet, exercise, sleep, and mental health improve the person and make disease and injury less likely. Education helps leaders and workers know why they are doing something, and training helps them do it right again and again. Cognitive aids such as checklists minimize reliance on human memory and other sources of failure.

In summary, “do no harm” applies to medicine, but also applies to every other area of life. We can and should engineer harm away, for it is the most effective way to minimize risk to life and health. Vaccines may be considered as a means of engineering harm away. We will attack dangers, block vectors, and strengthen individuals. To “do no harm”, health care professionals will use every tool in the shed, and will use them in a comprehensive and coordinated system. Our patients and our staff depend on it.  

Battlefield Acupuncture

Basic patient information on Battlefield Acupuncture, a medical modality that promises to help patients with pain, mental health issues, and other problems.   

Where did it come from?

Acupuncture is a type of Traditional Chinese Medicine (TCM) that has been practiced for centuries. Battlefield acupuncture (BFA) is a variation of auricular acupuncture which was developed in the US Air Force by Dr. Richard Niemtzow. BFA includes dry needling and trigger point acupuncture which are used on other parts of the body outside the ear. Thousands of medical professionals have been trained in BFA.

What is it used for?[1]

  1. Musculoskeletal pain (muscles, bones, and joints)
  2. Migraine headaches
  3. Low back pain
  4. Sore throat
  5. Gallbladder pain
  6. Various other pain sites

How does it work?[2]

  1. Local – Reduces pain by stimulating nerve fibers in skin and muscle, thus blocking pain impulses from other sites in the area.
  2. Segmental – Decreases the response to painful stimuli of the dorsal horn, part of the spinal cord.
  3. Regional – Reduces pain at the spinal cord by decreasing the response to painful stimuli of areas immediately above the
  4. Central – Stimulates the hypothalamus and the limbic system to produce a generalized calming effect and sense of well-being. This is partly due to a release of endorphins, natural pain-killing and mood improving chemicals in the body.
  5. Myofascial – Stimulates inflammation and attracts cells that foster tissue repair

Does it hurt?

Acupuncture uses tiny needles, much smaller than needles used to draw blood. Most people don’t feel anything when the needles are inserted. Some feel a pinch which quickly goes away on its own.

Are there side effects?

All medical procedures have side effects, but BFA is very safe. Slight pain, bruising, and slight bleeding happen occasionally. Some people feel lightheaded, drowsy, dizzy, or nauseous. Rarely, patients get a local infection or scarring of the ear.

Will it help me?

Most people get some improvement in pain and other symptoms. According to results in US military facilities in Germany, about 15 percent of patients do not respond to acupuncture, but of those who do, their pain reduction often averages about 75 percent.[3] Different patients may need one treatment, several treatments, or continuing treatments to get the best possible effect.

What should I do to get the best chance of success?

Just before your appointment, sleep eight hours, eat a healthy diet, and continue all medications (unless told otherwise by your doctor. Keep a written record of your responses to therapy. BFA is best utilized as part of a comprehensive care plan, including medication, exercise (core, flexibility, endurance, and strength), sleep, healthy diet, and other interventions as needed.

Aftercare instructions

Activity 

  1. Engage in only light activity only on the day of the procedure, avoiding alcohol for at least six hours after the procedure.
  2. Resume normal activity the day after the procedure.

Inflammation

  1. Look for excessive redness, warmth, pain, swelling, and drainage.
  2. If these occur, remove all of the needles immediately and apply a warm compress.
  3. If there is no improvement after several hours, seek medical help.

Medications – Continue all of your prescription medications unless otherwise instructed by your doctor.

Needles

  1. The ear needles will fall out on their own in two to four days.
  2. If they cause discomfort, wash your hands and a pair of tweezers and pull them slowly and carefully out.
  3. Dispose the needles in a container with a sealable lid.

Radiology – If you are scheduled for an MRI, ensure that all of the needles are out, and tell the technologist

Showering – Pat ears dry instead of rubbing them

Treatments (Present)

  1. Keep a written log of your responses to treatment. This will include changes in pain, sleep, mood, energy, and changes in well-being.
  2. Bring the log with you to each treatment.

Treatments (Future)

  1. BFA can be repeated every four weeks.

Contact your primary care provider, or follow up at the sports medicine clinic.

[1] Does Ear Acupuncture Have a Role for Pain Relief in the Emergency Setting? A Systematic Review and Meta-Analysis. https://www.ncbi.nlm.nih.gov/pubmed/29067138,

[2] An Introduction to Western Medical Acupuncture (London: Elsevier, 2008), 8-9.

[3] Battlefield Acupuncture for the Clinical Practitioner, https://www.acupuncturetoday.com/mpacms/at/article.php?id=31917

Kratom

The popular Southeast Asian botanical Kratom may be part of the solution to America’s opioid and mental health epidemics, or it may be part of the problem.

Joe (not his real name) was a veteran and heroin addict in his mid-30s. He presented to the emergency room with a deadly blood infection. So weak that he could barely walk, Joe ended up in the intensive care unit in a major hospital. Heroin followed him there, with drug dealers delivering to him in his room. Slowly he improved. He is off heroin. Today, Joe is in rehabilitation, gaining strength and trying to put his life back together.

There are hundreds of thousands of “Joes” nationwide. Suffering from mental health problems such as depression, anxiety, and post-traumatic stress, they use opioids (such as morphine and oxycodone), heroin, or fentanyl to ease their physical and psychic pain. West Virginia, lacking jobs with the decline of the coal industry, is particularly hard hit. In the city of Huntington, which has twice the national average of overdoses, overwhelmed police called the national guard for assistance in this war on drugs.

America’s opioid crisis killed 42,000 people in 2016. In response, authorities are cracking down on opioid use. Doctors and hospitals sharply curtail prescriptions, and offer other modalities such a neuromuscular medicine, acupuncture, yoga, tai chi, meditation, counseling, exercise, diet, and safer drugs to help patients. According to the advocacy group American Kratom Association, “millions” of people also turn to Kratom, which surfaced in the US before 2010.

Kratom (Mitragyna speciosa) is an evergreen tree in the coffee family common in Indochina and Malaysia. For centuries, locals have chewed its leaves or brewed Kratom tea to ease pain. Currently, Kratom also comes in pills and liquids. Low doses have a stimulant effect, similar to caffeine, and high doses act as a sedative, like opioids. Some patients on Kratom have had hallucinations and have become psychologically addicted. Kratom works by binding to opioid receptors in the brain. Unfortunately, there have been no human trials, so science’s knowledge of Kratom’s effects in man is limited. The US Food and Drug Administration considers Kratom a dangerous drug without a valid medical use, but advocates say that it is relatively safe and effective in controlling pain and mental health symptoms. At least, many contend, taking Kratom is better than having people go back to opioids.

The US Drug Enforcement Agency (DEA) has associated Kratom with 44 deaths since 2011. This number may be too high because some of those who died also had other deadly drugs such as opioids or alcohol in their systems at time of death, and it is not clear what drug actually killed them. However, it may also be too low, since doctors do not screen for Kratom in toxicology tests and medical examiners often do not look for it during autopsies. Early research suggests that Kratom does not depress the respiratory system as much as opioids do, which is the most common cause of death in opioid overdose. Due to the fatalities, the DEA considered banning Kratom in October 2016 but stopped the effort after a public outcry to allow for further study.

Kratom is banned in Thailand, Australia, Burma, and Malaysia. It is regulated as a schedule 1 drug (high addictive potential, no medical use) in Denmark, Germany, Finland, Romania, and New Zealand. Kratom is more loosely regulated in Russia, South Korea, and the United Kingdom. Among US states, Wisconsin. Tennessee, Vermont, and Indiana have banned it entirely, while Illinois, and some parts of Florida have heavily regulated it.

Kratom is cheap, only $9-20 per ounce on the open market. Walmart, eBay, and other mainline retailers sell it in stores and online. Unfortunately, product purity and consistency are other concerns. Some Kratom formulations available online are laced with opioids, while others contain inconsistent concentrations of the active ingredient. A user can underdose with a certain amount of one formulation and overdose with the same amount of another.

The debate on regulating Kratom is acrimonious and growing. Banning it entirely will freeze research, a problem since no one knows much about Kratom’s actual effectiveness and safety. A ban would also drive many users back to opioids, alcohol, and more dangerous drugs. This seems unwise, or at least premature.

