A Cross Necklace

Being a Christian refugee in this part of the world is a dangerous affair.

Unlike in America, where counting oneself a Christian is increasingly perceived as a designation that affords privilege, sometimes to an unfair degree (I have my doubts on that one), there is no question that the opposite is true in much of the Middle East.

It is easy to see that militant Islamists are actively focused on the eradication of Christianity in at least “Muslim” lands, if not the whole world. This is true to some degree in the refugee camps as well.

Even still, many of the refugees we worked with this week are either committed Christians, or are actively exploring the faith.

The stories of how these people came to their decisions for Christianity vary widely, but most are eye-opening. Few in the Middle East can come to Christ as easily and risk-free as nearly every American can if they wish. Apostasy from Islam is often regarded as an offense punishable by death.

One man I saw this week was openly wearing a prominent silver and gold cross around his neck. I didn’t notice it at first, but as I was listening to his heart with my stethoscope the bright golden object swinging in front of me was suddenly hard to miss.

crossRealizing I wasn’t in America, where crosses are so ubiquitous they’ve become a little trite to me, I exclaimed, “You’re wearing a cross!”

“Yes,” he nodded.

I pondered the implications of wearing that specific symbol in the Islamic world. A cross is better described as cross-hairs for a man like him. Yet he wore the symbol proudly, unapologetically. Should our roles be reversed, would I have the same courage?

“You are a Christian then.” I said, continuing in my new role of Dr. Redundant.

“Yes.” He nodded again, smiling.

Through my translator, I learned that a few months ago in Iran he was awoken in the night by the figure of a man calling him to follow Christ. He said he was convinced that the man speaking to him was Jesus, the Son of God. He knew almost nothing of the Christian faith, as he was raised a Muslim.

Still, upon waking the next day, my patient committed himself for following Christ. He felt he had to do this. It was an inner compulsion; he had been called to a new faith, a new life, no matter the cost to him.

But it was indeed a ‘costly’ decision. Read anything about the Islamic regime of Iran (I recommend the the wonderful autobiography Persepolis as a cursory intro if interested), and you will know that the government of Iran is itself a religious organization. Along with typical functions of any secular government, like providing running water, working roads, electricity and health care (which in many instances, the Iranian government does quite well), it also enforces a highly conservative interpretation of Shia Islam.

How do they enforce such a thing, you ask? How do you get a nation of 77.5 million people to follow extremely strict religious rules? How can you enforce an entire nation to put every woman in robes and headcoverings, to allow no music, no dancing and to enforce frequent observance of Islamic practices like 5x daily prayer?

With “religious police” of course!

As a kid from the suburbs of America, following a Christian faith I was always free to reject, it took some reading and imagination for me to even comprehend such a notion.

It was only in 1979 that the Iranian Revolution took place. Prior to that, Iran probably looked much more like America than it does today. But in ’78-’79, things changed dramatically, as that was the year of the Iranian Revolution. It was then that the Pahlavi dynasty, led by Mohammed Reza Shah Pahlavi was overthrown by the Islamic Republic.

revolution
Supporters of the Revolution. Didn’t Turn Out Like Many Expected.

The Republic was initially a political movement, comprised of a collection of leftist thinkers, activist students and numerous Islamic movements. It was led by a powerful Islamic leader named Ruhollah Khomeini, a scholar, author, politician and political revolutionary.

After the Shah was forced from power, to the surprise of nobody, Khomeini was designated as the Supreme Leader of Iran. However, TO the surprise of many, Khomeini was given final authority on both political and religious matters.

The irony of this transformation is hard to miss. Criticism of the Shah centered around how difficult it was for the commoner to be heard. The Shah’s rulership was a dynastic monarchy, with power passing from father to child generation after generation. This meant that nobody could rise from, say, a community organizer and member of a minority comprising 13% of a nation’s population, like Barack Obama, to the highest position of power in the land (Huzzah! Huzzah! Democracy!).

Yet the solution to this problem that emerged in Iran was the Islamic Republic, which consolidated both political and religious power in one man. The power of the rulers of Iran was, effectively, broadened as a result of the revolution. The “little people” never got their say. And, I suspect, many of those who supported the Revolution experienced colossal disappointment. Power just went from one ruling class to another. To this day, a Khomeini rules Iran.

