Faithfulness Not Success

I met a new pastor recently. I had visited his church a few times but snuck out the back after the service without introducing myself. As his church is in Huntington Beach and I am occasionally asked by patients for a local church recommendation I thought it would be good to meet with him. I reached out to him via email and offered to buy him lunch. We met a week later when our schedules lined up.

He seems to be a genuinely nice man. In his sermons and through out the lunch conversation he came across as someone who does not seek the limelight, someone who is content serving God in whatever place God leads him. He is a faithful and consistent Bible teacher whose sermons are relevant and instructive. For some reason his church has not grown in numbers over the years. His church is small (fewer than 50 members attend most Sundays) but he didn’t complain at all about the lack of growth or his relative anonymity. 

I visited the church again a few weeks ago. The music leader was talented and passionate, the people were friendly and the sermon was again biblically sound. Attendance was sparse yet the leaders gave their all. It was a good service.

A few days later I met another pastor for lunch. He had just returned from a week with musicians who were pioneers in contemporary music in the 1970’s. Some of the men had been “stars” in the Christian music scene. They had performed in all 50 states and in over 50 countries. For a period of time people everywhere were singing their songs. Thousands were coming to their concerts. They were "somebody" for a while, until their fame faded.

Some of these formerly famous artists have struggled mightily over the years. They were so focused on their music, so convinced of their calling and gifts, that they failed to develop other marketable talents and skills. They toil now in obscurity, writing songs and recording music for which there appears to be little demand. They press on, hoping that someday they will again have an impact. Discouragement is for some an ever present compassion.

I have pondered the relative circumstances of the small church pastor and the musicians for the last several days. They are both gifted, passionate and committed. They both love God and want to be used by him, yet they all currently labor in anonymity. The difference is that the pastor is content and some of the musicians aren’t. The pastor does not seek the praise and attention of others while many musicians long for it. The pastor trusts that God is at work, the musicians struggle with the idea that God’s work does not involve earthly success or greater recognition.

It seems to me that most of us are more like the musician than the pastor. Western churches mirror western culture. We live in a world that measures success by numbers and advancement. We look forward to bigger, brighter and better things. The idea that diminishing popularity might be God’s plan, that we might be called to lives of relative anonymity, is inconsistent with our understanding of God’s blessing. The thought that our time of influence may be brief does not resonate. We act as if planning for a life outside of ministry or taking the time to develop additional skill sets is a manifestation of a lack a faith.

We forget the lesson of John the Baptist. Jesus referred to him as the greatest man who had lived up to that time yet he had a ministry that lasted for less than a year. This did not seem to bother him. When someone came to him bemoaning the fact that people were migrating to Jesus and leaving John behind his answer was profound, “He must increase but I must decrease.” John seemed to understand that his life would be measured not by his sustained popularity but according to his ongoing faithfulness.

The pastor seems to have embraced this truth.

I am working on it.

-Bart

Medical Students Have Changed, So I no Longer Teach

For over 20 years I have been a teacher of medical students. I began my first year in practice with a third year medical student spending one morning a week in my office for a year. The one on one year long program lasted for 5 years. It was fun observing each student grow and mature as the weeks passed. Some students experienced remarkable intellectual and professional growth, transforming into doctors before my eyes. When UCI decided not to use community doctors for that program I was disappointed, but I transitioned into teaching second year students who were learning how to interview patients and perform basic physical exams. The students were green and lacked medical knowledge so the challenge was much greater, but the commitment was less extensive as they were in the office much less.

