An Easy Diagnosis- Missed

He was worried. He had lost over 30 pounds in the last few months and he did not know why. He had seen another doctor but the doctor did not give him an answer. Worried, he turned to a friend in the medical field. The friend referred him to me.

The visit started off as most new patient visits do, with a lot of paperwork and time spent reviewing his medical history. He had a history of high cholesterol but not much else of significance. He had no symptoms of depression and no obvious reason for the weight loss.

Until I looked at a copy of his blood work.

In December he had a fasting blood sugar of 295, nearly three times the upper limit of normal. He was diabetic. I asked him if he had been informed of the high blood sugar. He told me that the doctor had told him it was “something to keep an eye on” but that no additional tests had been recommended nor treatments suggested.

I explained to him that this was almost certainly the answer to his weight loss, as this was a common manifestation of diabetes. I ordered a repeat of his fasting blood sugar as well as additional tests to confirm the diagnosis. The results were as expected, confirming that he had been diabetic of a while.

At the end of the visit he asked why it was that the other doctor had failed to make the diagnosis. I did not have an answer for him. There was no rational reason that a blood sugar as abnormal as his would be ignored. The only explanations I could think of were ignorance, laziness or incompetence. I kept these reasons to myself, stating only that I did not know what the other doctor had been thinking.

I m not sure that the doctor was thinking at all or that he was truly concerned about the patient. The patient’s diagnosis was simple and straightforward and could have been made by most third year medical students. For several months the patient had needlessly worried about cancer or a life-threatening disease. I wished he had come in sooner and was grateful his friend had advised him to come to my office.

I wish I could say that his story was rare, but it is nowhere near as rare as it should be. Doctors are human and we make mistakes. We can get busy and distracted and we can be lazy and inattentive. Years of advanced training and education bring knowledge but they do not remove our innate tendency to mess things up. There have been many times when I was tempted to cut a corner or to tell myself I would address the problem "the next time." I have thus far been able to fight this tendency. This patient reminded me of why that is important.

- Bart

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The Church isn't Doing What it Should

She had not regularly attended church for a while. She still believed in God but she had been unable to find a church where she felt comfortable. She explained that she was particularly bothered by the fact that the Church wasn’t doing what it should, that it had lost its focus. When I asked her what it was the church should be focused on her answer was heartfelt. “They should be doing more for the poor!”

Her answer was heartfelt, but it was wrong. It revealed a lack of knowledge about the mission of the church and the teachings of the Bible. I wish I could say that she was alone in her erroneous thinking but she reflects a viewpoint commonly held by members of the millennial generation. Social justice has surpassed God Himself as the focus of worship. How did this happen?

Scripture teaches that Christians should be characterized by how they care for fellow Christians, not by how they care for those who are outside the faith. Jesus said it Himself, “By this all men will know that you are My disciples, if you have love for one another." (1) The prioritization of the needs of fellow believers is addressed by the Apostle Paul as well, “So then, while we have opportunity, let us do good to all people, and especially to those who are of the household of the faith" (2) It seems the clear message of these passages is overlooked. The focus instead appears to be on the misapplication of other verses, misapplication that supports the world's idea of what religion should be.

One of the greatest misapplications of scripture is of Jesus’ parable of the sheep and the goats found in Matthew 25.. In the story Jesus says that His followers will receive their eternal inheritance because “I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me."He then says that those who were not his followers did not do these things.

His followers are said to ask Jesus when it was that they did these things to Him. Jesus replied, “to the extent that you did it to one of these brothers of Mine, even the least of them, you did it to Me(emphasis added). The term "brothers of mine" is important.  It means that the evidence of faith is in how people treat  those who follow Jesus, not how they treat those who don't. 

Similarly, when those being condemned for lack of faith (the goats in the parable) asked Jesus when it was that they failed to do deeds of kindness  to Jesus, He replied, “to the extent that you did not do it to one of the least of these, you did not do it to Me.” The term "least of these" is important. "These" is a limiting word, it refers to a subgroup. In the parable, the subgroup that is separate from the unbelieving "goats" are the believing "sheep." Jesus is again making it clear that the evidence of faith is the treatment of His followers. Jesus' followers are His representatives on earth. When we are kind to them, we are kind to Him. 

