Dr Holly Dahlman's Blog

"Food Stamp" Jesus

2012-02-11T15:06:00.001-05:00

When three of my Facebook "friends" (my brother, my cousin and my childhood friend) all post the same image, I pay attention. When Stephen Colbert makes a comment, the "Nation" (coined term for his fans) pay attention, even double-attention. Most of the time, his ultra-conservative comedy persona pokes fun at the true conservatives, but here he is poking fun at American Christians... or is he really poking fun?

In actuality, this may be truer to the heart of the real Stephen Colbert, in truth as opposed to "truthiness". His quote is at once subversive and yet also challenging, and said by a practicing Catholic who reportedly teaches Sunday school. I think the challenge against the current bizarre Christeo-political fusion needs to come from within Christian ranks. This is not to attack the church as a whole but rather the idea that to be Christian and to be conservative are one in the same. It is simply not so. Jesus' politics can't be fit neatly into theocratic monarchism (from which the "Founding Fathers" emerged) nor socialism (which some imagine as a framework of a future America). If anything, Jesus' kingdom of God was operating outside of the zone of political ideas of his day, yet respecting Caesar's rule and the right of a ruling authority to collect taxes ("render unto Caesar...").

Jesus emerged from a longstanding Judaic tradition, one that was exhorted to let a field lie fallow in the 7th year not only to allow restoration to the crop but also so that the poor could come and gather food. The poor were helped, and loaning money to them at interest was forbidden. Then, every 50th year was to be the more radical "Year of Jubilee" (Leviticus 25). It was the year of freedom! Property bought from one who had become impoverished and was unable to buy it back was to be returned to the individual in the Year of Jubilee. Slaves were set free in the 50th year, The Year of Jubilee. The scholars are actually unsure whether the Year of Jubilee ever came to pass. It is possible that just as the Israelites disobeyed in other ways, like worshipping the golden calf while Moses was up on the mountain, they failed to love the needy in their midst.

Other prophets of Judaic tradition spoke of a God who is "near to the broken-hearted", "gracious and compassionate, slow to anger and abounding in love", "God of faithfulness, without injustice", a lover of mercy, One who hates oppression, and who draws close to those who are "broken and contrite" in spirit. God's prophets were not necessarily good looking nor culturally-polished, often living on the fringes and treated harshly or even put to death by their own people. There is often a tension in what God speaks, a discomfort. No one is really great at self-sacrifice, especially those benefitting from the status quo. The kind of action required by the Year of Jubilee mandate would cause a riot in modern America.

What of the New Testament? Did Jesus take a radically new view? Did Jesus support the "American dream" way of thinking? Did he come to bring ever-increasing blessing in the material sense? I think not.

Jesus did not say "Blessed are the well-to-do and religiously self-sufficient"; nor is "God helps those who help themselves" anywhere in the Bible. The overall message is much more like this: we all desperately need help, in one way or another. Jesus demonstrated laying down his life, and paved the way for his followers to do the same. He saw that the people were hungry, and fed all of them with an over-abundant supply of fish and bread, not once but twice (5,000 and 4,000!). In Jesus' economy, the last is first, and the guy showing up at the end of the day gets paid the day's wages. I don't think the New Testament is a cookbook for a modern economy, yet it provides glimpses into his heart.

When asked, "What the greatest commandment?" Jesus replied the Jewish way, from the book of Deuteronomy, "Love the Lord your God with all of your heart, soul, mind and strength," but then reminded his listener of the most challenging "and"! "The second is: love your neighbor as yourself."

It seems like Christians with conservative and more liberal views tend to see Jesus' attributes differently.

conservative emphasis liberal emphasis

heavenly kingdom-builder earthly kingdom builder

redeeming individuals redeeming society

ruling equalizing

Master Emancipator

powerful freeing the oppressed

holy forgiving

justice (legal) justice (social)

owning all coming into the world with nothing

Creator Restorer

God man

perfecting righteousness near to the broken-hearted

Author of faith confronting religious authorities

disciple-making connecting with marginalized

saving souls saving a people

died for our sins demonstrated self-sacrifice

blessed persecuted-righteous blessed poor in spirit

"ask and it will be given" "sell all that you possess and give to the poor"

The Word The Way

Yet, Jesus possesses all of these attributes and infinitely more. Americans can't have half of Jesus; though most American churches lean heavily toward one side or the other. I don't think we will see true revival and righting of social wrongs without the real unified Jesus shining through His bride, the church.

I think Evangelicals these days have forgotten the Christian heritage of caring for plague victims, abolition, fighting to end the slave trade, fighting for child labor laws, and sheltering Jews during the Holocaust (among other acts of faithful courage confronting evil). Social justice has been deep at the roots of our faith tradition throughout the ages. The early church, where the Christians were said to have shared everything with one another, isn't where it began or ended. I have been tempted again and again to disavow myself of the label "evangelical" since so many outspoken evangelicals in this age seem to lack concern for social justice and equality and have such high esteem for wealth, power, and war.

