After Orlando, Some Questions

Is there anything we can do to prevent another terror attack? Must we resign ourselves to a future where mass murder is the norm? Why can't our government protect us?

The answer to the first question is challenging, as it is dependent on an understanding of the actions and behaviors of the murderer. As is often the case, gun control legislation (or the lack of it, depending on your perspective) is a main topic of discussion in the immediate aftermath. In the days before the killing the terrorist purchased weapons and ammunition at a Florida gun store. He did so in compliance with existing gun laws in the state. Demanding that it be impossible for people "like him" to purchase a weapon is an understandable response, but it is not as easy as it sounds.

Two of the worst mass shootings, in San Bernardino and Newtown, occurred in states with strict gun laws. The guns were not purchased by the killers so no background check or watch list would have made a difference. The murderers found a way to get the weapons they wanted. This is an important point to remember. Individuals determined to commit mass murder are not going to be concerned with violating gun laws and will find some way to achieve their goal. We tend to forget the weapons used in the Boston Marathon attack were pressure cookers, nails and ball bearings. While gun control legislation may cause citizens to feel as if something is being done, little will be actually accomplished.

In the aftermath of the Orlando shooting discussion as also centered around the purported failure of the FBI to act on reports about the shooter. Two separate investigations of the killer were conducted. Apparently these were not insignificant investigations and included multiple interviews of the suspect, as well as co-workers and other contacts. One report indicated that the killer was also placed under some degree of surveillance for a period of months. While there was evidence that the killer had made threatening statements and expressed support for terrorist organizations there was no clear evidence that he was planning an attack. He appeared to be one of a number of Muslim Americans who verbally support terrorist views. As disturbing as this is, it is not a crime in America and the investigation was dropped.

Some might say that the FBI or other law enforcement officials should keep such individuals under ongoing surveillance and observation. Basic math illustrates the problem with such an approach. There are nearly 3 million Muslims in the United States. If 1/1000 of them are radicalized or potentially radicalized, that would amount to 3000 individuals. Counting support staff, it could take as many as 10 people or more to place someone under constant surveillance. That is 30,000 FBI agents. As the FBI only employs 35,000 people, and there is no way to clearly identify who needs to be watched and who doesn't, it is clear that the FBI cannot completely protect us. Identifying, monitoring and reporting individuals who sympathize with terror cannot be done by the government, it can only be done by citizens.

The people best positioned to help weed out the evil in our midst are the people who have ongoing contact with those who might wish to do us harm. As the terror problem is almost exclusively a Muslim problem any meaningful solution will have to include members of the Muslim community. It is time for Muslim clerics to speak out against not only acts of terror but against the ideology that breeds them. Leaders in the Muslim community need to work together to eliminate radicalism from their midst. Hateful acts begin as hateful thoughts borne out of hateful ideology. If Islam is truly a religion of peace it needs to go to war against the evil done in its name. 

The question of whether or not we must be resigned to mass shootings is dependent on many factors. Foremost among them is the duty of individuals to protect themselves. Every mass shooting reiterates the truth that law enforcement cannot save us. If we decide to rely on law enforcement alone we will continue to see tragedy occur. We need to be a society of vigilant citizens. We must also give consideration to being a society of individuals trained and equipped to defend ourselves. There is a reason that the majority of mass shootings occur in gun free zones. 

Finally, our government cannot protect us. Large entities are best equipped to defeat large threats. Massive bureaucracies are not nimble or quick enough to eliminate small threats and lone wolf attacks. We are not being attacked by uniformed armies landing on our shores. Individual enemy combatants are appearing on our doorsteps. Americans will need to rise up together to fight this. To do this will require us to speak the truth about the war we are in, the enemy we face and on how we all can contribute. This is not a war that will be won with hashtags or rainbow colored profile pictures. This one is on all of us.

 - Bart

Lessons From Social Anxiety

I think I have the world’s strangest form of anxiety disorder. I can stand in front of hundreds of people and speak without batting an eye. On a daily basis I have intense conversations about major life issues with patients from multiple different backgrounds without a tinge of nervousness. But if I am invited to a small social event or a dinner with people I do not know well I am a nervous wreck. I get sick to my stomach before the meal even begins.

I do not often show my nerves during the actual events and my wife is the only one who can tell that I am uncomfortable. I join in the conversations, tell stories and crack jokes, all the while wondering if I have said anything inappropriate or unknowingly offensive. I typically spend the drive home rehashing the evening, spending more time wondering what other people may have thought about something I said than I do on the actual events.