Some version of the above rushed through my mind as I stared at the cross hanging from my patient’s neck. An Iranian, 4 months in Greece, wearing a bright silver and gold cross. Wow.

As it turns out, the father of this man was a member of this religious police force. This patient had chosen to convert from Islam to Christianity as the son of a man who is tasked with enforcing and promulgating Islam in the country. More irony.

Imagine the shame on their family for such an act! Aside from endangering himself, my patient was possibly even endangering his own father (and mother).

Many immigrants come to Europe because they think it is rich, with jobs and money flowing like wine at a wedding party. Increasingly, they are finding that Europe is no utopia. Millions are unemployed. Millions are poor. Upward mobility is rare.

But one reality of Europe is that it does remain a place where you can follow a religion in nearly any any way you choose, to include no religion at all. Say what you will about the EU, but it remains a place of tremendous religious freedom, rivaled perhaps by only the U.S.

So it is understandable that this man left Iran. But it is still amazing that he was willing to do it. He left with nothing. No family, no friends. He slunk away in the night, alone. As the son of an important man, his life had no doubt been comfortable and safe. He upended all of that.

port
Pireaus Port. Lucky you if you have a tent.

My patient arrived at the Pireaus Port of Athens after crossing the Agean Sea from Turkey. He arrived nearly destitute, having given most of his money to a trafficker to get him to Greece. I think he slept on the concrete sidewalk the first night.

The next morning, he says he prayed that the God of his new faith would spare him, and shortly thereafter was approached by members of a Christian church in Athens who offered him a bottle of water. It was through this church that I met him.

ellenikoGreek authorities soon placed this man in the Elliniko refugee camp, where he made no secret of his faith, sharing it with any around him who would listen. Not long after his arrival, a riot broke out in the camp with Muslims targeting Christians.

The violence carried on for quite some time, as Greek police made no move to stop it, one even pointing out that if some of the refugees died, “there will be fewer of them for us to deal with.” My patient was beaten severely in the melee.

It is inhumane, of course, for anyone to think as these police did. But their attitude is understandable nonetheless. Would you wade into the middle of that mess?

Somewhere in this story, my patient picked up his cross. I don’t know if it was in Iran or somewhere in Athens. But he wears it daily. It is not merely jewelry to him, given at some Christmas party. It wasn’t bought from one of the ubiquitous Christian Book Stores in America, with every possible permutation of “cross trinkets” available for sale. It was bought for a price; worn for a higher one.

This isn’t necessarily a Christian story, although as a Christian I find it inspiring. But from this anyone can recognize the deep human desire to worship in freedom. This man’s life story is a reminder that people are willing to die for the right to think and act honestly in relation to their understanding of the divine.

The cross symbolizes the reality of this man’s beliefs, even if that symbol marks him for suffering or even death. Would that all Christendom be so committed. Would that all who cherish freedom be so as well.

Headed Back to Athens

 

The Acropolis in Athens, Greece.
Athens, looking pretty. A rarity, IMHO.

For the second time in less than a year, I’m on my way back to Athens. This will be a short trip with virtually no team. My colleague organizing things in Athens has stated that she “feels sorry” for me, as the number of people signed up for the clinic appears to be quite large.

From what I can tell, the situation in Greece has only gotten worse since I was last there. Many borders and routes into Europe have closed, and migrants are being turned away at far greater numbers than they were last year. But by “turned away,” I’m not describing from Greece itself. Nope. Thousands continue to arrive on the shores of Greece every day. I’m talking about further into Europe. So, the migrant population continues to swell in Greece, especially Athens. Although authorities have begun shipping back some migrants (numbering in the hundreds) in the past few days, this is a small small number.

I say I’m bringing ‘no team’ this time, but in reality this isn’t accurate. Aside from what sounds like a great number of willing helpers in Athens, I also will bring my 14 and 16 year old daughters with me this time. I don’t know what sort of role they will be able to play in the work we do this time. It could be simply watching the children of the patients while they’re waiting the doc.

migrantsHopefully, they can learn a bit about medical care in a refugee and/or underserved situation. As their lives are largely consumed with cheerleading, skinny jeans, teen-lit, French horn, Cello, soccer and boyfriends (ex…EX boyfriends), this might be quite an eye-opening experience for them. I hope so.