However, regulating products containing Kratom to ensure consistency of dosing and purity is important. Customers buying Kratom should get Kratom, and nothing else. Consumers buying Kratom should not face the physical and legal dangers of opioids unknowingly. Adding Kratom to recommended drug screens would vastly increase the amount of real world knowledge on this drug. A combination of human clinical trials and usage data would answer the questions and help policy makers decide what to do about Kratom.

There are too many “Joes” in the United States, especially in the veteran population. As a nation we are duty bound to help restore those who helped defend us. Advances in mental health, the wise adoption of effective practices from other traditions such as acupuncture, hypnosis, and herbal medicine, and a “whole person and community” approach to healing are parts of the solution. Kratom may be an ally, or it may be an enemy. Only strenuous research, careful policy, and time will tell.

The Mystery of Solar Totality

The solar eclipse of 2017 has meaning far beyond the moon passing in front of the sun.

21 August 2017 will be an important day in astronomical history. A total eclipse of the sun will occur, cutting a 70-mile-wide path from Salem, OR to Columbia, SC in the United States.  The physics of this event would humble Einstein, with sun, moon, and earth moving through space in perfect time and position, finer even than Fred Astaire, Ginger Rogers, and Mikhail Baryshnikov at their most magnificent. There will be eclipse parties, eclipse merchandise, and millions of eclipse viewers, some acting as citizen scientists for the US National Air and Space Agency (NASA). Schools are closed, and visitors in Oregon are renting tents for the weekend for $1,500 to get a front row seat.

Why do so many people care so much about an event that will last two minutes? Astronomers, physicists, and other scientists want to study it, building mankind’s knowledge of the universe. Artists want to get words, images, and video for bestselling books, family files or feature films. Many regular people just want to experience solar totality, and have the chance to tell their friends about it. A few people, saints and poets perhaps, will ponder the mystery:

  1. Does this solar totality have any transcendent meaning, more than the seemingly random effect of the laws of motion?
  2. If it does, what does the eclipse mean in the life of the universe, the earth, the nations, and each individual?
  3. The ancients believed that eclipses portended great events, such as the advent of kings, the beginnings of wars, and natural disasters. Were they right? If so, what does this totality portend?
  4. Does this eclipse contain power that I can use to accomplish goals in my life? If so, how can I get it?
  5. Does this totality provide evidence of a transcendent reality, such as God, the Force, or something else?

There are as many other questions, and variations on these themes, as there are people who see the totality. Even those people who are indifferent to such events will pause, if only for an instant, when the sky goes dark at midday. To do otherwise would be less than human.

Question 1

Observers will differ about whether the solar totality has meaning.  Nihilists may argue that it has none, because transcendent meaning does not exist. Postmodernists will contest that since man is the ultimate standard of reality, the only meaning of such an event is what the individual or group places into it. Muslims will see the eclipse as the work of Allah, pagans as the movements of Mother Nature and cosmic deities, and Christians as an act of God. Some people won’t ask this question at all.

Question 2

Whether an individual considers solar eclipses to have any transcendent meaning or not, such events have been considered omens since antiquity.[1] The historian Herodotus credits a totality on 28 May 585 BC for stopping the Lydian-Median war.[2] Traditional religious belief in Africa which has continued into modern times holds unusual events such as eclipses to be bad omens.[3] A solar eclipse on 27 January 632 and visible in Medina presaged the death of Muhammad on 8 June 632. Even in modern times, hundreds of millions, if not billions, of people worldwide consider eclipses to have meaning far beyond their impressive physics.

Question 3

This question is the hardest yet, as it demands specificity rather than generalizations. The Bible argues that a host of astronomical events accompanied the birth and death of Christ. For Christians, this must be considered prima facie evidence that God uses, or at least used, the stars as signposts to history.  Muslims may say the same about the coming of Muhammad, and Buddhists about the Buddha.

Asking what this particular solar totality means is tough, since no one knows what will happen after it. If a world leader dies, a natural disaster occurs, or some other major, news-worthy event follows, especially if it can be tied however loosely to the eclipse, many will associate the two. Some will even believe that the eclipse caused the incident. For example, if a major fire kills 50 people or if a local disease outbreak occurs on the track of totality within three months of the 2017 Great American eclipse, people will associate the two.

Question 4

Ultimately, people want power to fulfill their needs and accomplish their goals.  People who study eclipses or photograph them as part of their livelihood will see a direct, tangible benefit of the Great American Eclipse of 2017. Individuals that value eclipses for religious purposes will receive plaudits from the co-believers, and group leaders may enhance their spiritual authority in the eyes of their followers. Those who want a fun experience or bragging rights for their friends will get a return on their eclipse-viewing investment. Is there some other power, like the Force, that people can harness from an eclipse? Such power may exist, but either we don’t know it yet or it is not material (scientifically observable).

Question 5

As with everything else in life, our assumptions will dictate our conclusions.  Believers in God will see His work in every move of the sun and moon and in every beam of light. Non-believers will see mechanics, optics, and maybe a little beauty, but nothing behind it except what they put there.

Everyone should see one thing, at least. The Solar Totality of 2017 is an event over which man has no physical control. The mightiest nation, the wisest scientist, and the richest magnate are impotent against the forces of the galaxy. Yet these forces could destroy us all. A solar flare, a volcanic eruption, or a meteoric collision would devastate our carefully constructed modern world. Humility, not hubris, and preparation, not panic, are the right responses.

Conclusion

Millions of people in North America will enjoy the Great American Solar Eclipse of 2017. They will learn, make money, appreciate the spectacle, get pictures, and brag to their friends. Yet hopefully they will consider, at least for a moment, the possibility that such events have a deeper meaning, one greater than whatever these modern observers put there. People in other cultures have seen these meanings for thousands of years – perhaps we can do the same.

[1] https://www.usatoday.com/story/tech/science/2017/08/10/solar-eclipses-history-bad-omens-hungry-dragons-stopped-wars/553362001/

[2] Herodotus, The Histories, Oxford’s World Classics. 1998. 1,74,2

[3] Mbiti, African Religions and Philosophy, Doubleday Anchor, 31, 94

Fame – A Mathematical Model

A non-quantitative way to think about fame, how to increase it, and how to manage it. 

(Fame) I’m gonna live forever I’m gonna learn how to fly (High) I feel it coming together People will see me and cry (Fame) I’m gonna make it to heaven Light up the sky like a flame (Fame) I’m gonna live forever Baby, remember my name (Remember, remember, remember, remember) (Remember, remember, remember, remember)

When Irene Cara sang those words in 1982, she was predicting her future fame, and echoing a dream of people throughout the ages. Napoleon Bonaparte reputedly said, “glory is fleeting, but obscurity is forever.” Thousands of years before, women rejoiced with Naomi at the birth of her grandson Obed, saying “may his name become famous in Israel (Ruth 4:15).”  From the Gong Show to American Idol, from the high school gridiron to the Super Bowl, and from the county seat to the White House, many people are willing to do almost anything for fame.

Writing articles about a mathematical model to calculate (and predict) fame is not a good way to become famous, but it is intriguing nonetheless. This work will propose such a model. It is not based on a complicated statistical analysis of a massive data set, but based on anecdotal observations over a half century of life.

Fame = (Power*Works*Desire (for fame)*Connections + ½ Money2)/Avoidance (of fame) + ¼ Uniqueness

Alternately stated, F=(PWDC+½M2)/A + ¼ U

Fame is a continuum – even a hermit has a little, most people have some, at least in their social circle, and a few people have a lot. Fame can also be described as a bell curve heavily skewed to the right.

Some people are famous from birth, like William, Duke of Cambridge (2nd in line, after Charles, Prince of Wales, to the British throne). Even lacking political power, he, like all hereditary royalty, has tremendous soft power. Others start in obscurity but end up famous due to their great political power, like Dwight David Eisenhower after the Allied victory in World War II. William Shakespeare and J.S. Bach were neither royalty nor did they gain positions of power, but owe their fame to their work. People can diminish but not eliminate their fame but actively avoiding the limelight – Emily Dickinson was a recluse who wrote over 1800 poems but only published about a dozen during her lifetime.

Great wealth is a path to fame – it is hard to avoid fame when you are listed in Forbes’ The World’s Billionaires, even if you are number 1940 on the list. But the relationship between money and fame is not linear. Until a person reaches about $10 million in assets, wealth probably does not contribute much to fame. Once someone reaches about $100 million, fame seems to grow exponentially as money increases. This relationship might be best illustrated by an ew term, but for the sake of simplicity I have used the clumsier ½ M2 term. Using strategies of avoidance, fabulously rich people can intentionally diminish their fame. Let us consider each variable:

Power – The most important question that people usually ask of other people is “what can they do for me?” A doctor can make you well, a lawyer can defend you in court, and a musician can make you feel good; these people tend to have a high degree of power. A corollary question is “what can they do to me?” A policeman can arrest you, a lawyer can sue you, and a robber can hurt you. These people also have power. Experts in a field have power to answer questions. Chief executive officers, generals, and presidents have a greater degree of power and commensurately more fame.