I found myself reflecting on my social anxiety after a recent church event. Everyone was kind and there was not a harsh word spoken yet my customary sense of inadequacy was waiting for me in the car ride home. As I thought about my feelings I wondered if others may have similar struggles. I wondered if anyone else present had been similarly anxious.   I thought of those who had declined their invitations and not come at all and wondered if some of those who were “unable to make it” were in truth “unable to deal with it.”

I realized that I had never considered the possibility that there might be others present with similar feelings and fears. As is often the case my anxiety limits my ability to consider and respond to the feelings of others. I have always assumed that I am the only one feeling inadequate in a given situation. As I reflected on the evening I gained a new understanding of the tendency for some people to form cliques, to migrate toward those they know well and to seem to wall off those with whom they are not familiar. Actions I have often considered to be selfish and inconsiderate might actually be about emotional safety.

I wonder if there might not be two social assumption traps into which we typically fall. The first trap is the assumption that no one is like us, the second trap the assumption that everyone is like us. I have fallen victim to the error of assuming that everyone in the room is comfortable except for me, that I am the only nervous person present. I wonder if others who are comfortable may wrongly assume that everyone is as comfortable as they are and also be oblivious to those who are struggling.

I wish I could sat that I have come up with a brilliant solution to the dilemma I have identified but I can’t. The only response that seems to be appropriate is grace. I need to be more gracious in my assumptions about what others are thinking. I need to choose to believe that people are not thinking negatively. On those occasions when others do think negatively, I need to be forgiving, realizing that they may be struggling in the same way I am. I need to be gracious to those who are quiet, gracious to those who talk too much, and gracious to those who I do not understand, for we are all alike in one important way- we are all imperfect, and we all have room to grow.

- Bart

You can subscribe to the blog by clicking the link on the page, each new post will be delivered via email. I can also be followed on twitter @bartbarrettmd. Comments and questions are welcome!

We Need More Shame in Christianity

As I do with most new patients, I asked him how he had heard about my practice. He gave the current most common answer, saying he had found me online. He told me that he had read several reviews and visited my office website and that he liked my approach and the values I expressed. I mentioned that my approach and values stemmed from my faith, from the belief that I should treat others as I would want to be treated.

“I figured you were a Christian based on your views,” he smiled, proud that he had deduced correctly (I do not make any specific faith references on my office website.) He went on to tell me that he was a Christian and that he attended one of the large churches in the area. He shared that both he and his girlfriend really liked the church. As evidence of his faith and commitment to the church he told me that he had already signed up to attend the church's upcoming men’s retreat.

As we finished our introductory chat my attention turned to the history form I have all patients complete at their first visit. It has questions about past illness and current conditions, previous surgeries and hospitalizations, medications and allergies and family medical history. At the bottom of the page is a section for the “social history”, questions about habits such as smoking and alcohol use, as well as work history and sexual history. I noticed that he had checked the box indicating he had a normal sex life. I asked him if he and his girlfriend were intimate.

He understood the implications of my question. He knew his sex life did not line up with the beliefs and values he had proclaimed to me just a few moments earlier.

“Well, we all have things that we need to work on,” he offered in explanation.

“Indeed we do,” I replied, “but this is a thing the Bible is pretty clear about. If you are Christians who are committed to one another, why not get married?”

“We have talked about it,” he answered, seemingly implying that it was acceptable to ignore Scripture and engage in sin for short periods of time. It appeared that in his thinking having a plan to change his behavior at some point in the future meant that his heart was in the right place. Although such reasoning is easily deconstructed I did not think it appropriate to put him more on the spot. 

Although our conversation was not lengthy I found myself thinking about it many times in the weeks that followed. What struck me was not that he was living according to his own rules (I see this on a daily basis) but that he was shamelessly living in contradiction to his boldly stated beliefs. He was not at all bothered by the blatant hypocrisy he displayed. It appeared that in his version of Christianity actions were irrelevant and that all that mattered was his words and intentions. His thinking seemed to be that all his faith required of him was to admit that his behavior was wrong. Feeling badly about his behavior was not needed, shame was irrelevant and changing his behavior was not even a consideration. 