Over the last few years I have participated in two different programs. UCI’s family medicine curriculum now calls for students to spend a month in a doctor’s office (I say a month, but the students are often scheduled for lectures and meetings so they are in the office for a total of 13 days.) The second program was a new one in which first year medical students spent one day a week in my office for three months. It was their very first exposure to actual medical practice

As the curriculum has evolved it is not only the structure of the programs that has changed, the expectations of the students has changed as well. There is a sense of entitlement that I did to see 20 years ago. This was most evident with the first year medical students. Their medical knowledge was non-existent, as they had barely started their course work in anatomy and had not taken any courses in diseases, diagnosis or pharmacology. They did not even know how to diagnose a common cold! In spite of this lack of knowledge they all expected to spend time alone with patients conducting interviews and doing basic exams. They had no idea what questions to ask or the significance of answers given by the patients, but that did not stop them from grueling personal interviews or from giving misinformed advice. The students had been given only basic training in physical examinations and were ignorant about what to do with what they saw and heard. Patients were seen more as learning opportunities than people.

One student I had complained about not being assigned enough patients per day, oblivious to the fact that many patients were not comfortable spending an additional 30-60 minutes in the office so they could answer medical questions from an ignorant stranger. The student cared little for the time or comfort of the patients. It was all about her.

The third year students recently in my office were little better. They had more training and knowledge than did the first years, but they still lacked awareness of their limitations and how they impacted patient care. When a longstanding patient pulled me aside and told me about the wildly incorrect advice given by one medical student I knew I had to make a change.

I no longer teach medical students in my office.

It was a difficult decision at first, as teaching has always been a passion and there have been some students who were outstanding. I know with certainty that I have had a significant impact on some of the students, even converting some of them to pursue family medicine. Nevertheless, when I stopped and considered the negative impact teaching had on my practice the decision became easier. Electronic records and other documentation requirements have compromised the quality of patient interactions as it is and medical students were making quality interactions even more difficult. Since ending my participation in these teaching programs I have realized how much better patient interactions are when there isn’t a student in the room. Patients have my undivided attention in a safe and private setting. The office runs more smoothly and I do not fall behind as often. Patient care is better, and this needs to be my primary goal. 

-Bart

5 Lives Saved in 5 Days.

It was a scary week. It began with a call from the lab about a patient’s lab results. They were so abnormal that I was surprised the patient was alive, much less able to function. I sent him to the ER immediately. It took a week for the labs to approach a normal level. He was deathly ill. What was frightening was that the tests were ordered as an afterthought during a visit for a mild complaint. Just before I walked out of the exam room I remembered that the patient had a history of abnormal labs years earlier. Although this was not why the patient came in I decided to order the blood work, just to be thorough. If hadn’t the patient could have died. 

The next day a patient came in for a routine follow up visit. During the visit he thanked me for harassing him into getting a colonoscopy the previous year. He didn’t want to get it done but I argued that it could save his life. It did. He had a large precancerous polyps removed. If he had waited a few more years it might have been life-threatening.

Thursday morning my PA (Physicians Assistant) asked me to take a look at a patient she was seeing. The young man had been sick for a few days and had just started having shaking chills with a temperature over 104. I walked in, took one look at the man in his 30’s and said, “You need to be in the hospital.” He asked if he could treated in the office and I told him the only debate in my mind was whether to call 911 or let someone drive him. He was septic. Gram negative bacteria were found in his blood stream. When he walked into my office he was hours from death.

Friday morning saw a man come in for a refill on his blood pressure medications. The PA thought he didn't look right and asked me to take a look. I had known the man for years and the change in appearance since his previous visit was striking. He was severely jaundiced. He was admitted to the hospital with liver disease and a potassium that was dangerously low, low enough to trigger an irregular heart beat.

An hour later the PA grabbed me again as I came out of a room. There was another patient she was worried about. The man in his 60’s had mild chest pressure but an elevated heart rate in the 160’s. Although his blood pressure was normal and he did not feel that bad I had the staff call 911. The paramedics were there within a few minutes. They bundled him up and put him in the ambulance. Shortly after pulling away from the curb, his heart rhythm changed to ventricular tachycardia, a life threatening rhythm that can lead to sudden death. He needed to be shocked back into a normal rhythm. 