My biggest concern is that we will successfully collect accurate data on the patients we see. Last time we did a fair job, under the circumstances, but in my spare time I’m STILL working through the XL spreadsheet and trying to come up with data summaries that will be of some use to the wider medical world.

This time, I hope to have time to ask better questions, and to formalize how we input the data. It is well known among those who do medical research that 80% of the study is done before the study begins. Developing a means to collect data, to college USEFUL data, and to do it in a way that is searchable and accessible at a later date is difficult. It is especially difficult when at that later date, you are dealing with hundreds, maybe thousands of data points.

I’ve had enough training in this element of the medical world to feel a gnawing sense of anxiety as I approach the issue. My medical school heavily emphasizes epidemiology and biostatistics, and I was part-way through an Master’s in Public Health degree until I ran out of money. So I have a sense for how easy it is to do this stuff badly. But I wish I had a collaborator or better skills to know I could do it well.

Still, I’ve had some help from a colleague at work who maintains a quizzical affection for XL (I can’t judge, I was once in a steady relationship with Photoshop), and he has helped me clean up our data from October. And I have a much better sense for what I need to do this time around.

14_athens_imgIt should be mentioned that most relief agencies don’t actually do any of this, even the good agencies who actually help people (lots of them are there for the photo-op and little else, it seems). I received some generous help from a professor at the London School for Hygiene and Tropical Medicine prior to my last trip, and he noted only a small number of agencies who provide care AND do good, statistical research on the populations they serve.

So, it makes sense that I’m somewhat on my own here. It’s not easy to focus on research and practical care at the same time, as one is more empathy-driven, the other much more analytical and “cold.”

Example: if someone comes in coughing up blood, you can either turn and enter “hemoptysis” into your spreadsheet (and then get the heck out of there because…ew), or you can throw on some gloves, hopefully a mask, get them on a bed and start working them up for any of the many many possible reasons for that symptom (most of those reasons being prit-TEE bad).

So, we will see how this goes. We leave tomorrow (Sunday) afternoon.

 

Galatsi

On day 3 we left our makeshift clinic in the 2nd Evangelical Church of Athens to work in one of the main refugee “camps” in town. But it isn’t a campground. It’s one of the main stadia used in the 2004 Olympics, located in the Galatsi suburb of Athens.

The story of how this stadium came to be used for refugees is emblematic of the refugee crisis in generally. The stadium has been shuttered for years, no lights, no electricity. But with thousands of people suddenly camping in parks all over Athens, the people of the city were understandably upset. Furthermore, anti-immigration groups were organizing and preparing potentially-violent opposition to the influx.

So the Minister of Immigration apparently decreed that refugees would be moved to the Olympic Stadium. Only then was the mayor of Galatsi notified of the dictate, while also being told that he was, in fact, in charge of the stadium.

wpid-wp-1444681246447.jpeg
Queuing up for lunch. The food I saw was a step up from David Copperfield-esque porrige, but not by much.

On balance, it’s a good plan. There is lots of room there, the people and tents are out of the parks and off the sidewalks. The Greek Army (I think) has been tasked with feeding the refugees 3x per day, an endeavor equal to any reasonably-trained Army. It also protects Greek political leaders from human rights criticisms, since the people are being cared for while not upending entire neighborhoods.

There is both massive influx and efflux of people from the stadium every day. Nobody intends to stay for long; the Greek government does not plan on operating the facility indefinitely either.

We were given an emergency medical license under which I could function as a de facto Greek doctor on days when I worked at any of the camps. We were asked, really more like begged, to work at the Galatsi camp because over 1000 people were there, with hundreds requesting a doctor.

Here are some observations from that day:

  • 5
    Lots of people, all trying to help. Not a lot of organization.

    We worked out of a small room, filled with donated medicines, even some supplies. It was better-appointed than I expected. It was cramped, sweaty and regularly filled with people for myriad reasons. A hazy notion of ‘organization’ came and went throughout the day.