Works – Power requires the presence of the person and vanishes with death, but works can reach beyond the grave. A symphony, a scientific discovery, a novel, or an enduring institution confer lasting fame on whoever created, discovered, wrote, or established it. The Boy Scouts have made Baden Powell famous, as Johns Hopkins University has done for its namesake. Major historical events confer fame on their participants, regardless of success or failure, as General George Pickett discovered at the Battle of Gettysburg.

Desire – People who want fame are more likely to get it. They will talk to the right leaders, say the right things, and orient their activities towards fame. A young Bill Clinton stepped in front of a crowd to shake the hand of President Kennedy in a well-known photograph. A minor political figure named Adolph Hitler scrawled his name in the guest book of the famous arms manufacturer Gustave Krupp. But so many folks want fame that desire is not enough.

Connections – The famous, the rich, and the accomplished confer fame, riches, and even accomplishments on those around them. Children of such people tend to inherit traits, connections, and opportunities denied to others. It is not enough just to have connections – people who want fame need the right connections.

Money – Resources beg to be used; whether an empty house, an idle car, or a still machine. Money is no exception. My grandparents used to say, “money is burning a hole in your pocket”, and that saying is as true today as it was in the previous century. When resources are used, whether for a fat tip for a waitress or to buy a shiny new auto, people notice. Money can be used to increase fame – Conrad Hilton multiplied his fame by putting his name on all of his hotels, and Donald Trump did the same with his buildings.

The wealthy have hidden their abundance for centuries, wisely fearing the envy of those around, and continue to do so. However, with the internet and the flood of information available in the world, this is getting harder.

Uniqueness – independent of money, power, and the other factors, uniqueness is a minor factor in fame. A person named Zelda Zonkerstein is likely to be easier to find with an English-language internet search engine than any particular John Smith. Someone who is eight feet tall or four feet tall is probably more memorable, and more famous, than someone exactly alike in every other way than someone who is 5’5”. A woman who is dazzlingly beautiful, or a man “ripped” with muscle, will be well known in her or his circle.

Uniqueness confers a greater increase in fame if the unique aspect of the person is easy to appreciate, like fine clothes, expensive looking jewelry, or an endearing accent. Uniquenesses that are harder to see, like accomplishments that you might put on a resume, do not improve fame as much. Fear of negative judgment might prevent people who otherwise might want fame from getting it.

Avoidance – Refusing interviews and photographs is one way that people avoid fame. Avoiding public speaking is another. Most people do not need to use avoidance techniques.

Gaining Fame

The astute reader will notice that there is a significant amount of overlap between these variables (power, work, connections, money, desire, uniquenesses, avoidance). This is inevitable, because fame is far too complicated to be reduced to a single equation. Nonetheless, by identifying each factor, a would-be famous person can increase their notoriety.

  1. An executive wanting fame could take a volunteer leadership position in his community, thus increasing his power.
  2. A music teacher seeking fame could spend her summer vacation composing a great song.
  3. A shy person who hoped for fame could take an acting class and get more center stage in events.
  4. A politician needing fame could make connections with high profile leaders and donors in his district.
  5. An heiress could use her money to grab the public eye.
  6. An average Joe or Jane might start dressing differently, and unusually.
  7. Anyone could learn how to interest the press, and engage them.

The only question people who seek fame should ask is…why? Fame brings advantages and disadvantages; blessings and curses – as the songsmiths of The Eagles noted in their famous and haunting tune, Hotel California.

Conclusion

Like the Ring of Power in Lord of the Rings, fame is the heart’s desire of many in the world today. Fame is an elusive prey; many who try for it will not get it. Fame is also an unfaithful mistress; it will abandon all those who don’t constantly cater to it. Nonetheless, the model presented here is a useful way to think about fame.

A Christian Philosophy of Education

What is Christian, as opposed to secular, education? How do educational theories apply? What should Christians do?

I was reading George Knight’s classic Philosophy and Education on a recent flight from Charlotte to Memphis when Paul, a young man in the seat beside me, struck up a conversation. A Punjabi Sikh, Paul had been a math teacher in an all-black classroom in Memphis, and we discussed how hard it can be to motivate students, especially when cultural and racial barriers stand in the way. The hardest question to answer is “why learn?” The most obvious reply, to get a good job and make money, is effective but limited. While we all have to eat, the human spirit needs a transcendent answer, something beyond the individual, to give meaning to learning, and to life. A metanarrative is a story that provides structure to people’s beliefs and meaning to their experiences.

Secular education, with its postmodern rejection of metanarratives, can provide no answer other than for each individual to invent whatever meaning they want their lives to have. Thus, Joe’s meaning in life might be to help people, Maria’s meaning in life might be to have fun, and Ahmed’s meaning in life might be to get rich. All meanings, except violent or “intolerant” ones as deemed by the greater society, are equally valid because the individual is the final arbiter. No two individuals have exactly the same purpose for their lives, so although people may work together on common goals, their labors are ultimately by and for them alone. It is as if 10,000 people in New Jersey wanted to walk to 10,000 different places in California – some could help each other along the way at the beginning but as people spread out, less assistance would be available for everyone. Ultimately no one could help anyone else at all. Even if every traveler was completely successful, no one would end up at the same place – each would be alone.

Christians see the center of the universe as God, not man (either individually or corporately as mankind), and therefore the purpose of man is to glorify God and enjoy Him forever. Every believer has exactly the same purpose, but every believer glorifies and enjoys the Lord in a unique, individual way. Joe might practice medicine, Maria might dance, and Ahmed might run a business, but they would all be doing so to bring glory to their Creator and to revel in Him for eternity. It is as if 10,000 people in New Jersey wanted to walk to the mission at San Juan Capistrano in Southern California – they could help each other along the way, and if everyone was completely successful, they would all reach the same destination.

Christian education, therefore, must reflect the Christian goal and the Christian metanarrative – creation, perfection, the fall, incarnation, redemption, and restoration – rather than the postmodern one – that no metanarratives are valid. Without a metanarrative the subjects, from Algebra to Zoology, are united only in whatever organic similarities they possess. For example, biological organisms are made of chemical building blocks, the components of which act according to physical principals. With the Christian metanarrative the subjects are united in every way, both organically and as parts of Creation, as revelation of their Creator, and as examples of His grace.  All truth really is God’s truth.

Plato’s Idealism stressed the primacy of mind and ideas in philosophy and subsequently in education.[1] Aristotle’s Realism focused on the importance of the physical world, of matter in motion.[2] Aquinas’ Neo-Scholasticism strove to base itself on logical (based on the natural world) and unchanging truths, and emphasized mental and personal discipline.[3] Dewey’s pragmatism cared much less for the curriculum than for the needs of the students.[4] Nietzsche’s existentialism took the student-focus to extreme individualistic ends.[5] Each of these philosophies and their educational outgrowths capture some truth, but none encompasses all truth. Even the modern educational philosophies such as progressivism and critical pedagogy have something to commend them – especially the focus on power in learning and the need for social justice.[6]

Christian education will be thoroughly Biblical, encompassing the idea-focus of John, the practicality of Moses, the discipline of Paul, the pragmatism of David, the individuality of Job, and the social justice of James. It will be utterly Christ-centered, knowing that in Jesus Christ dwells the fullness of divinity and every good thing. Special revelation, the Bible, while the most important source of truth in the universe, is not the only source of truth. General revelation, the universe, declares the glory of God as well. Christian education assigns a high value to the sciences, revealing how physics, chemistry, biology, mathematics, and the others work together to create an orderly and even predictable universe. They demonstrate that not only can God be known, but He wants to be known. Our Lord loves us so much that He reveals Himself to us.

Medicine reveals God. The body is an amazing creation, mind-numbing in its complexity but even more wonderful in its self-awareness. We truly are fearfully and wonderfully made (Psalms 139:14). Each part of the body is dependent on every other part – the respiratory system provides oxygen to the cardiovascular system to supply the entire body, which then sends waste carbon dioxide back through the cardiovascular system to the respiratory system for final removal. When one part of the body suffers, the entire body suffers. For example, when you sprain your ankle, the other leg takes the additional body weight on itself until the injured ankle heals. The Body of Christ works the same way, as a complex, interdependent system that suffers as its parts suffer, and rejoices as its part rejoice.