The other commonly misquoted verse is from the letter of James, who wrote, “Pure and undefiled religion in the sight of our God and Father is this: to visit orphans and widows in their distress, and to keep oneself unstained by the world (3).” At first glance it seems that he is saying that the job of the church is to take care of widows and orphans. These are noble endeavors, but this is not James’ point. Just prior to this verse James attacked those who say they are religious but who are critical or foul in their speech, calling that type of religion “worthless”. He is making the point that true religion is not about words, but actions. The reference to widows and orphans is an illustration of that point.

James also railed in his letter against those who give honor and respect to those who are wealthy. He attacks the worldly practice of giving to those who can give back to you. By using "widows and orphans" as his example, he is making it clear that giving to those who can't give back is a truer expression of faith. He brings this home in the same sentence in which he mentions widows and orphans, saying that true religion also means "keeping oneself unstained by the world." (I find it interesting that no one ever quotes these words!)

Later in his letter James gives additional instructions that clarify his intent by writing, “If a brother or sister is without clothing and in need of daily food, and one of you says to them, "Go in peace, be warmed and be filled," and yet you do not give them what is necessary for their body, what use is that?” His use of the term “brother or sister” is a reminder that it is fellow believers we are to serve. Other passages, such as Acts 6 and 1 Timothy 5 provide additional support for this idea.

If scripture is so clear that our focus is to be on the needs of fellow believers, why is there such an emphasis on social justice? I believe that the current emphasis on deeds of social justice by the Church arises out of a need for people to feel good about themselves and a desire to perform external acts of kindness that are recognized by the outside world. Further, community service does not require spiritual transformation or personal purity. We can feed the poor and still be "stained by the world." It is much easier to spend a few hours a week in community service than it is to love your brother, sacrifice for your family and set aside sinful desires! 

Rather than being called primarily to community service true followers of Christ are called to be active participants in the community of faith. We are to be loving, serving, encouraging, challenging, and even rebuking one another as we strive to be better, kinder and purer people, people who more patient, more forgiving and more loving members of the family of God. The church can and should serve the community, but it is this that should be our primary focus.

- Bart

references-

1- John 13:35 By this all people will know that you are my disciples, if you have love for one another ESV       

2- Gal 6:10 So then, while we have opportunity, let us do good to all people, and especially to those who are of the household of the faith. NASU

3- James 1:27
 Religion that is pure and undefiled before God, the Father, is this: to visit orphans and widows in their affliction, and to keep oneself unstained from the world.  ESV

Watching a Marriage Die

The message was routine, a request for an antibiotic prescription to take on a trip out of the country. My staff had left for the day so I returned the call myself. The medical portion of the call was straightforward and lasted only a few  minutes so after discussing the antibiotic request I asked her about her family. I knew them all well as I had been the doctor for the birth of her 18 year old daughter. She told me that her kids were fine and that everything was okay with “them.”

Her emphasis on the word “them", referring to he children made me wonder if there might me something wrong with her "us", her relationship with her husband. It seemed she was implying that things weren’t going well in her marriage. I asked her what was going on. She told me it was a long story. I pressed her a little further and she confirmed my fears saying, “We are in the process of getting a divorce.” My heart sank. They had been married for over 20 years!

I asked her what had happened and if there was anything I could do to help. She was sure there was nothing anyone could do. She and her husband had drifted apart. They had little in common now that their children were grown. She was a busy professional trying to advance in her career while he had taken an early retirement a few years earlier. She was seriousness and business, he was having fun. They seldom talked about anything and the romance had died.

They tried a counselor but felt like it made things worse. In the counseling sessions they realized that neither one of them was willing to make the changes the other wanted. The sessions were circular, always keading back to the same place of disagreement. It seemed there was nothing anyone could do.

As she shared the story one phrase she spokejumped out at me. She said, “I have tried to take responsibility for my part of the problem.”

In that statement she revealed the root problem in their marriage (and many others). They believed that they each had “parts.” Their’s was a transactional, contractual relationship. It was a “I’ll do A,B and C and you do D, E, and F” kind of relationship, a relationship based on mutual benefit. If there was no longer any mutual benefit then there was no reason for the relationship to continue. If the other person did not do their “part” the marriage was effectively over.