  • We infuriated the Greek doctor, a pulmonologist, who is overseeing the medical room in the camp. We had been “begged” by the ministry of immigration to come work that day. She was never notified. So our presence was a surprise to her. She wasn’t, however, working. Nobody was. She showed up, yelled at us about attending a strategy meeting in a few days, hung around for a bit, then left.
  • The Greek Government is doing better with this crisis than reported. There
    greecemap
    Areas around Greece where people are helping with the refugee crisis either directly or by collecting donations, etc. Click this pic for an interactive map.

    were police on the campus (until later in the afternoon, when they apparently lost interest and wandered away). There were GIANT piles of clothes in the “clothes section,” and everyone had food at mealtimes. The camping areas were dry and were clean if the refugees cleaned up after themselves (some did, some didn’t). But the same Greek Government has relied heavily on individual donors, NGO’s and privately-funded clinics like ours’ to make this some sort of controlled chaos.

  • Before we started, I watched a T.V. reporter van pull up next to a nice black car, out of which stepped some guy in a suit. The camera started rolling as the guy stood next to a reporter-looking person. There was a quick interview, then some panning shots of the facility. Then the guy got back in his car and drove away. I found out later this was some politician getting time on T.V. “working” at the camp. This is happening on the local Greek news, with dignitaries, including local doctors, posing as helpers in this crisis.
  • The majority of refugees in the camps and on the streets are from Afghanistan and Iran, not Syria. In general, the Syrians have more money and are staying in rented apartments. Usually, those apartments are being sub-let (for a substantial profit) by other refugees. It’s a dog-eat-dog environment.
  • 4
    Quite a few meds. No smokable opium. No opium t all, in fact.

    I saw a patient with back pain who was smoking opium for pain control. He said he didn’t want narcotics for his pain, but also said nothing else worked for him. As our clinic absolutely has no narcotics of any kind, we offered him some non-narc alternatives. He left, unhappy, then returned later, forcing his way through the scrum outside to “complain” about our “service.” Apparently narc-addiction and the behavior it engenders knows no social or ethnic boundaries.

  • Our clinic lead, the Persian woman who organizes these clinics (a refugee herself 15 years ago), wisely did NOT allow advertising when we started our clinic day. Just by word of mouth alone, we were nearly overwhelmed with a shouting, occasionally-pushy mass of people that formed outside our “clinic” shortly after we opened for business. HUGE credit to a great team in front of me to help control and direct the traffic outside.
  • The Mayor of Galatsi, and manager of the camp, is not a happy man. The Greeks dislike him because he’s helping refugees invade their country. The refugees don’t like him because he oversees a camp perpetually under-resourced. The political class over runs him, taking their own photo-ops and garnering the credit for the work being done there. When I met him in the camp, he half-shook my hand, then tersely told me to “get to work.” Can’t blame him.

I was worried to work here for a host of reasons, but I’m glad I went. I wish we could spend more time in the camps. Getting patients to our clinic at the church was a big challenge. No problem here.

Tomorrow We Leave

We leave for the refugee clinic in Athens tomorrow.

I intended to blog the step-by-step story for how we arrived at this point. But THAT didn’t happen.

Here are some specifics:

wpid-wp-1443899443776.jpeg-We intend to see approximately 30 patients per day for a week, working half-days on Monday and Friday. I suspect we’ll end up seeing many more than this.
-We will be working in an abandoned church in downtown Athens. We’re staying in a Youth Hostel a short distance away.
-We have access to labs, Xray (maybe?) and some medications but I’m not sure which ones.
-I’ll be using an antique oto/opthalmoscope manufactured by the Riester Company, which was based in, you guessed it, Germany.
-We plan to see Afghan, Iranian, Iraqi and Syrian refugees. There could be many others.
-On the last day we will likely go into a refugee tent camp and set up our medical clinic there.
-Donations continue to roll in, to date over $6000.
-I’m not without a sense of concern. It isn’t lost on me that Americans aren’t the most popular people in the world today, especially in the lands where these people are coming from. On this, the night before our departure, I’m keenly aware of all that I leave behind, and all I hope to see again soon.

Your thoughts and prayers are most appreciated.

Athens, October 2015

Athens has long been a crossroads for refugees trying to make their way from the Middle East into Europe. So when I traveled there with my church pastor, David, this past February to explore the possibility of starting up a medical clinic, we had no idea what kind of summer was approaching.