History reveals the Lord. Who could have predicted in AD 50 that a tiny, persecuted sect in the Roman Empire, the Christians, would become the largest religion in the world 2000 years later? Tens of thousands of charismatic religious leaders have come and gone in two millennia, but only a few – Jesus, Mohammad, and the Buddha, have endured. Among these Jesus is supreme, an itinerant preacher and carpenter who never wrote a book, built a building, commanded an army, or ran a nation. Archaeology supports the accounts in the Bible. How else has God been working in history?

Other subjects also reveal God. Christians in literature discuss how great works communicate the dilemma of man on earth. Those in social studies debate what is a truly just society, how to achieve it, and how to keep it. Believers in the arts strive to communicate God and man in their craft. Followers of Christ in sports live out the fruits of the Spirit on the field of competition, and glorify their Lord with their bodies. The vocational arts are no exception – our Creator can be exalted and enjoyed with wrenches and hammers just as readily as with pens and paint brushes. Christian educators see everything through the filter of God, see God through the filter of everything, and help their students to do the same. Christian character, not merely knowledge or skill, is the ultimate purpose of a Christian education.

I spent 27 years in the US Army, and their theory of battle was to overwhelm the enemy, attacking him through the air, on the land, in cyberspace, in space, in the ocean, and under the sea. Senior army leaders teach junior army leaders to attack on the battle line, behind the enemy battle line, and to defend behind their own lines. While this example is far too adversarial for Christian teachers and students, it still illustrates the need to use every technique to teach, encourage, and ultimately disciple students. Professors immerse their students in the subject matter, using all five senses. World religions students can learn through lecture, discussion, reading, video, songs, foods, clothes, and visits to religious sites. Nothing is beyond consideration in our efforts to make learning a whole-body and whole-spirit endeavor.

Christian education is personal. Jesus lectured to the masses, but built His kingdom on 11 apostles and up to 120 other believers. God the Son invested His earthly life in just a few people, and changed the world. Educators, likewise may lecture to hundreds and write books for thousands, but their real impact will be in their children and the ten or fifteen people that they personally mentor in their careers. Just as good politicians win one vote at a time, so good Christian teachers mentor one person at a time in their walk towards Christ.

Finally, Christian education is a work of the Lord. No matter what a teacher does, he will win some and lose some. Some students, professors, and administrators will love him, but some will hate him. Some pupils will learn and some will not. Each Christian professor will get some publications, speaking engagements, and awards. Ultimately all followers of Jesus are called to be faithful to Him, but not necessarily successful in the eyes of the world. Late in life, we all look back over our lives, regret our failures, enjoy our successes, and ask if it was all worth it. Insofar as we trusted and obeyed God, regardless of the earthly outcome, it was. Even those times when we were not faithful, when we sinned with intent or failed with cowardice, God used for His glory and our good. Ultimately, our work really belongs to the Lord, because we have been crucified and He lives in us. This is our hope.

[1] Philosophy and Education: an Introduction in Christian Perspective 4th (Fourth) Edition by George R. Knight Published by Andrews University Press (2006), 4 ed. (Berrien Springs, Michigan: Andrews University Press, 1600), 43.

[2] Ibid, 50.

[3] Ibid, 54.

[4] Ibid, 66.

[5] Ibid, 75.

[6] Ibid, 104, 130.

Health Care Foibles – A Personal Tale

An example of the stupid things even doctors do when it comes to health care. 

In March of 2013 I wrote Healing the Health Care Cost Conundrum. Four years later, in March of 2017, I have retired from the US Army and am practicing medicine in Memphis, TN. My practice is in the inner city, and our focus is serving the Medicaid population. Our patients are impoverished and often very sick, with chronic diseases frequently showing up 20 years earlier than in their more affluent counterparts. Many live in dangerous communities, have no reliable transportation, and have unhealthy food. Obesity is the norm, violence is taken for granted, and serious mental illness is widespread. It comes as no surprise that many patients abuse drugs, citing chronic pain that may or may not be real. Some come to the clinic for no other reason than to feed their drug habit, and try to get narcotics to generate a little extra income. It is the toughest medical environment I have encountered since my combat tour in Iraq.

Meanwhile at the policy level, Obamacare is proving too expensive to sustain, and just yesterday Republicans in the House of Representatives failed to pass a bill with their plan to reform health care. While the survival of Obamacare causes rejoicing in some and consternation in others, the simple truth is that neither the Patient Protection and Affordable Care Art (Obamacare) nor the American Health Care Act (Republican bill) are health care reform, they are health insurance reform. Both pieces of legislation regulate how health care is paid for, not how it is delivered. With all due respect to our legislative leaders, they cannot improve health care delivery. Only health care professionals can make health care all that it needs to be. This is what those in my practice are trying to do – build a system that can provide quality, affordable, medical care to the poorest Americans. If we can do that, in conjunction with others around the nation striving for the same goal, American health care will be transformed.

Revolutionizing medical care, rather than merely medical insurance, may be a noble goal, but achieving it is like walking from Cairo to New Delhi; long, arduous, and dangerous. One reason for this difficulty is that no matter the education, resources, or social support, humans will be humans.

My Personal Tale

This past week I developed an eyelid infection. I ignored it for a few days, and one evening after a long day at work I decided to do something. Since most medical facilities were closed, and we had no other antibiotics in the house, I took some long-expired antibiotics that had been prescribed for someone else. Taking expired medications can be dangerous, or at least ineffective, and expired antibiotics can increase resistance. I regularly tell patients not to use expired meds or those given to someone else. In this case, I opted for short term convenience, and hypocrisy.

After unsuccessfully trying home care, I went to the Emergency Department at a local hospital. This infection could have been treated more effectively, and far more cheaply, at a local primary care practice. But it was only 6:30 in the morning, too early to call for an appointment. Most practices that we found opened at 8 or even 9, while I had to be at work at 8, and I could not be guaranteed to be seen. So again, I violated my own standards and took a my eyelid infection to an emergency department, costing my insurance about $1,000 instead of about $50.

I tried to be a patient instead of a doctor in this setting, but my secret came out when the nurse asked my occupation. It would have leaked anyway, because medical people talk differently about medical conditions than lay people do. My description of my eyelid as red, swollen, and tender but not painful, was a dead give-away. When the physician’s assistant (PA) came in to examine me, he suggested that Vigamox eye drops would be the best to cure this infection. Even though I thought an oral antibiotic would be a better choice, I was still trying hard to be a patient and not a doctor, so I agreed.

My wife later called from the pharmacy. Vigamox, with a generic name of moxi-floxacin, cost $200 for three milliliters. I was more than a little annoyed; a similar ophthalmic solution of ciprofloxacin would cost $15. Why had the PA prescribed as his first choice something so ridiculously expensive? Word of mouth? Pharmaceutical company marketing? Ignorance of the cost? All of the above? How would this affect others such as the uninsured or the underinsured?

A day later, my eyelid got worse. The Vigamox was not controlling the infection, because it was more widespread than the PA realized. We made an appointment with optometry, and I worked from home. The optometrist prescribed oral Bactrim, which cost $2 at the pharmacy. The infection gradually improved.

The Lessons Learned

This tale of minor misjudgment, multiplied hundreds of thousands of times, is much of the story of health care in America, and around the world. Patients do things that they should not, even when they know better, and do not do things that they should. We opt for convenient care instead of cost-effective care. Had I been faced with the whole bill, I never would have gone to the ED instead of a clinic; I simply would have called in late to work.

Well-meaning but hurried providers make poor diagnoses and prescribe dauntingly overpriced treatments. Because of mistakes in primary care, specialists get involved unnecessarily. Drug companies tout their latest miracle cures, but make no mention of comparative pricing. In fact, no one knows the real price of anything in health care. The ED did not provide a clear statement of the total cost, nor did the optometrist. Further, the prices for me, someone with commercial health insurance, are different than the prices for a Medicare patient, a Medicaid patient, or an uninsured patient.

Quality is an issue. Was the ED that I visited a high-quality ED or not? How did they measure quality? How would I know what the scores were? The PA was a pleasant chap, but the quality of care that I received was lacking. In the absence of metrics, word of mouth rather than clinical outcomes becomes the main quality measure. I went to the optometrist that my mother had recommended because when she saw him, “he was nice”.