Their contractual definition of marriage did not allow them to make the sacrifices needed to save their marriage. Marriage is intended to be a covenant, not a contract. In marriage two individuals make an unbreakable commitment. They leave their individual lives behind and become one. There are no longer individual parts, each person is committed to the whole of their relationship. It is a “I’ll do A,B, and C no matter what" kind of relationship, a commitment without limits.

We discussed how difficult this is. There is a natural tendency to want the other side to admit wrong and to work on things as well. As true as this is, it leads to hurt feelings and frustration as the imperfections and mistakes of the other spouse become the focus of attention. Marriages that endure are achieved by those who value the institution of marriage more than they do their own feelings of discontent. It is an incredible sacrifice.

I offered to meet with her or her husband, together or separate, if they wanted to talk further. I hung up the phone and said a prayer for them, their marriage and their children. I pray that they will come to the understanding that as painful as the road may seem, fighting to save a marriage is always worth it.

- Bart

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Fighting for a Patient's Sight

The vision in his right eye had been blurry for several days. It had worsened over the weekend and when he awoke Monday morning only a sliver of the vision remained. Worried, he walked into the office without an appointment, hoping he I could see him. My office staff quickly brought him back into an exam room.

I didn't even need to examine him. His story told the story. I was near certain that he was having a retinal detachment, a true medical emergency. As it had been progressing for several days I knew his vision was in severe jeopardy. He needed to see a specialist immediately.

Without leaving the exam room I logged into the HMO website to process the referral. He was a member of a new network in town, with a limited number of specialists available. I called the office of the only general ophthalmologist on the list. My heart sank when the staff told me the doctor was not seeing patients in the office that day. Who could I find to see him?

Worried, I called the medical group. After several minutes on hold I asked the staff to call so I could move on to my other waiting patients. When I came out of the next room my heart sank a little further. I learned that my nurse had not been able to get a referral but that we needed to wait for a return call from the assistant medical director. Not wanting to wait I searched my email for the number for the Medical Director, deciding to go higher up the chain as it was nearing the lunch hour when reaching a specialist would be near impossible. She gave verbal approval for the patient to be seen by a specialist in an affiliated group. Before I could hang up the phone my receptionist had that office on the phone.

More heart sinking. The receptionist at that refused to even get a doctor on the phone. As the patient was not officially a part of that group and they were not on call, she told me there was nothing she could do. I lost my cool for a moment, saying, “I guess we should just let him go blind!” as I hung up the phone.

The assistant medical director called me back a few minutes later. I quickly briefed him on the case and he promised to arrange a referral to a UCLA affiliated specialist a few miles away. Things started to move. That office called within 15 minutes, offering to see the patient on their lunch break. It had taken over 30 minutes of effort but he was going to be seen within the hour.

I went to lunch thinking that the problem had been solved but I was mistaken. Later that afternoon the eye doctor’s office called back with an update. It was a severe retinal detachment and the patient was at high risk for permanent vision loss in his eye. Emergency surgery was needed but the surgeon did not know if it could be done on time at the local hospital. He recommended that the procedure be done at UCLA first thing in the morning. The problem was that UCLA was over an hour drive away and the patient could not get to and from the hospital. They wanted my input.

My input was that the surgery had to be done locally, even if they had to transfer care to another surgeon. The doctor reconsidered, ultimately finding an assistant surgeon and getting time in the operating room of the nearby hospital for the next morning. I agreed to add the patient to the end of my day for the pre-operative medical exam and clearance.

One more glitch remained that day. After scheduling the procedure, the eye doctor was informed that the hospital did not have an operating room scrub technician available. His office called me again asking again about doing the procedure at UCLA! I was firm, "No! We have been over this, that is not possible!”

I looked at my watch. It was 3:45. If referral to another doctor was going to be necessary, we were running out of time. I pointed this out to the surgical scheduler. “We are running out of time to get help if we need it. I do not want to be rude, but this is ridiculous. This is an emergency surgery, and this is a hospital, someone needs to make this happen. If we cannot get a scrub tech in the next 15 minutes, we are going to need to call another doctor for help.”

They found a scrub tech.

He was back in my office within the hour for the pre-operative visit.

