Out of Jail, Out of Control and in Need of Help

She had been out of jail for a little over a week and she looked it. Her clothes were ragged, her hair was disheveled and her smile revealed broken and missing teeth. It came as no surprise that her incarceration was due to a parole violation for a previous drug conviction. She had clearly lived a very hard life. She was also completely overwhelmed by her medical condition. She had diabetes and based on her lab results had no clue as to the severity of her illness or how to manage it.

He fasting blood sugar was measured at over 400, four times the upper limit of normal. It was not a fluke result as her once weekly blood sugars taken at home confirmed she was seriously out of control. As we talked it was her home blood sugar log that was most significant to me. The lack of numbers meant that she did not understand the importance of monitoring her blood sugars and the lack of response to the markedly abnormal results revealed ignorance about the need to control her disease.

I turned the conversation to the importance of monitoring her sugars and quickly saw her eyes glaze over. She had no idea what I was talking about. I asked some questions to gauge her knowledge of her disease and soon learned the problem. She was of below average intelligence and the basics of diabetes were at that moment beyond her comprehension. What could I do?

I could send her to diabetic classes, but she lacked transportation. The classes were just 6 miles away but that was about 5 miles too far. She had no car, no job and very little money. It was clear that her diabetic education would need to come slowly and in small pieces for her to absorb it. I realized there was only one option. I would need to have her come and see me frequently. It was up to me to teach her and help her.

“We are going to take this one step at a time," I said, "The first step is going to be you checking your sugars three times a day and keeping a log of your blood sugar results and of everything you eat. Then I want you to come back in a week so we can go over the numbers together.”

Her face sunk. “I can’t afford to come back in a week.”

“How much is your co-pay for an office visit?” I asked

“It is $20. I had to borrow money from a friend to come in today. I don’t have a job yet,” she said, embarrassed.

“So we will waive the co-pay. You need to come back in a week," I replied.

I saw her every week for the next 4 months. At first it was a struggle to get her to check her sugars on a regular basis and write them in her log book, as she only remembered about half of the time. It took almost a month to get enough data to be able to make recommendations about her diet and make medication adjustments with confidence. We kept at it and by the end the second month we were making progress and by the end of the third month the majority of her results were in the normal range. After 4 months I ordered blood work that showed her average blood sugars for the preceding 90 days. We reviewed the results together a few days later and I was able to tell her something that had once seemed impossible.

“You are a well-controlled diabetic!” Her smile was missing teeth, but it was still beautiful to see. She had gained control over an area of her life.

A month later she disappeared. She lost her insurance and could not afford the test strips or medications. I offered to see her in the office for free but she did not return. I never saw her again.

Reflecting on her story reminds me of several things. First, that while standardized approaches to patient care can make life easy, not all patients are standard. Some people need extra help. Second, extra help needs to come from somewhere and from someone who is willing to do a little more and go a little further. Sometimes I need to be that someone. Third, in spite of our best intentions and efforts there will always be those who we cannot help, those whose choices or circumstances are too much to overcome. We need to try anyway

The greatest lesson I learned is that you never know who will respond, who can be helped or where you can make a difference. Our job is not to judge in advance but to be there for people and to help whoever we can it whatever way we can.

-          Bart

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Medicine is Changing. Are you Ready?

Medicine has changed and many patients did not get the memo. Electronic record keeping and computerized data bases have made it so every aspect of a patient's health is now monitored, tracked, and analyzed. There is no longer such a thing as a simple office visit as third parties are telling doctors what to do, how to do it and who to do it to. 

When I started in practice 21 years ago the business was pretty easy. Most patient visits could be divided into three categories- routine check-ups, follow up for chronic diseases, and sick visits. Check-ups were straight-forward, uneventful reviews of overall health. Chronic disease visits were also easy, encounters focused on the problem in question- check the blood pressure, review the cholesterol or blood sugar, and make medication adjustments and order appropriate tests. Sick visits were easiest of all, as most of them were upper respiratory illnesses that could be handled quickly. 

Another characteristic of that era was that patients were responsible for their own care. We told them what they needed to do to be healthy, recommended screening tests such as colonoscopy and mammograms and encouraged appropriate diet and follow up tests. Whether or not they wanted to follow instructions was up to the patients. Being human beings, many patients didn't. Some forgot, many simply had other priorities. It was frustrating when patients did not do what they should for their health but we accepted the reality of the situation.

There was another reality that eluded both doctors and patients, and this reality led to changes in the way health care is delivered. The bad decisions patients made did not just effect them. When illness occurred as a result of these poor choices someone else, the insurance company, had to pay the bills. Insurers decided they wanted healthier patients and determined that reaching this goal required a dramatic change in how doctors practiced. The change came in the form of quality measurements. Doctors were to be held accountable for the decisions patients made, graded and financially incentivized based on the percentage of their patients who did what they were supposed to.