An eyelid infection is a relatively minor medical problem. Imagine how much mischief the same combination of human laziness, misjudgment, opacity, and inconvenience causes for more serious diagnoses. Imagine how much these factors contribute to unnecessary expense, and to human suffering.

Conclusion

When I told my daughter, a student in Public Health, my story, she was disgusted. She called it “a personal problem”, but unfortunately the effects are more than just personal. Rather than getting an inexpensive prescription at a primary care office, spending less than $100, I got ED care, an expensive prescription, and specialty care, likely costing well over $1,500. Rather than taking two days to get better, it took five, including time off work and lost productivity.

My foibles are obvious, but they are not unique. I have met few doctors who have never used higher priced care when a cheaper care would do. I have met even fewer doctors who have never taken someone else’ medicine or used expired medicines. Nurses and other health care professionals do the same, and we all know better. Little wonder that patients, who often don’t know better, follow our example.

How then do we revolutionize health care, my stated goal at the beginning of this article?

  1. By engineering hazards out, including mistakes, misjudgments, and misunderstandings.
  2. By transparency in quality and pricing.
  3. By better rewarding good behavior.
  4. By practicing evidence-based medicine.
  5. By intentionally using low cost medications and other interventions when the outcomes are similar.
  6. By making the patient more responsible for costs and outcomes, having “more skin in the game”.

Please also see Healing the Health Care Cost Conundrum for more ideas.

Republicans and Democrats at all levels, local, state, and federal, will continue to fiddle with American health care. Their work is important, but can only address a small part of the problem. We as health care professionals must figure out how to provide quality, affordable, and accessible care to everyone. Using lessons learned from stories like this, we can do it.

The Next Surgeon General

As Donald Trump prepares to assume the presidency, media outlets are aflutter with his nominees for Cabinet positions, and office seekers are glued to telephones calling for Executive Branch jobs. Amidst the tumult, President-elect Trump should soon consider another job that must be filled. It is less powerful than many cabinet positions, but often high profile. It deals not with bombs or buildings but with health and humanity. With Ebola just behind us, and who-knows-what disease disaster just ahead of us, this job is crucial. Donald Trump must select the next Surgeon General (SG) of the United States.

C. Everett Koop (1916-2013, SG 1982-1989) had recently retired as the Surgeon General when I graduated from the Loma Linda University School of Medicine in 1991. He was our commencement speaker, and his words shaped my thoughts as a young doctor. This article will review the job of Surgeon General, and consider some attributes that have made recent Surgeons General successful. Many have served as acting Surgeon General since the post tends to be low on Presidential appointment priority lists, but we will only consider the appointed office holders here.

The Surgeon General is “America’s Doctor”

Americans expect their Surgeon General (SG) to be their top doctor. Whether dealing with health care reform or influenza epidemics, the SG must speak with authority, clarity, and honesty. He* must be an expert in medicine. Koop was such a man. As a pediatric surgeon, he was the surgeon-in-chief at the Children’s Hospital in Philadelphia (CHOP), establishing the nation’s first neonatal surgical intensive care unit there. He did groundbreaking work in many areas of infant surgery, such as the separation of conjoined twins. Aged 65 and with a grandfatherly look when he took office in 1982, Koop was one of the few Surgeons General who became a household name.

Since preventive medicine and primary care are the foundation of any health care system, the SG must have a comprehensive understanding of both, preferably being a specialist in these areas. Of six appointed Surgeons General since Koop, the following four have been primary care specialists: Jocelyn Elders (pediatrics), David Satcher (family medicine), Regina Benjamin (family medicine), and Vivek Murthy (internal medicine).  The Surgeon General should be familiar with subspecialty care as well, from allergy to urology, to best represent this large and influential community.

The next Surgeon General should have experience in all health care settings, including inpatient, outpatient, and community care. Having lived and practiced in many areas of the US would enable him to understand regional differences in needs and resources. The SG should have practiced in academia, from medical schools to residencies, and published in his field. All recent Surgeons General have shared this variety of experience.

One of the biggest problems worldwide is health disparities between groups. While some people can get the most effective treatments and medications, some can’t get even the most rudimentary. These inequities are fundamentally unfair, and put everyone at risk. For example, people in poverty with active tuberculosis who cannot afford and therefore don’t take their antibiotics will infect others. David Satcher (1941- , SG 1998-2001) released the influential report “Tobacco Use Among U.S. Racial/Ethnic Minority Groups” and did other important work to reduce health disparities during and after his tenure.

Other important health problems loom. Americans are aging, getting fatter, and exercising less. As American medicine is learning more about behavioral health and mild traumatic brain injury, we are discovering how harmful and prevalent they are. The problem of substance abuse is growing. America’s next Surgeon General will face these vexing issues, and must have ideas of how to combat them. Antonia Novello (1944-, SG 1990-1993), launched the “Healthy Children Ready to Learn Initiative,” and Regina Benjamin (1956, SG 2009-2013) issued “The Surgeon General’s Vision for a Healthy and Fit Nation” to address such problems.

No one can appeal to all Americans, but the next Surgeon General must be willing and able to engage people of different ethnicities, religions, and backgrounds. He must speak at churches, community centers, schools, and other religious venues; anywhere he is invited to spread messages of health and fitness. The SG must work with community leaders to devise and implement programs that will resonate in their community. He must work with local, regional, state, and Federal governments, with businesses, and with other organizations, to provide resources for the right interventions. Koop was probably the best example of the engaged and engaging surgeon general.

The Surgeon General must be what he wants others to become

A good SG will encourage a healthy body weight and physical fitness, and so he must have a healthy body weight and be physically fit. A good SG will be moderate in alcohol use and will not use tobacco products. Americans need to see their Surgeon General running, cycling, lifting weights, stretching, engaging in sports, eating right, and doing the things the things that he is asking them to do. Regina Benjamin faced intense criticism for warning people about being overweight and yet having extra pounds herself. Health and fitness should be a genuine part of the SG’s life, not something invented for the camera. Vivek Murthy is an avid walker.

The Surgeon General is the leader of the Commissioned Corps of the Public Health Service

The Commissioned Corps (CC) of the Public Health Service (PHS) has over 6,800 officers, including physicians, veterinarians, nurses, engineers, scientists, and a host of other health care professionals. These men and women improve the health and well-being of Americans from Alaska to Florida, and even overseas. The CC is a uniformed service, just like the Army, Navy, Air Force, and Marine Corps. Antonia Novello, the first woman and first Hispanic to serve as surgeon general, was a uniformed member of the Public Health Service for years before her appointment. The next SG should have experience in the PHS or at least in the uniformed environment. Richard Carmona (1949-, SG 2002-2006) is an Army veteran, having served as a Special Forces medic in Vietnam.

The US Public Health Service falls under the Department of Health and Human Services (DHHS) and so the ideal candidate for Surgeon General would have experience working in, or at least with, DHHS. Knowing the people, the places, and having an existing social network would better allow him or her to “hit the ground running.”

The Surgeon General is a de facto leader in medicine and health care worldwide

America leads the world in many areas, and medicine is no exception. The United States took a leading role in the eradication of smallpox and in the fight against Ebola. As the face of American medicine, the Surgeon General will interact with other health care leaders to advance health around the globe.

The Surgeon General is a representative of the President and must be confirmed by the Senate

As a political appointee, the SG is the face of the President on health care and medical matters. Presidents want to appeal to everyone in the nation, but in reality they are elected by a segment of the population. The SG must appeal to as broad a constituency as possible, but must especially appeal to the groups that elected the President. Koop was well aligned with Reagan’s priorities, and well aligned with Reagan’s working class and religious base. Donald Trump has a similar base. Carmona, less successful than Koop, opposed some of George W. Bush’s priorities, and those of his base.  Jocelyn Elders (1933-, SG 1993-1994) was removed by President William Clinton for making controversial remarks.

In addition to appealing to the voters, the Surgeon General must pass Senate confirmation. He must have credentials that make him a plausible candidate, and not have any disqualifying history or associations. The confirmation process will be grueling. Murthy was outspoken against gun violence, and his confirmation as SG was opposed by the National Rifle Association. After a strenuous fight, and with a Democratic majority of 54-45 in the Senate, Murthy was confirmed 51-43.

Nonetheless, the next SG must have the courage of his convictions; “with firmness in the right, as God gives us to see the right.” No one who wants to be Surgeon General more than he wants the truth deserves to be Surgeon General.