He was frightened. Everything had happened so fast and his world had been turned upside down. He was facing not only the loss of vision, he was also facing 7 days of immobility and weeks of work. It was hard for him to wrap his mind around it all. Worse, he was alone in town and had no support system.

I completed the clearance form and faxed it to the eye doctor’s office. When 30 minutes passed without any further glitches or delays I breathed a sigh of relief.

After the patient left I realized how drained I was from the day. While there was nothing medically challenging about the diagnosis getting the appropriate treatment had taken an incredible amount of effort. Between my staff and I over 20 phone calls had been exchanged in a period of 5 hours.

It wasn't over. 

We called the eye surgeon in the morning to check on the patient's status. The surgery had gone well, but there was a new obstacle. To preserve the sight in the eye, he would need to lie face down on a special table twenty-four hours a day for 7 days, with only one 10 minute break each hour. The table rental was $300 for a week and was not covered by insurance. As he was out of work and already poor, he could not afford it. The secretary at the eye doctor's office said, "This is sad because if he cannot get the table he will likely lose his sight." She acted as if there was nothing anyone could do. I could not believe that we could not step up and cover $300 to save the man's sight. Hadn't thousands already been spend on the surgery?

Multiple more phone calls later, we got the table paid for. That left us with another more basic need. How would he eat? He lived alone and could not cook or shop. Who could help him with meals and basic survival? Desperate again, I called a Calvary Chapel Church near his home. He had told me he had a friend there. I was forwarded to the staff member who oversaw the church's compassion ministry. She was immediately receptive. Two men in their church had experienced similar issues in the last year and she understood what the man needed. She committed to making sure that meals would be provided.

Tears came to my eyes as I hung up the phone. I did not know if we were going to be able to save his sight, but I knew we had done all we could. I was proud of my office staff, and especially grateful to the church. His case reminded me of why we all do what we do. We are here to help people in need, because we can.

I pray his vision will be saved. I ask that you pray as well.

- Bart

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Boomerangs, Broken Windows and Responsibility

Australians lie. There is no purpose or task for which a boomerang is needed or helpful. From my experience they are nothing more than devices of destruction and mayhem. No matter how many times one reads "the instructions" they never come back when you throw them. Even if they did no finger-loving human would want to catch one in flight. The only possible use of boomerangs is as a tool for lessons in personal responsibility. 

Case in point: When my son was about 7 years old one of the boys in the neighborhood had a boomerang. Nate was playing at their house and asked if he could throw it. He had a pretty strong arm for a little boy and he gave it quite a heave. It was traveling pretty fast when it struck the window of their garage. It is basic law of physics that when an irresistible force strikes an immovable object that the boomerang wins. There was glass everywhere. It was time to buy a new window.

I was across the street when it happened and hurried over to survey the damage. I told the neighbor that we would pay for the window. He initially refused but I insisted. I turned to my son and asked him how much money he had in his piggy bank. "Nine dollars" was his hesitant reply. I told him he would be contributing that amount to the repair of the window and tears welled up in his little eyes, "But it was an accident!" 

I explained that even when we accidentally break something or do harm, something is still harmed or broken and someone will need to fix it. The window had to be replaced, that would cost money, and because the damage came from him he was responsible to for it.  We have to take responsibility for the consequences of our own actions even when they are unintentional. This wasn't punishment, it was just the way life worked. We went home and retrieved his life savings and I added the remainder. The neighbor graciously did the repair himself. 

Reflecting back on the story I am reminded that personal responsibility is a lost value. People are often quick to apologize but very slow to make amends. It seems no one wants to be held accountable for their mistakes. I see this all the time. Just this week we received a bill from a medical office. We were surprised because we had been asked to "pay in full" at the time of service had done so. The collections agent explained that they had made a mistake and "forgotten" to charge us for a portion of the services. My response that "payment in full" typically means you have "paid in full" and that we should therefore not have to pay for their mistake fell on deaf and uncaring ears. 

I have made similar billing mistakes in my practice but my worldview is different from that of the other medical office. In every circumstance I bear the expense of our mistakes. Both me and my son can attest that accepting responsibility is costly. Apologies are not. Here's hoping for a resurgence of responsibility in the world.

- Bart

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