A new era of accountability has dawned. Doctors are now bombarded with forms and scorecards showing the percentage of patients who had mammograms, Pap Smears and colonoscopy. Reports pour in every week with the names of patients who have not been filling prescriptions on time, asking doctors to confront their patients about their non-compliance. Hours and hours of staff time are spent tracking chronic disease such as diabetes, with patients being reminded again and again to get eye exams, control their blood pressure and cholesterol and get their sugars under control.

The rules haven’t only changed for disease management. MediCare wellness guidelines are so arbitrary that we are required to annually discuss incontinence, fall risk, memory loss, ability to care for oneself, end of life issues and control of chronic pain with every single patient above the age of 65 regardless of health status. We have to check the same boxes for a debilitated 88 year-old as we do for a vibrant 65 year-old who plays competitive tennis, which is a bit puzzling to the 65 year-old!

The result of all of these metrics, reports and guidelines is that patients who come in for one problem find themselves being bombarded with instructions and questions for multiple other conditions they didn’t come in for. This can lead to defensiveness and a breakdown in communication, encounters that leave both the patient and the doctor feeling frustrated or dissatisfied.

So what to do? We start by understanding the new paradigm. I have begun educating my patients about the changes in healthcare. I explain to them the standards to which I am held and how their compliance has a dramatic impact on my practice and I am asking them for their help. The result? Increased cooperation, better understanding and decreased frustration. Medicine has changed  but if doctors and patients truly partner together we should be able to find a way to make it work for all of us.

- Bart

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Responding to Anti-Vaccine Hatred

“You killed that kid. You are a c---.”

“You are a part of the problem!”

“You should be ashamed of yourself and should not be a doctor at all.”

Since I published my posts on measles the attacks have been vicious and continuous. Multiple emails have flooded my inbox challenging my character and my motives and questioning my ethics and my intelligence, all sent by strangers who have never met me or spoken with me. As I read each one I ask myself, “How should I respond?”

The Barrett in me wanted to fight back, challenge every negative assertion and correct every false claim. I wanted to not just defend myself but to destroy their claims and show them to be the misguided people they were. I didn’t. Something stopped me.

That something might actually be a Someone, for at the time I was dealing with these responses I was also preparing to speak at a church in Burbank. The scripture for that Sunday was from the Sermon on the Mount, the part where Jesus informed His disciples that they were likely to be insulted, persecuted and lied about viciously in the course of following Him. He went on to describe how his followers should respond in such difficult circumstances, “Love your enemies and pray for those who persecute you.”

I must confess that this response was not the first one that entered my mind when I read the hateful emails! How could kindness be the appropriate response to hatred? As I continued to review the passage of Scripture and prepared my talk the answer to that question became clear.  Jesus consistently taught about eternity, about the blessings of the life to come. When the temporary attacks of others are placed in the context of the enduring blessings of faith it is easier to see the attacks for what they are, the responses of lost and broken people, people in need of a relationship with their Creator.  in this eternal context it is also easier to understand the appropriate response, as my goal should not be retribution or punishment but an effort to guide them to truth.

With this in mind I tried to answer every email I received. I avoided argument, instead choosing to acknowledge receipt of their message and suggesting web sites they could visit if they wanted more information. I did not apologize for my stance or affirm theirs, for that would be disingenuous. When there were specific questions I did my best to answer them. I doubt that I changed any minds but I hope that I may have challenged some presuppositions. I did not act in the way they expected. I pray they will reflect on my words and maybe even read other posts on the blog.

As I consider my responses to these strangers I am led to reflect on my responses when hurt and offended by those who are closer to me. I think of patients who have complained or given me negative reviews and of recent employees who unjustly accused me of unfairness. I have concluded that it is much easier to brush off the accusations of a stranger than it is to deal with accusations from someone who you thought knew you better. It is easy in such hurtful circumstances to justify an angry or defensive response. It is easy, but that does not make it right.

I need to learn to not take these slights personally, to respond in kindness whenever possible and to love and pray for those who hurt me, for this is the response that should characterize those who follow Christ. I know this because it was the response of Christ himself when he hung dying on the cross, his prayer for his persecutors, “Father forgive them, for they do not know what they are doing.” What a powerful example

May we all become more forgiving people.

-          Bart

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The World Lied. Millions Died

600 bodies were found when the Soviet soldiers arrived on January 27, 1945. If only they had been the only ones. The 7500 survivors that remained on the site told the terrible tale of how many others there had been and what had become of them. Over time the world learned of the horror. Nearly a million of their people had been executed or exterminated there in Auschwitz, millions more killed in other death camps. When confronted with such sheer evil the cry, “Never Again!” spread around world. Nations through their leaders promised that they would not repeat the mistakes of the past, not remain passive or silent when innocent lives were again threatened or taken.

