When does Serving Become Enabling?

Get a group of Family Doctors together to talk about improving patient outcomes, any outcome, and one question is certain to come up, “What is the patient’s responsibility?”

Doctors are measured against a number of standards. Each month I get reports on the percentage of my patients who have had colon cancer screening, mammograms and pap smears. For diabetic patients the list is extensive and includes blood pressure control, cholesterol medications, blood sugar control and whether or not the patient has been screened for kidney disease.

In my office, staff members review the reports and make phone calls and send out electronic reminders to encourage patients to get the necessary tests and treatments. Every time I look over the list of names and review the charts I see that regardless of the test or screening all of the patients have something in common. Every one of them has been previously told what the tests were and been given the necessary orders and referrals to get them done. They just haven’t bothered to do it.

It is a source of unending frustration for doctors. We went to school to be doctors, to care for disease and provide treatment to patients under our care. None of us signed up to be patient care reminder professionals. Yet that is what we are becoming. My medical group recently announced a new quality measure that illustrates the absurdity of it all. We are now being measured according to how consistently our patients pick up their prescriptions at the pharmacy. Telling a patient to take a medication daily and sending the prescription to the pharmacy is not enough. If they don’t pick up their refills consistently we are held responsible!

Too many patients do not prioritize their health and instead expect their doctor to pick up the slack. Several months ago a diabetic patient came to our office for an initial visit. We started a new blood pressure medication, ordered the appropriate lab work and asked the patient to return in a month. Four months later the patient returned. The blood work had not been done, so the order was sent again to the lab.

Two months later, 6 months after the initial visit, the patient called the office requesting a refill of his medications. I checked the chart and saw that the patient still had not been to the labs. Reluctantly I decided I needed a firmer response. I left a voice mail and sent an electronic message saying that we wanted to partner with him in the care of his diabetes but that he had failed to follow our recommendations in spite of repeated calls from our office. I told him I would refill his medications for 5 days to allow him time to get his blood work done and be seen in the office and that no additional refills would be given until he was seen.

Nine days later on a Saturday I received a page from the patient. He had been to the lab that morning but he was out of his medications and he wanted an urgent refill. I was unable to hide my frustration when I returned his call. I reminded him that I had told him that he had to get his labs done and be seen in the office but that he had failed to follow my advice.

“So you are going to deny a diabetic his medication?” was his angry reply. My reminder that his lack of medication was a result of his personal choices did not go over well. He started to argue with me and I wondered what to do. I finally decided to offer a compromise.

“I’ll give you three days of medications and see you in the office Tuesday morning,” I said. He begrudgingly agreed. Before hanging up the phone I shared with him a truth that I often share with similar patients saying, “You know, If I care more about your diabetes than you do, there is something wrong.”

What was wrong with this patient is what is wrong with many patients. For a multitude of reasons, many of them understandable, patients fail to take care of themselves and to follow recommendations. Twenty years ago they alone suffered the consequences of their poor decisions. What few of them understand is how their poor decisions impact the physicians providing their care and how these consequences put a strain on the doctor/patient relationship.

As a physician who is committed to providing the very best care for his patients I find myself frequently wondering if I am enabling instead of serving, if there is a point when going the extra mile is actually a disservice to my patients, and how to determine when that point has been reached.

Although I think this patient may have reached it…

-          Bart

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When Schools Can't Be Trusted

The words on the page took us by surprise. The graphic description of the rape of a young boy was not something we expected to find in required reading for our 15 year-old daughter. We did not expect the faculty of a public school to go out of their way to encourage morality or protect the innocence of students but we did not expect that vulgar material would be chosen and assigned.

I arranged a meeting with the teacher and the principal to bring my concerns to their attention and see if there was a possible remedy. My concerns were summarily dismissed. While I expected my concerns to be ignored the reason given for the choice of reading material was not expected at all. One of the teachers said, “It is our job to expose children to mature content.”

I did not hide my anger well when I replied, “No, it is your job to teach them how to read and write. It is the parent’s job to decide what children should be exposed to.” The reality that teachers and administrators believed it was their responsibility to determine when and how children should be exposed to sexual content was deeply disturbing to me. The belief seemed to be that it was up to parents to simply shut up and go along, to allow the “experts” to teach morality to their children.

I had two goals in meeting with the principal and teachers. The first was to get an alternative assignment for my daughter. The second was to get them to reconsider their policy on assigned reading. While I was able to get an alternative assignment for my daughter, I eventually gave up the second  fight, convinced that there was nothing I could do to change the minds of the faculty and administrators.  For the remainder of her years in school I did my best to teach Biblical values to my daughter and to teach her how to determine right and wrong. There were a number of times when that meant correcting things her teachers said but I did not make any further formal protests. She graduated from high school a few years ago and the issue faded from my mind.

The issue returned to my mind this week. Recent developments in the state of Washington reveal that the sentiments expressed by my daughter’s teachers are not isolated. It seems that the belief that public schools are responsible for determining when and how children should be exposed to sexual concepts is widespread.