Conclusion

C. Everett Koop’s legacy lives on in the hearts and minds of physicians, like me, who finished medical school in the 1980s and early 1990s. To many, he was an American icon. Perusing a list of prior Surgeons General of the United States, I was struck by how often in recent decades no SG was appointed and how often acting SGs served. As qualified as these acting Surgeons General have been, the failure to appoint a Surgeon General of the United States is a big mistake. Medicine and health care are getting more and not less important in America and across the globe. President-Elect Donald Trump should appoint a Surgeon General of the United States. If he finds someone with the skills, experience, and priorities comparable to the best of recent SGs, he will pick well.

 

 

 

 

*I have used the pronoun “he” rather than “she”, “he or she”, “their”, or some other combination for the sake of readability. Both men and women have successfully served as Surgeon General. No offense is intended.

Health and the 2016 US Presidential Candidates

The 2016 Presidential Campaign is nearing its end; in only two weeks American voters will decide who, most likely Hillary Clinton or Donald Trump, will sit in the Oval Office. The US presidency is a hard job, with grueling hours and the need to make critical decisions at any time, day or night. Campaigning for president is itself a tough physical endeavor, one that speaks loudly of the health of the candidates. This year has been especially bitter, with accusations and recriminations more appropriate to a college dorm than to the highest office in the land.

My primary work is as a family, preventive, and sports medicine physician. During this season, many people have asked me what I think of the health of the candidates. On one hand, I am not the personal physician of either candidate. I have never met either of them, much less taken a medical history or performed a physical. Any opinion that I render is dependent on publicly available medical information and observations that I have made from afar. On the other hand, the coverage does provide a great deal of data. For the sake of my friends and readers, who have asked me repeatedly, I will give an opinion.

Donald Trump

An article on CNN dated 15 Sept 2016 states that Trump is 70 years old, stands 6’3” and weighs 236 lbs, giving him a body mass index of 29.5.[1] By medical standards, he is overweight and therefore is at higher risk for diabetes, heart disease, and various types of cancer than Americans with a BMI between 21 and 25. A recent blood pressure was 116/70, remarkably good for a 70-year-old unless he is on medication, and is fasting blood sugar is 99 (normal is around 100). Trump takes Rosuvastatin for high cholesterol and triglycerides (the fat in his blood), and recent triglyceride results were 61, which is normal.[2] He also takes a low dose aspirin for cardioprotection. Trump’s latest liver function tests, thyroid tests, electrocardiogram (ECG), and chest xray were normal. His colonoscopy (2013) and transthoracic echocardiogram (2014) were also normal. These results suggest that Donald Trump is in good health for a man his age, although I have not seen independent confirmation.

Observations are also important. The human gait changes over time, with stride length diminishing and pace slowing. Medical students are often taught that “gait is the signature of the nervous system.” Trump’s gait is essentially normal, comparable to those of other older presidential candidates such as Ronald Reagan and Bob Dole. His facial expressions and muscle movements are equal and fluid, suggesting a normal nervous system.

His posture is fair, but he rolls his shoulders in, as most people do. Thus Trump is at higher risk for shoulder weakness and chronic pain, although I was not able to find a picture of him without shirts or shoes on the internet.  Given his age and weight, Trump is at high risk for arthritis of his weight bearing joints, especially his knees, hips, and spine.

Trump’s mental health has been the source of speculation and scorn for thousands of talking heads. His statements certainly come across as arrogant, but the same can be said for most billionaires, politicians, and otherwise prominent people. Some have suggested that arrogance is a prerequisite to run for president. Though a character flaw, arrogance is not a diagnosis. Narcissism, the excessive admiration of one’s own attributes, is a diagnosis that has been applied to Trump, but could equally well be applied to most rich, famous, and powerful people.

Hillary Clinton

On 14 Sep 2016 Dr. Lisa Bardak, Hillary Clinton’s attending physician, states that the 68-year-old Clinton is “healthy and fit to serve as President of the United States.”[3] It mentions her having sinusitis and a left ear infection in Jan 2016, for which she received a CT scan of the sinuses and brain as well as antibiotics and a myringotomy tube (ear tube). Clinton received antibiotics again for a “right middle lobe pneumonia” in Sep 2016. Bardak notes that she “felt dizzy” at a 9/11 commemoration event, and gradually improved. Clinton has hypothyroidism (treated with Armor Thyroid), Coumadin (which Bardak did not explain), and vitamin B12. Her other results are as follows:

“Of note, she has remained stable for many years on Armor thyroid to treat her hypothyroidism (a low T3 level).  Her laboratory testing (vitamin D, CBC, fasting blood glucose, comprehensive metabolic panel, hemoglobin A1-C, vitamin B12) was normal, including cholesterol of 189, LDL of 103, HDL of 56 and triglycerides of 159. Her vital signs showed a blood pressure of 100/70, heart rate of 70, respiratory rate of 18, temperature of 97.8, and pulse-oximetry (oxygen dissolved in the blood) of 99%.[4]

Hillary’s publicly available health history includes the following:

Coughing fits

Coughing fits can be due to many conditions, ranging from allergies to acid reflux to serious respiratory disease. Hillary has had several episodes of these fits. She also suffers from hoarseness, which can be related. Dr. Bardak states that Clinton has had allergies for many years and that they are controlled on Clarinex, an antihistamine.[5]

Right elbow fracture

While serving as Secretary of State in 2009, Clinton fell and fractured her elbow in the basement of the State Department. The fracture had to be significant because she underwent surgery to fix it. A small, non-displaced fracture would likely have been treated non-operatively. White women are at high risk for osteopenia and osteoporosis (thin bones). Epidemiologically speaking she probably has both, and this may have contributed to the severity of the fracture. By contrast, in the 1996 campaign, for example, a 73-year-old Bob Dole leaned on a fake railing at a campaign event, which gave way. He fell three feet to the floor and hit his right side and arm but was not seriously injured.

Secretary Clinton is not thin, which lowers her risk for osteoporosis, but raises her risk for high blood pressure, diabetes, heart disease, and various types of cancer. Fortunately for her, the blood pressure and HgbA1C are normal.

A bigger question is why she fell. It could have been something as simple as tripping over a rug. Standing equilibrium decreases with age, as does vision, muscle strength, and many other factors that protect against falls. Past falls are a significant predictor of future falls.

Fainting and Traumatic Brain Injury

In late 2012, Clinton fainted and hit her head, sustaining what was then announced as a concussion. The State Department suggested that a stomach virus and subsequent dehydration caused the fall. She had chronic headaches after the fall and in December a follow up brain scan revealed the presence of a subdural hematoma, a collection of blood between the brain and the skull. This reveals that the blow to the brain was far more significant than originally thought. Her history is significant for a blood clot in her right leg in 1998, which means that she may have a genetic tendency to get blood clots easily. Clinton began taking Coumadin, a blood thinner which she continues today. Clinton’s head CT in January was probably a follow up on her brain injury in 2012.

In January 2013, observers noted that Clinton was wearing glasses with a Fresnel Prism, used to treat double vision.[6] This was likely related to the fall in the previous December.

Pneumonia and Near Collapse

While getting into a black van after a 9/11 commemoration ceremony in Manhattan, Hillary nearly fell to the ground several times. Had she not been physically held up by supporters and Secret Service agents, she would have fallen.[7] The video begins with Clinton leaning against a metal bollard with a woman holding Clinton. As Hillary moves she slumps, is caught by the Secret Service, and slumps twice more. Her head bobs several times. She lost a shoe while being whisked away. Common causes of such symptoms include dehydration, as in the earlier episode, heart conditions, and seizures. Dehydration is the most likely culprit, although Clinton’s history of brain injury elevates her risk of seizures, and her family history of heart disease is also concerning.

Sometimes Clinton’s upper body movement seems normal, and other times she seems to be supporting herself with a podium. Sometimes her step length seems normal, and other times it seems short and halting. Even at her best, such as during the second presidential debate, she looked repeatedly at her feet while walking. Each step was carefully placed. This suggests that her balance is poor and she needs visual cues to stay upright. She sat every time that she could while Trump stood without support during many intervals.

Other notes

Some may argue that the president’s health is less important because a president has access to the best medical care in the world. Having worked with the White House Medical Unit on more than one occasion, I appreciate their dedication and professionalism; working long hours and traveling anywhere with little notice. The volume and variety of patients that they see is low compared to many primary care clinics, but their training is excellent.

Whether or not presidents have access to the best medical care in the world, they certainly have access to the most medical care in the world. Powerful people tend to want to stay powerful, and since their power is related to their work, they are impatient with the healing process. They want short cuts, usually in the form of more interventions, more drugs, and more procedures. To some extent this is true of everyone, but powerful people are able to get what they want. Often this is harmful.