At the time, it was clear that activity in Syria/Iraq (ISIS territory spans both) was worsening, so we predicted an influx of migrants seeking refugee status in the EU. We knew the numbers this summer would jump. But we didn’t predict anything to the level of what we’re seeing today.

Be advised that anything you read below this blog is from the days when my blog was largely a chronicle of my time in family medicine residency in Olympia, WA. Some of the posts are fun, some whimsical, some serious, some maybe a little helpful.

After residency I moved to Germany and live here still. I’m a practicing family medicine doctor and have long planned on working in international and relief settings. This is the primary reason for moving away from friends and family, and my decision has positioned me well to help with the current crises in Europe.

Can I, and this little clinic we’re building, do much to address these massive problems? Hardly. I understand that. But if lots of people do lots of little things, it can equal one big thing over time. So I’m starting with this little thing.

As such, from this blog forward, I’ll mostly be talking about the work we’re doing in Athens and the topics that relate to that work. Namely, cross-cultural medicine and global public health. If you care about these things, you may enjoy following along as I navigate through this project.

The media element of this project is just getting started, and it’s been awhile since I flexed my creaky “blingers” (that’d be blog-fingers). So bear with me.

However, already I’ve been met with scenarios for our clinic that I hope to present to you, SW101 nation, for input and ideas. This isn’t an easy challenge, with lots of questions that have no easy answers. So approaching this as a community is, I think, a much better way forward than going it totally alone.

So, if you’re willing to jump in with me, thank you, and welcome!

Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...
Father Ventura, surely a surfer
Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.

‘Concierge’ Medicine – A De Facto Manifesto

My blogging output has been at an all-time low since moving to Europe.  Who knows why…this place is such a bore.  I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.

The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine.  It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States.  In my email reply to him, I found myself writing my own little manifesto on the subject.  A treatise, if you will.  A declaration.  A primer? A resolution, a promulgation…

William Osler (1849 - 1919), Professor of Clin...
I have a idea...how 'bout I actually know who you are, AND care about your medical issues?

 

I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms.  Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries.  So the idea isn’t new.  It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen.  It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans.  I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap.  If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good.  Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too.  Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply.  Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards.  It requires real cash investment.  But it IS better.  And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different.  We’re talking about your life, here.  Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way.  Most people in the richest nation on earth perceive they can’t afford it, but really can.  I blame this perception on the invention of the 10-dollar co-pay.  This idea was such poison in American medicine.  It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food.  They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels.  But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments.  But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health.  I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous.  On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests.  High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up.  NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making:  that is, if X symptom, then Y action with little analysis involved.  recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment.  When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately.  Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer:  I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians.  Most I’ve met are smarter than me.  But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000).  This differential limits mid-levels to algorithmic, rather than analytical, decision-making.  When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels.  The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.

XBox – A Medical Necessity

“Dr. SW101,” Says the curly-haired assistant, “will you sign this memo.”

I don’t look up.  As usual, I don’t read the memo, reaching for the closest pen and signing as fast as possible.  I look up at him, smiling cheerfully.  “What’d I just authorize?”

This is a photo of my Xbox
Image via Wikipedia

 

“Oh, you just told General Forth that the unit has medical need for 6 additional XBoxes.”

I pause, wondering why I’m so morally opposed to all paperwork that I can’t bring myself to even look at paperwork unless I absolutely have to.

“Xbox,”  I say, brows furrowing.  “Do you get ’em at the pharmacy?”

“No!”  He says, cloyingly earnest.  “You’re SO funny, Dr. SW101.  You should write a blog!”

“I do.”  I say, feeling sardonic, looking dour.  I reach for Volume I of Harrison’s Internal Medicine.  I lick a thumb and start flipping through the thousand-page tome.  “Hmmmm, Xbox.  Nope.  Nothing here.”

Assistant waits dutifully, no doubt inwardly rolling his eyes while clutching his well-typed letterheaded memo, with my signature still drying at the bottom.