The State of Washington’s recently released K-12 learning standards include a section of “core ideas” to be a part of the sexual health portion of the health and safety education of elementary age students. It is suggested that kindergarteners “understand that there are many ways to express gender” and that by second grade children should “understand there is a range of gender roles and expression” and that by grade 4 children should be able to “define sexual orientation.” In the eyes of educators, hand washing, tooth brushing and basic nutrition are no longer enough. 5 year-olds need to be introduced to the concepts of gender identity.

The presumption that all children need to learn these concepts at such a young age is absurd. There are many families who try to protect the innocence of their children. I did not know where babies came from until I was 11 years old. My son was 10 when we had “the talk” and he was clearly overwhelmed with the concept. I did not think he was emotionally ready at that age but was compelled by the reality that his elementary school was going to have a class on the topic the following month. I had to change my parenting plans because of a school program.

Parents who wish to defer exposing their children to sexual concepts are going to find themselves increasingly at odds with their school districts. According to the state of Washington, almost all children as young as 9 are all old enough and mature enough to be able to understand sexual orientation. The fact that a significant percentage of families of faith do not believe that all sexual orientations should be expressed and acted upon seems to be irrelevant. It is the responsibility of the public system to teach morality. 

I am left wondering how it is that our society has evolved to this point. Public schools across the nation are failing in their essential responsibilities to teach children reading, writing and arithmetic, but they are deciding to take on the additional responsibility of teaching young children about sexuality. More remarkably, parents are allowing it.

It is clear that concerned parents need to be increasingly involved in the education of their children. Parental responsibility extends far beyond simply making sure students get their homework done and have good attendance. Parents need to know exactly what their children are being taught and be willing to stand up for their innocence. It is likely no one else will.

Bart

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reference: http://www.k12.wa.us/HealthFitness/Standards/HPE-Standards.pdf 

Christian Universities in the Crosshairs

Politicians lie. I have known this for years but the breadth and depth of political falsehood continues to amaze me. Politicians lie about their experiences, their agendas and even their beliefs. One of the common lies is about the purpose or impact of legislation. A current law being considered in California, SB 1146, is a law based on a lie.

SB 1146 is a law that has as its stated intent the elimination of discrimination against individuals who are LGBT which is currently a popular issue among progressive politicians. While this is the stated goal of the legislation its actual goal is more sinister. It is a major step in what appears to be a goal of crippling Christian Universities.

Many of the most prestigious universities in America began as religious institutions. When Harvard was founded in 1636 it trained Puritan clergy. Yale was founded in 1701 to educate ministers in the Congregationalist faint. Princeton was also a school for minsters when it was founded in 1746. Jonathan Edwards, the preacher whose ministry launched the religious revival known as the Great Awakening, was at one time the president of Princeton. Over the years these great universities have become increasingly secular, so much so that most Americans are not even aware of their religious heritage.

While religious training, in the classical, biblical sense ceased to be important to these institutions it continues to be valued by many Americans. A large number of private Christian Universities have come into being with the goal of providing young Christians with a university education in the context of a Christian worldview.

These colleges do not limit their education to merely religious instruction. While all include courses in the bible, they offer degrees in a wide variety of disciplines, including degrees in the biological and physical sciences, engineering, computer science and the humanities.

Students are attracted to these private universities for many reasons, both faith based and practical. Students are drawn to campuses that align with their personal values and beliefs. Codes of conduct and morality which discourage sex outside of marriage, alcohol use and other behaviors are attractive to parents.

It is these codes of conduct and morality that have drawn the ire of legislators in California. Schools that adhere to traditional Christian teachings will by definition be opposed to LGBT lifestyles. The obvious solution to this dilemma would be for those individuals who are of the LGBT persuasion to not enroll at a Christian university. This solution is obvious but completely unacceptable to California legislators. They are determined to force Christian universities to change their approach.

The proposed law would require all Christian universities not directly owned and operated by an established church, and whose students receive any form of governmental assistance, grant or scholarship, to notify all current and prospective students that they do not comply with federal anti-discrimination law under Title IX. This notification must be included in all handbooks, policies and recruitment packets sent to students. Failure to appropriately notify students is grounds for civil action.

It does not take a law degree to understand the ramifications of such a law. Individuals who disagree with a university’s moral stance will apply for admittance and sue if any mistakes are made. The same tactics that have been used against Christian baker’s and florists who declined to participate in same sex weddings will be wielded against the schools. The cost of litigating the inevitable lawsuits will be a significant strain on university budgets.

The only way a Christian institution can absolutely protected from such actions would be to end participation in government financial aid programs. As a large proportion ofstudents are dependent on these programs, the loss of this source of financial support would make Christian schools unaffordable and enrollment would decline. Christian universities are left with no viable options. They can deny their faith and their teachings or they can face financial distress and potential ruin.

California legislators have been fully educated on the ramifications of SB 1146. As a result no one can claim that the harm to Christian schools is an unintended consequence of well-intentioned legislation. The intention of the progressive legislators in California is clear. They want to punish those who do not share their worldview. Anyone who says otherwise is not telling the truth.

Bart

Thanks for reading. If you share my concerns about the impact of SB 1146, please share this post with others and consider contacting your state representative. 