Sadly, I am beginning to realize that this young patient is representative of what passes for Christianity today. The teachings of Orthodox Christianity about the holiness of God, the sinfulness of man, and the need for us to repent of our sinful behavior (actions done contrary to God’s will) are being cast aside for a new type of Christianity. This new religion emphasizes love and acceptance for each person “right where they are.” In this new version of Christianity there is typically no need for guilt and shame. Guilt and shame are only appropriate for the really “bad” sins like murder, not for the sins that “everybody” does.

The problem with this new form of Christianity is that it is not Christianity at all. If the essential components of the faith are set aside what remains is empty and valueless.

I have no interest at all in this cubic zirconia version of the faith. I do not want to be accepted just as I am, for I am an anxious, selfish, short-tempered person who frequently is ignorant of the feelings of others. I do not want to waste one millisecond defending my faults or justifying my sins. I want to be better, to be different. I want to be transformed. I understand that every sin is terrible, and that is why Jesus died. Because I believe this I cannot continue to live in sin. 

Because I hate the bad that I do I have consistently prayed for help in changing. God has heard my prayers. The greatest testimony I can share is not the sermons I preach or the good deeds that I do. The greatest testimony is the change wrought in my life by God as I have refused to accept my shortcomings and instead confessed them, and with his help, addressed them. It was shame and sadness over my tendency towards anger that began the process of casting my anger aside. It has taken years, but I have changed. It is a blessing to know that when my longest tenured employee talks about how I used to lose my temper my nurse of the last two years says she can’t believe I  was ever like that.  Shame brought blessing and change.

Grief over our sin is important. I can't help but wonder- if we Christians showed more concern for our own sins than we did for the sins of others, if we hated our sins enough to forego excuses and cast them aside, could we have a greater impact on our world?

-Bart

When Every Day is Memorial Day

When I saw that she had “liked” a post on my office Facebook page I clicked on her name. I was taken to her Facebook page where I saw an amazing picture. It was of her, embracing the marker on her father’s grave. She had never mentioned him, perhaps because he had died when she was a little girl.

The grave marker read “Leonard G. Svitenko, Captain USAF”. Curious, I Googled his name. I learned that he died in the service of our country, the lone fatality in one of the most significant events of the Cold War. He was 27 years old.

In the early 1960’s the Cold War was at its peak. American leaders viewed the Soviet Union as a constant threat and the fear of nuclear attack was constant and real. The United States had an Air Force Base in Greenland that was tasked with monitoring radar for Soviet missle launches. In order to be able to rapidly respond to a nuclear attack, US bombers equipped with nuclear weapons were continually in flight over Greenland. Captain Svitenko was the copilot of such a flight in January 1968.

Prior to take off a member of the flight crew stored some seat cushions under a seat in the back of the plane, seemingly unaware that they were in close proximity to a heater vent. During the course of the flight the plane's heater was malfunctioned. Halfway through the scheduled flight Captain Svitenko was relieved to take his schedule rest break. As the temperature in the plane continued to drop, the officer in the co-pilot’s chair opened an engine valve to allow for heat to enter the cabin.

Another malfunction allowed the air flow from the engine to enter the cabin unfiltered and extremely hot. The stored seat cushions caught fire. By the time the fire was discovered it had progressed to the point where it could not be suppressed with the onboard fire extinguishers. As the cabin filled with smoke the decision was made to evacuate the aircraft.

The crewmen who were in seats ejected safely. Captain Svitenko, who had given up his seat, attempted to exit through a bottom hatch. He didn’t make it. He suffered fatal head injuries as he tried to leave the plane.

The plane crashed. Although the nuclear weapons did not detonate, their payload dispersed in the crash and contaminated the area, resulting in an international incident. The radioactivity and policy of continuous flight received a lot of attention in the following months but the incident ultimately faded out of the national consciousness.

The nation may not remember the death of Captain Svitenko, but his family does. His daughter grew up without her father. She is one of the millions of Americans throughout our history who have experienced first hand the high price of military service. Although Captain Svitenko was not a combatant in a war and did not die in direct engagement with an enemy, he nonetheless died in defense of our nation, doing his part to keep his country safe.

On Memorial Day, may we all take the time to honor the sacrifices of servicemen and women like Captain Svitenko, those who believed in service, in freedom, and in duty and who proved their commitment with their lives. My we also pray for their families, those who remember the sacrifices every day of their lives.

- Bart

Demented. Demanding. Depressed

She was worried. She had lost 20 pounds in a matter of months, her blood pressure was elevated and her blood sugars were out of control. Her worry had led her to walk into the office without an appointment. As abnormal blood sugar can be dangerous in the short term (especially if it is low) this was what I focused on first.