“OH!  Right.  I’m only in Volume I.  Stupid me.  I should be in Volume II, where the X’s are.”  I pause.  “Just a minute,” I say, reaching for the second book.  A few minutes of earnest searching, “Nooh.  Darn.  I just don’t see anything talking about how XBox is an accepted therapy for anything.  Not even my favorite disease of all time – mitochondrial infectitis.”

“You’re kidding, right?”  He says, now looking worried.  “We can get the Red Cross to buy XBoxes for the unit if you say they’re medically warranted.”

“So, my patients – most of whom have seizure disorders, PTSD and post-combat anxiety – can sit around all day blowing each other up and staring at flickering lights?  Maybe I should prescribe a Rave too, so we can add drugs to the strobe lights.  Or would they be used for the Xbox version of Myst or something?”

Regions of the brain affected by PTSD and stress.
Bzzzt. What I need is some rapidly blinking lights and simulated death right now.

 

Assistant gets all serious, fearing the loss of his beloved memo.  He starts reading some of the Pulitzer Prize material, “Gaming has become a central element to the Soldier’s past time.  When they return from war zones, the lifelike quality of the Xbox combat games approximate the environment they just left.  For many, this represents a “return” to their former lives, thus producing a sense of calm and reassurance.”

“I said that?!”  I exclaim, eyes wide.  “What kind of crap-pile hash was I smokin’ when I wrote that letter?”

“Oh, huh.  Um.  Well, if you didn’t notice…I wrote it.”  Says the assistant, looking dejected.

Short of tearing the letter out of his hands, and no doubt derailing an already fast-moving train with lots of passengers, I know I’m on the hook.

“Ok.  You win.  Xboxes all around!  On me.”

Relief, profusion, gagging urgency and more of that I-want-to-help-soldiers-but-won’t-listen-to-reason earnestness.  “Oh, THANK you!  Man, you have no idea what this will mean to the guys.”

“Can we just agree that you got me to sign yet another of those goofy Army things where you’re not really asking for medical opinion but if I sign the memo about 25 people will have busy stuff to do and somebody somewhere will get something to further the impression that they’re entitled to things that the average American pays for?”

“Um.  Sure.”

“Can we further agree that Xbox is not an accepted medical therapy for anything?

“Yep.”  Confidence growing…clearly the doctor is too weak to actually stop any administrative freight trains now.

“Fine.  You have your memo.”

He turns to leave.  Then turns back, “Oh, and about that memo for the massage chairs…”

But I don’t hear him.  I’ve crawled under my desk, looking for the Lost Thumbtack.  I don’t “find” the thing until I hear my door open and close.  Carefully I look up….he’s standing there, hand on the doorknob.  He’s smiling, one of those serious smiles that makes perfectly clear that nobody’s fooling anybody.  “Find your thumbtack?”

I sigh.  The sound is tired in my ears.  “Yes.  But I just tossed another one down there to go look for later.”  He doesn’t say anything.  “Yeah, the massage chairs.  Bring me the memo.  Until then, take this script-” I scribble onto a piece of paper.

He crossed the room and takes the script from my hand, smiling.

Massage Chair
1, bid.  Do not swallow.

 

Graduated – No Crying

The last days of residency passed – perhaps with a bang, and certainly no whimpers – and I am now full into my first week as a real, live doctor.

Everything feels the same, but with more sleep.

My graduation ceremony occurred 4 days ago, on Saturday.  For as emotional as I felt that night, I managed to survive the entire ordeal without much blubbering.  This had largely to do with my particular approach to the ceremony itself, which involved a skateboard, a wacky helmet and some iffy poetry.

Since there are only 6 graduating residents from our program, each of us enjoys (or endures) a sizeable amount of limelight as we graduate.  It starts with a picture slide show of us from our earliest days up to the present.  Some of my shots were strange, if not embarrassing, as you might imagine.

We are then introduced – for an agonizingly long time – by a faculty member.  Here our history, foibles and dreams are put on display for all in attendance to see.  This part can also be rather painful too.

It was then my turn to speak.  We aren’t given time-limits on our speeches.  As mentioned, there’s only 6 of us, so I guess we have the berth and he right to ramble a bit if we want to.

I survived the process with almost zero public display of emotion.