When I went home Friday afternoon I was emotionally drained. I do not typically have so many near misses in such a short period. I found myself thinking about how easy it would have been to miss these diagnoses. If we had waited to order lab tests, not pushed for the colonoscopy, given the septic patient oral medications instead of sending him to the hospital, refilled the BP meds and scheduled a follow up or not called paramedics, patients could have died. I was grateful that I have a PA who is diligent and excellent and that together we had come through for our patients.

Each case reminded me of the importance of relationship in medicine. The young man with abnormal labs is alive because I knew him and remembered his lab work from three years earlier. The man with the colon polyp trusted me as his primary care physician and as a result followed my advice. I had seen the septic patient before, and as a result I could tell in seconds that he was not himself, as I could with the man with the liver disease and jaundice. While relationship did not aid me in the diagnosis of the heart rhythm, it was the reason he was seen immediately when he called the office. 

Relationship is being devalued in health care as patients change insurance every few years and are forced to seek new doctors and hospitals. This week reminded me that relationship matters.

-Bart

Love and Hate on Yelp

You can learn a lot by reading reviews on Yelp. While you can learn a little about the menu of a restaurant or the quality of service from a physician’s office, you can learn a lot about the person writing the review. You can learn a lot about our culture as well.

A physician colleague received a one-star review because the receptionist asked for a co-pay when a patient came in for a physical. The patient got angry, left the office and wrote the scathing review, calling the office “Dispicable.”

I received a one-star review from a patient who did not like the advice I gave. It may not have been brilliant, but it wasn’t like I told him to take poison or perform a coffee enema. Looking at one of his other reviews helped me understand. He also gave a one-star review to a strip club. Apparently he was upset at the “no touch” policy. For the first and only time in my life I have something in common with a strip club. In the eyes of this man we are both out of touch.

The Yelp page for a mechanic in town reveals something else about our society. We are a love it or hate it culture. His shop has 139 reviews, all but 7 of which are either 1 star or 5 star reviews. How can this be true? It can’t be. It is close to impossible that his service is always either terrific or terrible, the law of averages dictates that there should be occasions when he is just "okay." The reviews can't all be true. What is true is that we tend to publicly express our opinions in hyperbole, and that we are more concerned with persuading than we are with being completely accurate. When people post reviews it is not about informing a reader, it is about persuading others to join us in our love and hate.

Negative reviews reveal another dark aspect of our culture. We are often more concerned with ourselves than others, more concerned about avenging a perceived slight then we are at being understood. I read several one-star reviews written by people who had not actually utilized the business they were reviewing. A bad interaction with a receptionist, a missed appointment or dislike of a policy led a person to choose to leave the business. Even though their knowledge of the quality of the business was incomplete, they felt comfortable telling the world to stay away.

Perhaps the saddest observation is how disconnected we are. Most of the businesses reviewed on Yelp are small ones. Small businesses are not things, small businesses are people. People struggling to make a living and provide for their families, people who do not have business degrees or PR managers. Many small business owners are learning as they go. Scathing and spiteful reviews written over small misunderstandings reveal a culture in which people do not matter as much as things do. The lack of grace, the refusal to give the benefit of the doubt or to seek reconciliation, and the personal nature of many of the attacks is truly saddening.

Online reviews are here to stay and negative reviews are inevitable. As a businessman I understand that I have no control over what people say about me. Nevertheless I do have control over what I say about others. I can and will make it my goal to be truthful and  accurate in what I say, and as much as possible, to be kind, for my reviews say as much about me as they do about a business.

-          Bart

Our Newest Dilemma- Deciding What Bathroom to Use

To pee or not to pee. That is the question.

North Carolina recently passed a law about bathrooms. The text of the law is 5 pages long, but it essentially states that when it comes to multiple occupancy bathroom and changing areas (such as locker rooms) in government controlled facilities, people will need to use facilities that correspond to their biological sex. Boys must use male facilities and girls must use girl facilities. It also prohibits law suits against private entities that institute similar policies.

The response to the law has been one of vehement anger by many corporations, individuals, celebrities and politicians. Those who support the law have been labeled as hateful and bigoted. Curt Schilling, a former All-Star baseball pitcher, lost his job with ESPN for tweeting in support of the law. Is it is easy to wonder how our society came to arrive at such a place.

