An Army for Christmas

We have been told that a heavenly choir sang the news of Jesus’ Birth. We have been misled. On that first Christmas night there is no record of any singing or of any choir. A close look at the biblical account reveals something even more amazing.

On the night long ago, on a hillside outside of the small town of Bethlehem a group of shepherds watched over there sheep. Their mood went from quiet supervision to overpowering fear in an instant as a light brighter than any they had seen enveloped them and out of nowhere and stood before them. The angel told them not to be afraid, for he was bringing “good news of great joy which will be for all the people; for today in the city of David there has been born for you a Savior, who is Christ the Lord.”

Then things got REALLY crazy, for “suddenly there appeared with the angel a multitude of the heavenly host.” The word “multitude” implies a very large number, or a crowd. The word “host” is filled with meaning, as it may also translated as “army”! Right, there on the hillside in front of the shepherds, was the army of heaven. This angelic army is not mentioned frequently in scripture, but the descriptions we are given (found in 2 Kings 6 and in Revelation 20) make it clear that it is indeed a mighty army, and that it will be the means by which God executes His judgment.

What was this heavenly army doing on a hill outside Bethlehem? Why were they the ones proclaiming the birth of Messiah? There is profound meaning in their presence. They are the army of God, those who will one day be the agents of God’s wrath poured out on sinful man. Wrath is indeed what all men deserve, for all have rebelled against God and His plan. But on this night, this powerful army does not come to do battle or wage war. On this night they lay down their weapons and announce the birth of the One who will deliver men from the punishment they deserve, the One who will one day take this wrath upon Himself. On this night, the army proclaims “Glory to God in the highest, and on earth peace among men with whom He is pleased."

Amazing. God, for His own glory and at His pleasure, provided the means through which rebellious men could find peace. He provided a Savior, born in a stable, Christ the Lord.

-          Bart

Mini-Skirts and Divorce at Christmas

As with many children of divorce my childhood Christmases were rushed and awkward. Every holiday season my parents haggled over how much time we spent in each dysfunctional home. The rules of math are suspended in divorce. Doubling the number of families did not double the love I received. Christmas time was stressful and difficult.

Each December my twin brother, my older brother and I left our youngest half-brother at home as soon as the Christmas break from school began. We headed down to San Diego by plane or by train from our home in North Orange County. We arrived at the home of our father, step-mother and two older step-brothers, abruptly inserted into their lives every holiday season.

My father was a man of anger and violence, but for some reason he loved Christmas. He had elaborate Christmas decorations on his house with a wood cut-out version of Santa and his reindeer that, to my recollection, approached actual size. He was extravagant in his giving and he showered us all with gifts every year. He felt it was important that we all join in the gift giving and I remember being forced to do chores around the house and in his office so I could earn money to purchase presents for my San Diego family.

The gift exchange occurred on Christmas Eve. My dad handed out the presents one by one and as the evening progressed each of our gift stacks increased in size. When our stacks reached maximum height the gifting was finished and we jumped in the car and hurried over to my grandmother’s house for Christmas dinner and a second gift exchange. My uncle was there with his family, cousins we only saw once a year, and we received presents from our grandparents after dinner. We loaded up the car and headed home to my father’s house, where we packed up and prepared the return home in the morning.

Looking back over the years it is amazing to me how little I remember of these holidays with my father. I remember one or two gifts, and very little else of the actual celebrations. I do remember feeling stressed and fearful, feelings that return even as I write these words. My father’s love of Christmas was not strong enough to cover his anger and the years were marked with explosions of temper at his wife and step-children. I vividly remember one year when he completely lost it. I can still picture his contorted face screaming at my step-brothers with white hot rage.  What I do not remember is feeling any love or joy at Christmas time, any time at my father’s house where I felt embraced, wanted or safe.