I’m not sure why this was some sort of goal for me.  I’ve always been a lousy crier.  I’m good at complaining, whining, moaning and bellyaching, mind you.  Rather too good.  But my crying skills must have atrophied somewhere in my childhood.

If I were to guess, I suppose it happened when I was about 5 years old and my biological father had just punched his girlfriend in the face.  He then leered at me and asked, “You gonna cry about that like a little girl?” in a drunken haze.

“Nope.”  I said.  And I never have.  These days, I can only cry when Ariel gets her statue of Eric blown up by King Triton, or the Broncos trade their franchise quarterback to the Bears.

So, I have some issues.  Fine.  I’ll bet you do too.  Intellectually, I admire the Roger Federers of rhe world who can stand on the international stage with unabashed tears streaming down their cheeks when they lose (or even win, sometimes) their latest tennis match.  Emotionally, I want to smack them with their own tear-stained pink hankies, tell them to find their purse and go back to the parlour where life doesn’t hurt so much.

Anyway, I wasn’t going to cry.  Smash my thumb with a hammer…we’ll talk.  But for this?  No way.

So, my approach was to first ride my Sector 9 longboard skateboard up to the podium wearing a tin foil-wrapped, overly-festooned bike helmet.  Why such a rather dumb graduation display?  Why, especially, at a solemn ceremony for a new practitioner of the healing arts?

sector9Aside from the fact that medicine is frequently too pompous and full of itself, I figured that if I could keep it fun and light, I could keep my eyes dry.  Plus, I ride my longboard to work most days, and I religiously never wear a helmet of any kind, much to the dismay and consternation of virtually every person I meet on the hospital campus.  For 3 years I’ve put up with near-constant haranguing to wear a helmet.

Why don’t I wear a helmet?  Well, I just figure that anyone traveling less than a mile, at about a mile an hour, while less than 3 inches off the ground…should garner me the right to feel the wind in their hair.  Granted, there isn’t much wind at that speed…and I don’t have much hair.  But that’s my metaphorical argument, people, and I’m sticking to it.

I also think that Americans are too stupidly safe these days.  We think we have allergies to things that 6000 years of humanity had no problem with.  We pad every corner in our houses and put seatbelts on our T.V.’s just in case the wall trembles and pushes that deadly thing over on a kid.  We have warnings on things like plastic 5-gallon buckets and nylon shower curtains.  Frankly, the fact that my children will never ride barefoot in the back of a bouncing pick up truck, screaming like golden-haired eagles as the wind whips wildly into their eyes, brings me no end of sorrow.

I grew up burning leaves, shooting bottle-rockets out of my hand and hunting fish with a whittled stick.  I think life is risky, and living life is an exercise in managing that risk.  Knee-jerk safety measures without true analysis of risk leads to heard-mentality that rarely leads to anything but really really bad groupthink: racism, genocide, militant nationalism, day-glo, Milli Vanilli, toilet-seat-shaped pillows for airplane flights that everyone carries around airports but never actually use for more than 10 minutes, to name a few.

So, in truth, I don’t wear my helmet when longboarding because I’m determined to not become a Nazi.  Gotta admire a guy like that, right?

Anyway, I understand that most of you dear readers will find fault in my little tirade, and will probably want to admonish my opinion about helmets just like all of the faculty, nurses, staff and freaking maintenance workers I see.

But take heart!  You don’t need to worry!  I rode to the podium in a helmet for the first time.  Just to make everyone happy.  Just to acknowledge that I’ve finally heard the message.  I give up.  It’s time to be responsible and extra-duty safe.  I’m a doctor now.

‘Course, my helmet was covered in tin foil and had sticks extending from it in every direction with tinfoil balls on the end of the sticks…but it was a helmet.

Then I delivered a poem.  It was supposed to be a rap – with a thumping beat and maybe a couple of dancers and lights flashing/spinning with everyone on their feet, their hands in the air all hip-hoppin’ on the floor.

But I’m white.  I’m a doc.  I’m in a tie.

Forget it.  It’s a poem.  A really bad 1-2-3-2 rhyme sequence that rhythmically scans like ice cream might feel if you were dumb enough pick a pile of it out of a sandbox and eat it.  But, in honour of my creation and the initial inspiration for it, I allowed that I would not in fact be delivering a rap, OR a poem that night.  It would be an amalgam, a mixture…a PAP.

