As We Think

Directing our emotions, our thoughts, our words, and our actions…to be who we were created to be.

The Economist is no fan of Donald Trump. The October 27 to November 2, 2018 issue featured a column by the editor Lexington describing the foreign policy failures and successes of the President. It was accompanied by the picture noted here, which shows Trump as an archer rejoicing over a single bulls-eye while quivers of arrows are far off the mark. He seems to be ignoring his many failures and raising his arms in triumph over one, perhaps random, success. Maybe Lexington sees Trump as an incompetent egomaniac who sometimes gets lucky. Certainly, other people do. While catchy, this illustration is a snowflake in an avalanche of political cartoons criticizing the US leader.

In my primary care medical practice, I encounter dozens of patients every week who, if they were featured in the same picture, would be sad. The context wouldn’t be foreign policy, but might be success at work, a loving family, new hobbies, losing weight, quitting smoking, or any of a hundred other things.  Rather than looking out of the illustration at the reader with upraised arms and a self-satisfied smile, their eyes would be downcast. Their brows would be furrowed and the corners of their mouths drooping. Instead of more than 30 arrows there may only be 10, or 5, or 1, because the person would have given up. He or she might tell a bystander “this is a stupid sport anyway. I have better things to do.” Just below their level of consciousness, they might get a queasy feeling – “why show my failures to the public, and to myself? How much better would it be to stay home alone with my screens, my games, and my programs? That way I cannot fail.”

There is danger in an excessive focus on our successes, but likewise danger in an excessive focus on our failings. The best focus is outside ourselves – at the problem to be solved or the grace to be enjoyed.

A focus on failures is not only a problem for patients, but for all of us. How do we regard each moment of our lives? Do we ruminate on our regrets? Do we marinate in our missteps? Do we refuse to forgive those who hurt us? Do we choose to take offense at the clumsy words and actions of others? Do we reject others for what they are, and reject ourselves for what we are? Do we put ourselves and others in the worst possible light? Do we cut others out of our lives when they don’t consistently meet our expectations and fulfill our wishes? Do we withdraw into a cave of confusion, sit down in den of darkness, and finally lie in a coffin of loneliness?

Conversely, do we bounce back after our blunders? Do we stand up after we fall? When faced with a seemingly impossible task, do we act as the inventors did in The Roses of Success, from Ian Fleming’s children’s musical Chitty Chitty Bang Bang:

Every bursted bubble has a glory!
Each abysmal failure makes a point!
Every glowing path that goes astray,
Shows you how to find a better way.
So every time you stumble never grumble.
Next time you’ll bumble even less!
For up from the ashes, up from the ashes, grow the roses of success!
Grow the roses!
Grow the roses!
Grow the roses of success!
Oh yes!
Grow the roses!
Those rosy roses!
From the ashes of disaster grow the roses of success!
(spoken) Yes I know but he wants it to float. It will!
For every big mistake you make be grateful!
Here, here!
That mistake you’ll never make again!
No sir!
Every shiny dream that fades and dies,
Generates the steam for two more tries!
(Oh) There’s magic in the wake of a fiasco!
Correct!
It gives you that chance to second guess!
Oh yes!
Then up from the ashes, up from the ashes grow the roses of success!
Grow the roses!
Grow the roses!
Grow the roses of success!
Grow the roses!
Those rosy roses!
From the ashes of disaster grow the roses of success!
Disaster didn’t stymie Louis Pasteur!
No sir!
Edison took years to see the light!
Right!
Alexander Graham knew failure well; he took a lot of knocks to ring that
bell!
So when it gets distressing it’s a blessing!
Onward and upward you must press!
Yes, Yes!
Till up from the ashes, up from the ashes grow the roses of success.
Grow the ro… (continue)

To succeed after failure, we must control our emotions. Years ago a young woman told me of a time when she felt awkward. I replied, “Awkwardness is a choice. If you chose to not feel awkward, you will not feel it.” She paused, a look of realization crept over her face, and she smiled.

Offense, discouragement, and every other emotion is also a choice. We cannot control the initial flush of feeling that we get from any situation, but we can control what we do with that flush of feelings. Emotions roll over us like a wave for the first few seconds, but then we must decide whether and how to redirect the waters.  We can nurture resentment over an injury or to forgive it. We can see any circumstance as a defeat or a victory. We can dwell in the prison of our fears or dance in the pastures of our joys. We can consider that both compliments and criticisms say more about the giver than the receiver.

The Bible tells us again and again to control our thoughts and our emotions and channel them toward success. We are to “Fear not!” (Isaiah 41:10) and “Not let our hearts be troubled (John 14:1).” Day by day success is performing the tasks which He has given to us with all our might (Ecclesiastes 9:10, Colossians 3:23). Ultimately, success for the Christian is loving, glorifying, and enjoying God.

The Economist probably did not mean to make Donald Trump look good in this illustration. I do not know Trump’s thoughts or his character. However, insofar as the Trump in the picture is rejoicing despite many, many failures, the British newsmagazine may be revealing a secret of his success.  

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/