Health care professionals wittingly or unwittingly collude to give presidents more health care than they need. Lincoln and Garfield might have survived had their physicians, in well-intentioned zeal, not probed to get the bullets that killed them. Even Bardak’s reassuring letter notes that Clinton got more care, not necessarily better care, than most people would for the same conditions. A single ear infection, even if it is persistent for a few weeks, is not an indication for a myringotomy tube. A sinus infection is not an indication for a brain CT scan, although it may have been done because of her prior subdural hematoma. Most people with pneumonia never get or need a CT scan, and a temperature of 99.4 is not indicative of a fever (100.4 is the generally accepted cut off for healthy patients). Clinton sustained the risks of relatively high medical doses of radiation and the risks of surgery, perhaps unnecessarily. More care does not equal better care.

This is not to blame Mrs. Clinton or her team; the pressures on a presidential candidate are extreme, especially in this era of inescapable public attention. High ranking generals, sports stars, and famous entertainers are also at high risk for getting more care, not necessarily better care. However well intended, this exposes them to risks that can be a detriment to good health.

Limitations

As I mentioned above, I am not the physician for either Donald Trump or Hillary Clinton. I have never examined or even spoken to either. The information that I have reviewed is a small sample of all of the information available about these people. I am writing at the request of friends and readers. The question about the health of the presidential candidates is important.

Conclusion

Does Trump’s health disqualify him from being president? No. Does Hillary’s health disqualify her from being president? No. President William Henry Harrison caught pneumonia and died within 40 days of taking office, and it is unlikely that either Trump or Clinton will do the same. Franklin Delano Roosevelt was crippled from polio his entire presidency, a fact concealed by the media of his day, but he was an effective president. Nonetheless, just like an employer needs to know if the applicant sitting in front of her is physically capable of doing the job, voters need to know if their two applicants, Donald Trump and Hillary Clinton, are physically capable of doing the job.

Donald Trump shows no evidence of being physically unable to be the President of the United States. Voters can choose against him for a variety of reasons, but his physical health probably should not be one of them. He seems to be as healthy as past candidates of similar age, including Ronald Reagan and Bob Dole.

Hillary Clinton’s health is more concerning. She has many medical problems both past and present. Some of these are very serious. She has current symptoms possibly consistent with ongoing neurological impairment. She does not appear to be as healthy as past candidates of similar age. Voters will decide if Clinton is healthy enough to receive their vote.

Whichever candidate wins, time will tell if they were healthy enough to serve as president.

 

[1] http://www.cnn.com/2016/09/15/health/donald-trump-health/index.html

[2] http://www.nytimes.com/2016/09/19/us/politics/donald-trump-health.html?_r=0

[3] https://m.hrc.onl/secretary/10-documents/05-physician-letter/HRC_physician_letter.pdf

[4] https://m.hrc.onl/secretary/10-documents/05-physician-letter/HRC_physician_letter.pdf

[5] https://m.hrc.onl/secretary/10-documents/05-physician-letter/HRC_physician_letter.pdf

[6] http://www.foxnews.com/health/2014/05/16/ophthalmologist-weighs-in-on-clinton-glasses-spectacle.html

[7] http://nypost.com/2016/09/11/hillary-clinton-has-medical-episode-at-911-ceremony/

Mental Health – Context of Care and Recovery

Years ago a friend of mine was abandoned by her husband. She and her sons have remained in the church but now the boys are out of the house and she is alone. A couple of months ago I saw her in the hall and greeted her with a big hug. Her eyes lit up – it had been a long time since she had been touched. The Beatle’s Eleanor Rigby is not just a song, but a statement of an exploding problem throughout the world – people are lonely. Doug Saunders captured this problem in his book Arrival City in which he remarked on “the silent isolation of the middle class.” He wrote of new immigrants “no longer would they hear every word and movement around them; no longer was the air constantly vibrating with the parry and banter of the entire community.”[1] The only regular noise many people hear at home are the sounds of the television and the computer.

Whether I see them for physical or psychological complaints, I confront loneliness frequently in my patients. Even more, whether a person feels lonely or not, being chronically alone has a negative effect on health. For example, patients with chronic knee or hip pain frequently have tight quadriceps, hamstrings, hip flexors, and heel cords as contributing factors. Improving flexibility will enhance function and decrease pain. Patients who have a spouse at home who will help them usually do better than those that do not. The same is true for other health outcomes, from shoulder pain to diabetes. Ecclesiastes 4:9-12 is right.

Doctors, counselors, and pastors frequently care for people with personal problems and mental health concerns. While we often help these patients improve, complete recovery seems elusive. Chronic pain, chronic depression, chronic insomnia, and long term poor function are maddeningly hard to beat. One reason is that we try to do it alone. In our optimism, or perhaps our vanity, we expect that our few minutes with a patient a couple of times per year, or even per month, will revolutionize their lives.

When I treat a patient, whether in the doctor’s office or the counselor’s chair, I try to get the family, friends, work, school, church, and others involved if the patient agrees. Below is a diagram entitled Context of Care and Recovery that I use to help those under my care.

Mental Health – Context of Care and Recovery

How to use this paradigm

The Context of Care and Recovery paradigm actually comprises a systematic way to look at the total milieu of the patient and family, addressing each area, and thereby maximizing the likelihood of success. Lasting recovery from serious and chronic behavioral health problems requires major shifts in lifestyle; not just that of the patient, but the lifestyles of the family and close friends as well. More than just recovery for the sick, the Context of Care and Recovery paradigm can help with keeping the healthy well, and even making them healthier. I will use “her” to refer to therapist and patient and use “he” for pastors, reflecting the predominant demographics of those populations. I use the terms “patient” and “client” interchangeably.

The Inner Square – patient and family (specific factors)

The patient and family are in the inner square and are the focus of the intervention. Note that the patient is not alone in the center. The therapist will focus her efforts on the patient, but the patient must not focus on herself. Likewise, the family will not focus on the patient; they will focus on each other. The idea is to get each person in the group to focus on the others in the group.

Self-focus is as natural as it is deadly. We are by nature selfish people, but the foundation of mental health is to consistently look outside ourselves.

  1. We consider the person and glory of God in creation, in the Bible, and in other people (Hebrews 12:2).
  2. We consider the good things about others; their virtues, their skills, and their aspirations.
  3. We consider the needs of others.
  4. We consider our own needs.

There is more than just one person in the inner square. Therapy for behavioral health will not fully succeed until everyone on the team realizes this truth and adjusts their thoughts, words, and actions accordingly. Getting there is the hardest thing to do in therapy.

As patient is unique, so is every family, and one of the first tasks in regaining or improving health is to identify and accept the uniquenesses of each patient and family. Therapists should identify specific factors that have the potential to affect recovery and health.

What about the person who has no family? This is difficult, because one person is ill-equipped to stand alone. Try to involve concerned friends, distant relatives, or anyone else who is willing to help. People with behavioral health problems are less likely to have close personal ties; this is one of the effects of the disease. Nonetheless, everyone needs someone, and care professionals should mobilize helpers on behalf of their patients.

Counseling

The counselor has two jobs: to guide the client and her family through the mazes that they encounter on the road to recovery, and to make sure that the client and her family are not ultimately alone. The counselor walks alongside the patient and family in the maze. For our purposes, a “maze” represents confusion about what to do and where to go to get better. People in mazes take many wrong turns and end up at dead ends, only to retrace their steps and try again.

The client is in her own mental maze, but also likely in the physical mazes of insomnia, chronic pain, overall ill health, and sometimes substance abuse. The family is in the maze of uncertainty about how to help the patient, and lack of resources, whether money, time, knowledge, or patience. Other concerned parties such as friends, co-workers, and caregivers are in mazes of their own. Navigating the health care system itself is a maze.

Some people chose pastoral counseling, some chose secular (non-Christian) counseling, and some choose both. Either way, the counselor must address all aspects of the person:

  1. Physical fitness – strength, endurance, flexibility, mobility
  2. Environmental fitness – heat/cold, altitude, noise, air quality
  3. Medical fitness – access to care, immunizations, screening, prophylaxis, and dental
  4. Social fitness – social support, task cohesion, social cohesion
  5. Behavioral fitness – substance abuse, hygiene, risk mitigation
  6. Psychological fitness – coping, awareness, beliefs/appraisals, decision making, engagement
  7. Nutritional fitness – food quality, nutrient requirements, supplement use, food choices
  8. Spiritual fitness – virtuous living, positive beliefs, making meaning, ethical leadership, accommodating diversity

This paradigm comes from the Total Force Fitness program in the US military, and is a comprehensive way to look at the health of each individual and group.