This lack of love may be why one of my fondest Christmas memories comes not from the actual celebration but from a trip home from my father’s house one Christmas morning. I do not recall the year, but seem to remember being around 7-8 years old. My father took us to the airport for the flight home. We walked across the tarmac, up the stairs and into the plane, a brightly colored PSA (Pacific Southwest Airlines) jet. We were welcomed by three beautiful stewardesses in brightly colored PSA mini-skirts. As it was Christmas morning and a very short flight we were the only passengers on the plane. For the next 45 minutes we were the center of attention. We were showered with smiles and affection as the stewardesses did their best to make our Christmas trip special. Looking back I wonder if they felt sorry for us, realizing that only children from a terribly broken family would be flying alone on Christmas morning.

Whatever their motivation was the end result was that I felt wonderful. In that short flight I received more love and personal attention than I had received in a week at my father’s house. That flight is a vivid reminder to me about what really matters when it comes to Christmas giving. The greatest gifts are not the ones we buy. The greatest gifts are the love and time we give to others.

• Bart

The value of an Apology? Usually Nothing

I have never been good with my temper but there are some things that really tick me off. Near the top of my list is an empty apology. I get these a lot when I call the help line of a large company. Something isn't working so I call. I eventually end up with someone named "Bob" or "Susie" (who definitely does NOT sound like a Bob or Susie). I explain my problem and immediately receive the programmed, standard issue, repeated so many times it is committed to memory apology, "I am so sorry for your inconvenience, I am sure that must be frustrating."

Quite often Bob and Susie can't help me so I am transferred to "Bill" (again, sounding like no Bill I have ever met). After repeating my previous information verbatim, Bill inevitably says, "I am so sorry for your inconvenience, I am sure it must be frustrating."

I must confess that on a few occasions I have replied, "What is really frustrating is having someone half way around the world repeat an empty and meaningless apology! I would prefer it if someone just fixed my problem!"

The empty apology has become a part of our culture. Doctors are notorious for this. Too many patients have waited for over an hour in an office, ultimately to be told  "I am sorry for your wait." I don't think they are truly sorry, it seems to me that if someone is truly sorry that they should do something to make amends, something to indicate that they actually care.

I have started doing this in my practice. If I am not in the exam room within 30 minutes of an appointment time, I give the patient a Starbucks gift card. On those extremely rare occasions where the wait is over an hour, I waive co-pays or don't charge at all. Perhaps it is because meaningful apologies are rare, but I have seen these gestures have a profound impact. Frowns turn into smiles and anger fades when the patient realizes that we value them and their time.

There is another benefit as well. Now that being late actually costs me something, I seem to make a more concerted effort to be on time! Makes me think I should be like this in all areas of my life. Imagine if every time I was rude, late or inconsiderate my apology was accompanied by a gift card! If being a jerk had real consequences, I might be nicer!

- Bart

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6 Reasons Doctors Hate Their Jobs

I love what I do for a living. Every day I get the chance to make a difference in someone’s life, which is incredibly rewarding, and I make a comfortable living. Based on conversations with my colleagues I think my joy in my work may be an anomaly. Job satisfaction amongst physicians is nowhere near what it used to be, and many physicians are thinking of retiring early. What happened? What happened is that a large chunk of the joyous parts of our days are being crowded out by parts that are discouraging and depressing. At times it takes effort to focus on the blessings. Here are some of the negative things that have had an impact on physician's attitudes-

1. Disrespect. It used to be that patients respected their doctor’s opinions, most still do, but the ones that don’t are a real challenge and can consume large chunks of time. In the last week I dealt with a 21 year-old who would not put her cell phone down (and got angry when I asked her to), exchanged 7 emails with a patient who refused to accept my choice of cholesterol medication, (he instead wanted something weaker and not recommended) and spent 30 minutes with a patient who thought he was constipated but wasn’t (he was going EVERY day), only to have him demand a specialist when I told him I could not find anything wrong. Physicians typically don’t mind honest questions, but we do need the “easy” stuff to not be so hard!
   

2. Insurance companies. Insurance companies make more money when they don’t pay for care. A new trick, when a doctor bills for an office visit and an injection (such as a flu or tetanus shot) they will pay for the shot and deny the visit charge. We have to appeal if we want to get paid. When you have to fight to be paid for what you do, discouragement can follow.
   