I grew up in an era where the girl’s bathroom was a place of mystery. No male dared enter the girl’s bathroom for fear of eternal punishment. Accidentally walking into the wrong bathroom was one of the most shameful acts imaginable. It could take years for the facial redness to fade.

Shame was not limited to opposite sex facilities. As an adolescent male there was more than enough shame for a boy in the boy’s locker room. Puberty is cruel and it arrives on an inconsistent schedule. In the 7th grade locker room some boys were already men while for others signs of manhood had not even begun to appear. While I have no firsthand knowledge of the girl’s locker room I am certain there was similar variability. Young women at opposite ends of the pubertal spectrum dealt with similar angst. The thought of changing in the presence of someone with the opposite biologic gender would have been terrifying!

Yet a new variable is being introduced into the locker room equation, a transgendered one. Individuals born male (with male genitalia) who identify as female have sued school districts for the right to use girl’s locker rooms. Their belief is that it is unfair for them to not be able to have access to the same facilities as all of the other “girls”. Many of the other girls, who do not have penises, have expressed discomfort with having to change in the presence of someone who does. Remarkably, a federal court sided with the transgender student and against the district.(1)

The battle is not limited to middle and secondary schools. Elementary schools have been met with similar law suits. While there are typically no common circumstances in which fully disrobing occurs in elementary school, there have been arguments regarding bathroom use. Parents are understandably concerned that their young children who have not yet learned about the birds and the bees may not be emotionally equipped to process transgender issues. The problem is compounded by studies that have shown the overwhelming majority of “transgender” school age children ultimately identify as their biological sex. (2)An argument can be made that given the potential harm there is no need to accommodate what is likely to be only a temporary preference.

There are different concerns when it comes to adults. For the overwhelming majority of adults who are transgendered the reality is that if they have taken steps to appear as the gender with which they identify and use a bathroom stall there is very little chance of anyone even knowing their biological identity, much less objecting to it. Even if the law “prohibits” them from a facility the risk of prosecution is miniscule. The risk most often cited by proponents of laws such as North Carolina’s is instead the possibility of sexual predators taking advantage of the opportunity the law affords and preying on innocent women. While the risk of sexual assault is minimized by those who oppose the law, it is nonetheless real. There are documented instances where such assaults have occurred. (3,4)

Lawmakers are left with a difficult decision. Apart from the extremely costly and unrealistic option of mandating that all facilities be single user and non-gendered any policy implemented will favor one side of the debate over the other.

An often overlooked part of problem is the rarity of transgenderism (estimates I have seen range from 1/3000 to 1/12,000 or less). Rarity results in it being very difficult to make any scientific assertions as to the normalcy of the condition. It also makes it less reasonable to demand governmental protections. Even if a biologic cause is ultimately discovered it will not necessarily constitute evidence of normalcy, for there are many genetic conditions that are considered abnormal (sickle cell anemia, cystic fibrosis and other such diseases). Normalcy for such things is always a matter of value judgments rather than facts.

It is obvious that there is no solution that will be universally acceptable. There is nevertheless a common sense answer available. If a policy or practice has been followed for centuries without significant or widespread negative consequences, and there is not overwhelming evidence that it should be changed, it is best to leave it alone. A law such as the one in North Carolina should not be necessary but it is. The definitions of male and female that have been the foundation of societal relationships since the dawn of humanity need to be defended, as does the innocence of our children.

-          Bart

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1.       http://www.chicagotribune.com/news/local/breaking/ct-transgender-student-locker-room-palatine-met-20151012-story.html

2.       Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 2008; 47:1413.

3.       http://www.crossmap.com/news/sexual-predator-jailed-after-claiming-to-be-transgender-to-assault-women-in-shelter-26962

4.       http://www.dailywire.com/news/330/university-toronto-dumps-transgender-bathrooms-pardes-seleh