Personal spiritual direction

In our context, being “spiritual” means that a person acknowledges some level of existence beyond the material world of atoms and molecules. Almost everyone is “spiritual” by this definition, and even those who say they are not usually are. Most people will say that they are spiritual. Those who deny it, typically believe that love exists, such as that between a man and a woman, and that it is more than the fluctuations of atoms in the body.

Being spiritual, most people seek some type of spiritual direction.  This may or may not involve “god” and certainly will not come completely from the counselor; religious leaders, family and friends, and even the media play a role. For the Christian, some aspects of spiritual development are universal. God intends certain things for all of His people:

  1. That they be genuine Christians.
  2. That they forgive as they have been forgiven (Matthew 18:21-35).
  3. That they exhibit the fruits of the Spirit (Galatians 5:22-23).
  4. That they engage in the spiritual disciplines (see Fasting in the Bible for the whole list)
  5. That they be active in ministry.

Pastors, doctors, and other caregivers must understand the spiritual direction of the patient and her family and incorporate that into therapy. For example, if a patient says that God wants her to serve in a food ministry, the pastor should inquire further. Unless there is some major concern, he should try to help her find such a ministry.

Pastoral care

Assuming that the patient is involved in religious practices, leaders in that setting (pastors, deacons, elders, priests, rabbis, imams, etc.) will provide pastoral care. This may include home or hospital visitation, marriage, burial, or other services. The person providing pastoral care may not be the same person providing counseling, but these people must work together.

For example, if a younger woman is seeing a counselor for marital problems, that counselor could arrange for the patient to meet with an older woman who is trusted and respected in the church. By providing this “pastoral” care, the older woman could become part of the younger woman’s care team.

Medical care

People whose bodies are unhealthy cannot have minds which are healthy. Therapist and physician must work hand in hand to treat the whole patient and the whole family. Counseling for depression will be limited in value if the patient eats poorly and cannot sleep. Similarly, medication for depression won’t work as well in a patient who is trapped by anxious thought patterns.

Families provide more medical care than doctors and nurses. Doctors prescribe the medications, but families help the patient take the medications daily. Nurses dress wounds once in the outpatient clinic, but families dress them every day at home. Nutritionists and cooks ensure healthy and tasty meals while in the hospital, but families provide them for breakfast, lunch, and dinner.

Community care

Communities have their own effects on health and well-being, and have different resources to assist their members. Companies have employee assistance programs, schools have educational programs, and other organizations have resources to benefit their participants. By working with leaders in these areas, caregivers can help their clients and patients recover from mental and other illness, and better their health.

Pastoral ministry

The purpose of the Context of Care and Recovery paradigm is to help caregivers and clients systematically identify contexts in which patients with mental health problems live. It is also useful to identify contexts of people without diagnosed disease who wish to improve their well-being. Having identified such contexts, caregivers use them to promote recovery and better health. Pastors preach, teachers teach, and administrators lead in the church, and all of these activities contribute to the healing milieu for patients. Preachers should make mental health, and health in general, a periodic topic from the pulpit. Teachers should offer classes on health, mental health, recovery, and similar topics in Sunday School, Bible Fellowships, and other teaching venues. Administrators likewise should arrange church or organization-wide opportunities for health, from blood drives to immunization campaigns.

Health is not the raison d’etre of the church, but the church (and other religious organizations) can make a huge difference in the health of its people. For example, a young woman in our church group struggling with anxiety improved markedly when she went on a mission trip with the youth choir.

Churches can improve the health of their congregations with the arts. Music has been shown to improve health outcomes, and even nature art in the halls can improve overall well-being. Gardens, lighting, and water features can be therapeutic.

Information and experiences from outside sources

The world is full of information and disinformation, and helping the patient separate truth from falsehood is one of the key duties of the counselor. Medicine advances in ways that can help patients, with new medications and other effective therapies arising constantly. Other areas in science and technology also progress. For example, self-driving cars will help epileptics and the elderly drive safely, providing flexibility and freedom that many today lack. Doctors, therapists, and families must be constantly on the lookout for new products, procedures, and paradigms that will help the patient and family.

Other interventions from animals to arts can help with mental and physical health. Theater, drama, dance, and music at all levels, from the high school to the Kennedy Center, can make people healthier. Both watching and participating are helpful. Outdoor activities such as riding, hiking, and photography make a difference.

At the same time, disinformation abounds. The internet carries 10 lies for every truth, and even facts on the internet are often misinterpreted. How many people look up medical symptoms on a trusted site, get sound information, and then convince themselves that they have that disease? In the 21st century, expectations are equally skewed. Photographs of beautiful women in magazines and on television/video put tremendous pressure on young women to be equally beautiful, even though the images are lighted and retouched as to be unreal.

Pastors, doctors, therapists, families, and patients should identify what information they consume, evaluate that information against the standard of truth and falsehood (including the Bible and the creation), use what is true and useful, and discard the rest. They should then modify their lives to exclude misleading and damaging information. Permanently turning off (or at least curtailing) the television and limiting the internet can be a good start.

Friends and acquaintances

The media and other factors are influential, but nothing shapes people as much as other people. Friends and acquaintances outside the home and the church can help or hinder a patient’s recovery. All those concerned about the patient, including the patient, can try to align their efforts to promote health.

Community and societal well-being and public health

Beyond the confines of the patient’s environment lies the wider world, and this wider world has an enormous effect on the health, and the mental health, of patients and their families. Poverty is associated with a litany of poor health outcomes. Pollution, whether air, water, food, noise, or any other, can kill. Cholera in London killed 616 people (1854) and smog in London caused about 4,000 premature deaths (1952). Even factors that do not kill can cause disease, harm function, and decrease quality of life. Lead poisoning was once widespread due to lead in paint and lead in gasoline but is now declining. It rarely kills but often harms, causing abdominal pain, anemia, confusion, headache, irritability, seizures, and long term brain damage. Large organizations such as government and major corporations typically act on this level.

The sovereign work of God

Bible-believing Christians are compelled to acknowledge the sovereign hand of God over all of the affairs of man. They are also commanded to understand the power of prayer to influence the work of God. Pastors, doctors, counselors, and other care givers must acknowledge these truths and use them in their patient’s/client’s life. The Lord will bless the efforts of all those who belong to Him, although He does not usually do so in the time or way that we expect (Romans 8:28, 2 Timothy 1:12). He will ensure that His perfect will is done in the lives of Christians, but we need to persist in faith, hope, and love. The Bible contains thousands of beautiful promises for those who know and love God, and counselors cannot fully succeed in their mission without believing and using them.

Life is hard, and medicine is hard. I could not do it without the strength of God. I pray for my staff and patients every day because I want, and need, to enlist the power of the Almighty on their behalf. The health and well-being of our patients and clients is so important, I do not know how caregivers could do otherwise. I strongly encourage all care givers to pray with and for their patients regularly.

People who deny Christ are still under the sovereignty of God. Muslims believe in a sovereign lord of the universe, as do Orthodox Jews. Patients of other religions and secularists, agonists, and atheists will react in accordance with their own beliefs. Therapists will do likewise.

Conclusion – Putting it all together

The Context of Care and Recovery paradigm focuses attention on the entire milieu surrounding a patient and family. Consider an obese, elderly woman suffering from arthritis, depression and diabetes. Many people will be involved in her care:

  1. She will comply with instructions and actively participate in all aspects of her care.
  2. Her family will help her with medications, appointments, diet, exercise, sleep, and coordinating with professional caregivers and other stakeholders. Her close friends will assist the family in these efforts.
  3. Her pastor will preach and teach on health issues occasionally, provide pastoral care, and lead the church to support her and others like her.
  4. Her church administrator will help organize elder transportation and an immunization fair to help keep her from getting the flu.
  5. Her employer will arrange her schedule to accommodate appointments and provide an employee assistance program to optimize her support at work.
  6. Her community pool offers a water aerobics and workout class that will help her move better, lose weight, and have better blood sugar control.
  7. Companies will support health in their employees, workplaces, and communities.
  8. Local, state, and federal government will help ensure a safe and healthful environment.

By helping coordinate the environment and all of its players, the patient, the family, the church, and all involved will benefit.

[1] Doug Saunders, Arrival City – How the Largest Migration in History is Reshaping Our World, Pantheon Books, New York, 2010, 282.