“What have your blood sugars been?” I asked.

“I don’t know, they have been all over the place,” she replied.

“Do you have the numbers with you? Did you write them down?” I asked, hoping for some data I could rely on.

“I don’t have them with me, I left them at home,” was the discouraging answer.

The remainder of the visit was even more discouraging, which did not surprise me. I knew her answers would be unreliable. I had diagnosed her with early dementia months earlier.  At that time I had my staff call her son and ask him to come for the next visit. That visit had occurred a month before the day she walked in without an appointment. At that time I shared with them that I did not feel it was safe for her to live alone any longer. I told her son the she had not remembered to get blood tests done ordered a month prior and that it seemed her forgetfulness was worsening. Since she was a on over 10 medications for nearly as many diagnosis, I was very concerned about her safety. She clearly needed help.

When she walked in worried about her blood sugars I had not heard anything from either her or her son for over three weeks. The blood tests had still not been done, so I was in the dark about her long term diabetic control, kidney function, thyroid levels and blood chemistry. All I had to go on was what she told me and that was completely unreliable. She was also still living alone. 

She was truly concerned and worried about her blood sugars and I felt I needed to communicate that I wanted to help her but I needed more information. I told her I could not make any changes to her medical treatment because I could not be certain that she was taking all of the medications as prescribed. I did not know what changes to make because I did not know that her current status was.

I gave her instructions and wrote them down as simply as I could. I told her to get the blood work done in the morning and then to return to the office two days later. I asked her to bring her medication bottles and her blood sugar measurements when she came. I stressed the importance of each instruction as clearly as I could. She had an elderly friend with her and I stressed it with her as well. After she left I had the office call the son so I could share my concerns with him. They reached his voice mail but left a message asking him to call us back right away.

A week later she called the office. The blood work had still not been done and she had not come in for the follow up visit. Her son had not called us back either. This was disappointing but not surprising. What was surprising was the reason she gave to the receptionist for not coming back- “I know Dr. Barrett never wants to see me again.”

It seemed her memory was worse than I thought! Apparently my words that "I can't treat you without more information" had been remembered as "I can't treat you."

We tried again to reach her son. He did not return our calls, but his wife did. Unfortunately the patient had never given permission to discuss her care with anyone but her son, so I could not speak with her daughter-in-law. The staff told her to have her husband call as soon as possible. When 24 hours passed without a call I organized an impromptu office meeting to discuss what we could do to help her. I had one receptionist call the medical group to see if we could urgently send a social worker out to her home. My other receptionist, who had worked for years in a neurology office, suggested we call Adult Protective Services to see if they could help. “Do it!” Was my reply.

Within a few minutes I was on the phone with the APS case worker. I told her that my patient was a diabetic who lived alone, that I was worried about her taking her medications correctly, that she was demented and I was concerned for her safety. I told her that I had left a message for her son and had not heard back for a week. She said they would send someone out within a day. I hung up the phone thinking I had done all I could.

The following day I learned that that not everyone agreed with me.

Her son walked into the office the next morning, seething with anger. I was not in the office, so he proceeded to loudly tell the receptionist that I had abandoned his mother by telling her that I did not want to see her any longer. He said I had committed malpractice and that he was going to report me to the medical board. Not knowing what to do, the staff called me at home. I asked them to put him on the phone, hoping I could calm his anger. I attempted to explain the misunderstanding and my concern for his mother but his mind was made up. As far as he was concerned I was an arrogant and prideful doctor who had abandoned his mom. After over 10 minutes on the phone and multiple insults and accusations I gave up, finally telling him that his anger did not change the fact that I thought his mother was a wonderful lady and I was concerned about her. He made it clear that I would never see his mother again and hung up the phone.

Although they had dismissed me as their physician I made several phone calls over the next few days making sure that the social worker made it to the home and that her new doctor would see her as soon as possible. I made the calls with a great deal of sadness.

I wish I could say her son's words did not effect me but they did. On several occasions in the days that followed I found myself replaying events in my mind, wondering if there was anything I could have done differently or better. While I do not know what I could have done to better resolve this patient's situation I have gained a greater understanding of the importance of supportive and accepting families in the care of those with dementia, and of how denial can complicate matters. 

- Bart

Thanks for reading, and a special thanks to those who share posts with others. You can have future posts delivered to your inbox by clicking on the subscribe link. Comments and questions are always welcome. I can also be followed on twitter @bartbarrettmd.