The world lied. Since 1945 millions of innocent people have died at the hands of ruthless oppressors around the world, their only crime being the color of their skin, their religious faith or their ethnic heritage. The lack of concern or response from outsiders suggesting their lives were of no apparent value to the western world who had promised to protect them from such harm.

The lives lost include-

1.5-2 million Cambodians from 1975-1979 at the hands of Pol Pot and the Khmer Rouge

1-3 million ethnic Igbo people in Nigeria from 1967-1970 from starvation and slaughter

800,000 Tutsi killed in Rwanda within a 3 month period in 1994

200,000-400,000 non-Arab minorities in Darfur, Sudan from 2003-2010

The numbers are still rising in Syria, where the current estimate is 200,000 civilian lives lost, and in ISIS controlled areas of Iraq where Christians are being persecuted and killed for their beliefs.

How could it be that a world so horrified by the Holocaust could turn a blind eye to the suffering and persecution of so many?

There is only one possible answer. Human life is not as valuable to society as we proclaim, particularly when those lives are far away. When it comes to human life, it seems that the responses we are most comfortable with are the safe ones such as marches and hashtags and the lives we care about are the ones closest to home.

Which means that “Never Again” has become little more than a slogan.

-          Bart

The post is written in honor of Holocaust Remembrance Day, which occurs on the Anniversary of the Liberation of Auschwitz on January 27, 1945. 

A Woman Killed over 57 Dollars. What is One Life Worth?

“We just got robbed. I’m not kidding Bart! We just got robbed!” Kendall was standing in the corner behind the counter, white-faced and trembling with fear. The tone of her voice, the look on her face and the open cash register drawer removed all doubt. I had only been in the back room for two minutes but in that short time something terrible had happened.

It was 1978 and I had been working at the Baskin Robbins store on 19th street for about 6 months, which meant I was one of the more experienced staff members. It was 5:30 in the afternoon, the slow time of the day during the dinner hour and before the evening rush. It was a time for restocking cones and cups and for swapping out near empty tubs of ice creams with new ones. I was heading for the back to get a tub from the freezer when I saw him enter. Dark hair, dark jacket and a bandana. I didn’t think anything of him, he was just another guy. I went through the door to the storeroom as he approached the counter.

When I came out he was gone, and so was the money. When Kendall told me what had happened my first (and in retrospect, stupid) instinct was to chase after him. The fact that he had a gun and I had an ice cream scooper did not register in my mind. As I ran out the door I saw a car pull away. It had been parked just out of view of the door, about 20 feet away at the curb to the walkway of the center in front of the bar next door. It was a dark blue car about 10 years old. It had a black California license plate with gold numbers, “965 HTM.”

I ran back inside and called the police. This was pre “911” so I dialed the operator. “I need the police we just got robbed!” I was immediately connected to a police dispatcher. A squad car appeared outside within seconds. The dispatcher took the description and plate number of the car and told me to hang up and speak with the officer on scene.

Kendall told us the full story, how he had pulled the gun and told her to give him all the money in the register. She had nervously filled a brown bag with what was in the register and handed it over. He had turned and walked out. The whole event had taken only 1-2 minutes. Kendall had barely finished her story when the news came in over the police radio. They had found him! I had, amazingly, correctly identified the make and age of the car and there were officers in pursuit. The chase was on, the robber was racing down Newport Boulevard.

It was over in a matter of minutes when the thief crashed into another vehicle. He suffered no serious injuries but the woman he hit, a mother of three young children, was not so fortunate. She died at the scene. On the front seat of the dark blue Chevy the police found a toy gun and a paper bag with 57 dollars in it.

57 Dollars. Three children were forever motherless over 57 dollars. It is hard to process the tragedy of such a selfish and stupid act. How could such a thing happen?

The next few weeks saw a flurry of investigational activity.  There were a police interviews at work and at the police station, a photo lineup, and I was called to testify at a preliminary hearing. I was not told about the ultimate resolution of the case but I assume there was a guilty plea before trial as I wasn’t called back to testify again. My life went on.

I think about the robbery every so often. Each time I do it is the 57 dollars and the death of the mother that are most troubling. So much was lost over so little. I think about this every time I hear of a robbery. I wonder how someone could become so thoughtless, so heartless, so evil. At what point does the life of another human being become worth so little?

Life needs to be defended. It needs to be fought for.

There is nothing more valuable on this planet than human life. The Old Testament truth that we are created “in the image of God”, created with the ability to love, to reason, and to choose, is a truth we need to pass on to our children. This truth is the basis for valuing life, every life. Each and every person on this planet is of infinite worth, far more than 57 dollars.

-          Bart

Thanks for visiting the blog. Please remember the power of the share button and let your friends know about this and other posts. You can subscribe to the blog by clicking the link on the page and follow me on Twitter @bartbarrettmd. You can read more about the value of life in my book Life Medicine, available on Amazon.com.