This is fitting, of course, since we were all gathered to celebrate my new status as a fully-trained family medicine doctor.

My Pap made my mom cry.  I think my Dad too.  Kinda my wife.  And most of the people I talked to afterward said it made them a bit misty.  My goofy, two-bit hyper-syllabic tossed salad?

Cool.  People cried.  I didn’t.  I was too busy looking goofy, or saying goofy things.

Dear old Dad would be proud.

Pullin’ Bear

Ever wonder how big game – shot in the vast American wilderness – gets brought all the way back to civilization?

I recently visited a Cabela’s that just opened in our town. For the uninitiated, Cabela’s is easily the most expansive and comprehensive hunting, fishing, outdoor-gear store on Planet Earth.  They’re basically a small city with a roof.  Along with every gear component you can imagine, they have an eye-popping display of stuffed animals in the center of their store.

By “stuffed” I mean taxidermied.  So we’re talking, real, wild, once-alive animals now stuffed and posed to look alive.  I have stuffed animals all over my house, but none of them ever had teeth or laid claim to primordial carbon.

Personally, I’m not much attracted to killing animals of the natural world, and stuffing them and putting them on a wall isn’t very interesting to me, either.  In general, this city boy thinks of taxidermy as nothing more than bald carnivorism on guiltless parade.  Who ever thought the severed head of a deer, garrishly hung from a wall, would serve as decoration?  Isn’t some version of humility or mourning in order for this kind of thing?  If I were a taxidermist, I would recreate the entire scene, complete with twisted, exposed entrails, horrid death-grimace, contorted body and spattered blood in wide, fan-shaped arrays.  And every display would always include the GUN that did the dirty work.

Anyway, these guys have HUGE bears stuffed and in fierce poses with claws bared.  This includes a real polar bear, over 8 feet tall.  Somebody killed a freaking polar bear! I thought we just studied those things.  Staring up at that ginormous carcass, I wondered first where the hapless thing had been shot (heart?  head? gi tract, perhaps?), then ruminated on the ethics of such an action, then wondered how the freaking hell they carried an object that huge out of the woods and into my Cabela’s.

Today I saw a patient with back strain who encountered a similar problem.

“Hurt my back.”

“Oh?”  I replied, trying very hard to be interested in yet another low-back pain problem.

“Pulling a bear out of Porter Crick.”

I looked up, interested without trying now.  “Like, a bear? You mean with claws and fur and omnivorous urgings and the hibernation thing?  That kind of bear?”

“Yep.  Reared up while we were deer-hunting.  Stood about 6 feet.  Took him down with one clean shot.”

“Holy crap!”  Oops.  Professional, professional.  Be PROFESSIONAL, stuipd!  “Jeez, how’d you get him out of there?  And, on a non-medical note…were you a little worried about getting your face swiped off?”

“Yeagh.  Poor bastard was coming right for me.  About 50 feet off.  He had a bee up his arse for some reason.”

“So, once he was down, what did you do.”

“Me and Jake field dressed ‘im,”  I nodded approvingly at this…I can only imagine what the heck it really is…maybe try wikipedia later.  “Then we dug some motorcycle straps outta our packs and pulled the critter by his paws.”

“You pulled him by straps from his paws,” I repeated, acting normal but thinking of No Country For Old Men. “How far?”

“‘Bout 8 miles.  Through brush and trees.  Plus our guns and packs and all.  Bear was about 400 lbs.”

“Good GOD, man.”

“Yep.  Well, whadda ya gonna do for my back, doc?”

“Pretty much nothing, dude!  Anybody carrying a 400 lb. bear out of the backcountry is going to have back pain.  And I doubt you’ll listen to me telling you to rest it, right?”

“Wahl I was only comin’ in today because we leave for some elk hunting in Idaho in 2 days and I wondered if you could give me something to help with the pain before I go.”

“If you want to stand across the room, I’ll shoot you with one of those tranquilizers they shoot into elephants on the nature channel.  That might make you woozy, though.  It might affect your ability to shoot safely.”

“Nevermind, then.  I’ll be fine.  Just checkin’ in, doc.”