Going Through Life With Blinders On

His life could be better, if he took the time to actually focus on it. Unfortunately  he was too busy to prioritize his health. He had high blood pressure and cholesterol but did not exercise or watch his diet as he should. He battled anxiety and took medication every day to keep it in check. I recommended counseling and he agreed that it would be helpful but did not see how he could fit it into his schedule.

I wondered if he had people in his life who could encourage him and help him with his priorities so I asked him about other sources of emotional and spiritual support, if he had any faith or was a member of any church. He told me he had been raised Catholic but had left the church many years before in the wake of  a scandal involving one of the parish priests. He didn't have much use for faith any more and didn't give God much thought. He was too busy going through life, doing his job, raising his children and supporting his family.

He told me that he went through life with blinders on. He figured that he was a pretty good person, that he was doing his best and that he was therefore confident that he would be okay with God, if there was one, when the time came. He didn't believe in an afterlife but thought if there was one it would be good to see bad people get what they deserved.

As he spoke I realized his words embodied the majority of American’s religious  thinking.  His theology was completely his own, an individualized belief based on personal opinion and unfounded hope. He had never tested his opinions or explored his beliefs. His worldview was convenient, comfortable and superficial. It could not withstand even superficial scrutiny, which did not matter because he never allowed it to be scrutinized. It was what he chose to believe and no one had the right to challenge it.

I tried to encourage him to think a little more deeply about life by sharing with him the observations of Ravi Zacharias, a leader in Christian thought and apologetics. Ravi says that for any worldview to be valid it must answer the four great questions of life, the questions of Origin, Meaning, Morality and Destiny.

Origin- Where did we come from? What is the source of matter, energy and life? 

Meaning- Why are we here? What is the purpose of life? What are the goals of existence?

Morality- How do we define good and evil? Why does evil exist and where does it come from? 

Destiny- What happens to us when we die?

I should not have been surprised that these questions had no impact on him. It is a lot easier to go through life pretending there are no questions than it is to search for answers. The problem he will face is that these questions do have answers, truths that exist independent of his interest or belief, truths for which all men, including him, will one day have to the give account.

His refusal to address his physical issues may result in serious harm later in life. His refusal to address spiritual issues will impact him in the life to come. 

Someday, the blinders will come off. 

- Bart 

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Good Dad, Bad Dad, Disowned by Dad. Happy Father's Day.

I was a little nervous as I walked to the bulletin board outside my professor’s office. The final grades had just been posted for his class, the last grade of my first year at UCI as a biology major, and I desperately wanted an “A”. I was one “A” away from what had seemed to me an impossible achievement, a 4.0 grade average for my first year in University.

I grew up in an abusive home where I was repeatedly reminded of every awkward deed and innocent mistake. The persistent put downs and constant mocking had left a mark. I constantly doubted myself.  I started university hoping against hope that I had what it took to make it into medical school, not at all confident I did. Straight “A’s” had not even entered my mind.

I reached the bulletin board. My eyes found my student ID number and scanned across to the grade column. “A”. I had done it. I let out a yell and hurried to find a pay phone to call my wife. (This was 1984 after all) “I did it!” I yelled into the phone, fighting back the tears. The conversation was brief as I wanted to share my joy with others. I hung up and dialed my father’s number to give him the news, certain he would be proud. I blurted out, “I just got my last grade! I got a 4.0 for the year!”

His words were a punch to my stomach, “Wow. I honestly didn’t think you had it in you.” My father didn’t believe in me. I hung up the phone deflated and hurt.

7 years later I graduated from medical school. All of my family, including my father, were in the audience as I walked across the stage to receive my degree. I received my diploma from the dean and turned out to the audience to search for my family. I saw my dad first. He was standing on his chair, head and shoulders above the rest of the crowd. He was pumping his fist in the air, a huge smile on his face, overwhelmed with pride for me.

These stories are two of my most vivid memories of my father and illustrate the enigma that he is. On many occasions he was a viciously and abusively mean, reducing me to fearful tears. At other times he could be incredibly generous and supportive. For the three years I was in residency he gave us $500 each month so we could afford to have Lisa stay home with our infant son. My final year of residency he gave our almost three-year-old son an empty box for Christmas, telling him that Santa said he was a bad boy. When I questioned him about it he disowned me.

As father’s day approaches all of these memories come flooding back. I have not seen my father in over 23 years but he still impacts my life. I work every day to overcome the negative traits I inherited from him and the abuse wrought insecurity that remains.

I am not alone in my struggles. A while back I wrote a blog post entitled “The Day my Dad Disowned Me.” Although it was posted two years ago, each day brings new readers who have been similarly disowned. Almost every month I receive a message or comment from someone dealing with issues of abandonment. The stories of pain and rejection shared by strangers are heartbreakingly sad. Dysfunctional and absent father’s damage their children in unimaginable ways.

I pray for these hurting people every Father’s Day.

There is nothing I can do for them, and there is nothing I can do to about the damage done by my father in the past. All I can do is be the best father I can be for my children and encourage others to do the same.

On this day that we celebrate dads, my prayer is to be a good one. 

- Bart

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