3. Medication denials. I am currently dealing with a patient who has severe nerve pain. He was prescribed a medication twice a day that provided good relief, but did not last the full 12 hours. Since the medication is indicated to be prescribed 2 or 3 times a day I upped the dose to three times a day to cover the hours when his pain was not treated. The medication was denied as it exceeded the insurance plans quantity limits. I wrote a letter explaining the patient’s condition and was denied again. I called and spoke to a “doctor” who informed me that nothing I said or wrote mattered, the medication could not be approved unless I wrote another letter and sent it to an appeals board. A patient suffered and my time was wasted. This happens frequently. Nothing kills your professional soul more than having to fight for the obvious.
   

4. Paper work. The fact that I have a computer does not mean I do not have to do paperwork. Disability forms, worker’s compensation forms, return to work letters, letters saying a patient had a physical exam (findings irrelevant), records requests, excuses from jury duty, the list is endless. Add this to medication refills, referral forms and reviewing lab results and one can understand why a 10 hour day may include only 6-7 hours of patient care. As the drudgery of such work comes at the end of the work day, it is no wonder many physicians go home discouraged.
   

5. Quality Standards. Everyone wants better quality care, but the arbitrary nature of the standards set by insurers adds a significant amount of stress. For example, good care for a diabetic is defined as a blood pressure below 140/90. If you treat a patient who originally had a blood pressure of 200/130 and get results of 141/92  you get no credit, you have failed according to the standards. Take a patient who started at 141/92 and edge him down to 138/89 and you are considered to be providing stellar care and worthy of a bonus.
   

6. MediCare.  Low pay and ridiculous restrictions, such as MediCare refusing to pay for some recommended tests or a lab test done one day to early according to guidelines. For HMO patients we are forced to search our records to find evidence to support documenting for meaningless diagnoses such as alcoholism 30 years earlier, mild calcifications the aorta or the normal decline in kidney function that occurs with age, all because MediCare pays more for these "sicker" patients. More important and impactful diagnoses such as dementia and anxiety add nothing to reimbursement, even though good care for these patients takes significant time.
   

I recently heard someone on the radio say doctors should not complain as we have a good life. We do. But we would be happier and more satisfied if we were able to devote more time to taking care of people and less time to mindless work. Something to remember the next time your doctor seems rushed and grumpy!

- Bart

Some Not so Happy Holidays

Death is a part of life that is always difficult. It is especially hard this time of year. In the course of a few days I sat down with someone who lost a loved one in sudden fashion, with someone who was making the decision to place her father on hospice care, and with a woman whose husband was losing a battle against advanced cancer. I wonder what these holidays are going to be like for these families.

In each conversation words did not come easy. What do you say to someone who had lost someone they loved  just a few days earlier? I avoided the clichés and simply acknowledged the magnitude of the loss, adding that they would be in my prayers. For the woman facing her father's severely declining health I did my best to support her, validating her love, her efforts and her advocacy for her father for the last several years. For the woman facing the loss of her husband I could do little more than promise support in the coming days.

As I prayed for these families tonight my thoughts turned to the life that came at Christmas. When Christ was born, the Jewish nation was in a time of great darkness. God had not spoken for over 400 years, the voices of the prophets seemingly silenced. The people were at the mercy of the ruthless Roman empire, ruled by an immoral King appointed by the pagan emperor. They were heavily taxed and oppressed. It was a seemingly hopeless time. Where was the light?

The light was coming, the darkness would not last. As promised through the prophet Isaiah-

"The people walking in darkness have seen a great light;
on those living in the land of the shadow of death a light has dawned...
For to us a child is born, to us a son is given,
and the government will be on his shoulders.
And he will be called Wonderful Counselor, Mighty God,
Everlasting Father, Prince of Peace.
Of the increase of his government and peace there will be no end.
He will reign on David's throne and over his kingdom,
establishing and upholding it with justice and righteousness
from that time on and forever." Isaiah 9:2, 6-7 NIV

I pray that this Christmas, for these patients and for the so many others who are dealing with loss, pain and darkness, that the light that came into the world 2000 years ago will shine for them, bringing hope, peace, and one day, joy.

- Bart