All said, I think Liberation Theologians miss a huge part of Jesus, the Jesus who reaches into our own hearts and does not leave us unchanged. One does not have to look far to see the truth of our sinful nature in ourselves and in individuals and in groups. We desperately need the Cross, as individuals and as a whole. Heart transformation has to be the root of any social change. That is why I cannot espouse Marxism, because God is subtracted from Marx's equation. Multiplying by zero = zero, and God is the power of our salvation.

Yet, I venture to think that Jesus would be in support of food stamps. Seeing that the church has faltered in caring for the poor and averting other social ills, it is reasonable to allow the government to work as a force for good and ensure that the poor do not starve. How do we expect the poor to rise from their circumstances if children sit through school with gnawing hunger? How do we expect an unemployed single mother to get the job if she is distracted by food insecurity? How do we expect her to have hope, unless she is payed a fare and equal wage? How will she ever be able to adopt family values if her basic needs are not met?

On Target @ Practice

2012-02-05T17:10:00.002-05:00

A little over a year ago, I was notified that we were NOT selected as a site in the Maryland Multi-payor Patient-Centered Medical Home Pilot program (MMPP). After waiting for months to hear the outcome, I was totally crestfallen. I was nearing my limits as a primary care provider and business owner. I was disappointed. Deciding that I had little to lose, I contacted the Maryland Healthcare Commission to ask for advice. We were told to send a letter back to the Committee who was reconsidering applications, as some of the invited practices had opted out in favor of the CareFirst PCMH Pilot Program.

In March, I attended the PCMH National Summit in Philadelphia and returned to the practice inspired but with no idea how I might pull off PCMH transformation without financial resources. Shortly thereafter, I got a call and a letter from the Maryland Healthcare Commission, inviting us to join the MMPP program. I was ecstatic! Though we were two months behind, if the ruth be known, some pieces had already been put in place for years. I also put in long hours in the first quarter of 2011, forging ahead toward PCMH.

The term "Medical Home" was evidently coined by the American Association of Pediatrics in 1967. The concept evolved over many years. Over the past 10 years, the major primary care publications such as Annals of Internal Medicine have been publishing more and more articles about the topic. Then in 2006, IBM Corporation grabbed a hold of the concept and created an organization called PCPCC, or the Patient-Centered Primary Care Collaborative. Facing the ever-increasing cost of insuring employees, other large companies have begun to support and participate in PCMH initiatives. Outcomes thus far: a decrease in the cost of healthcare, with increased patient, staff, and provider satisfaction.

The National Committee of Quality Assurance (NCQA) has set the gold standard qualifications for a Patient-Centered Medical Home. As part of the 2011 Standards, we had to meet 75% of the specifications in 6 overall categories, in other words, to "enhance access and continuity (of patient care), identify and manage patient populations, plan and manage care, provide self-care support and community resources, track and coordinate care, (and) measure and improve performance." In the process of implementing these standards, we believe we are providing better patient care at Green Spring Internal Medicine than ever before. We have had to adopt a culture of change, which has sometimes resulted in fatigue, dissent or even all-out rebellion at the office, though we always seem to recover to an overall enthusiasm and pride in a job well done.

Our gigantic NCQA application was submitted at the end of October, and we were hopeful to come in at the highest level. We just found out last week that our wish came true, we were granted Level 3 Recognition! Of course, it wasn't just wishful thinking but a lot of teamwork and practice changes that made that happen. At Level 3, our practice will be paid the maximum per-member-per-month by all of the major insurance carriers, except Medicare. We are hoping that Medicare will become part of the program, as the PCMH is of benefit to our entire patient population.

We are now fast at work on the next project for the MMPP, reporting on 18 clinical quality measures to the Maryland Healthcare Commission. 6 of them were part of Meaningful Use Attestation, 6 of them were easily obtained, but 6 of them were much more challenging. I spent the day yesterday using several different eClinicalWorks features (Registry, MAQ Dashboard, and Quality Measures features) to gather the data. As the February 29th deadline looms ahead, there are still 3 more measures to tackle.

A complimentary personal goal of mine for 2011 was to achieve Meaningful Use through Medicare. What began as a simple process in May, turned into a major project requiring countless phone calls and requests for help from eClinicalWorks to get our software set up to capture the necessary data. Once the data was captured, three months of analysis were required. Submitting my attestation was delayed three successive months for a variety of reasons before I was finally able to reach the last page and send the data to Medicare. Our clinical quality measures, for example, should reveal how well we are controlling hypertension in our population or whether we were counseling smokers to quit. However, not all of the measures were truly reflective of our practice as we were unable to capture all of the data due to various software idiosyncrasies. There will be additional measures to report to Medicare in coming years, and my hope is that the process of setting up the system for data capture will be simpler and more uniform across practices, that the data will be more accurate, and that we will be able to use it to improve patient care. At very least, Medicare did just send the first incentive payment to us!

We will also report additional measures to Medicare's PQRS reporting system for a small (0.5%) annual bonus. We are working with the Delmarva Foundation, a Quality Improvement Organization, to optimize the process of obtaining and reporting this data. We also partnered with Delmarva to make this project a Practice Improvement Module (PIM) for ABIM recertification.

It is our hope that with the help of the MMPP, Medicare, CRISP, Wavelength MSO, the Delmarva Foundation and eClinicalWorks, we will be able to blaze the trail for other small practices to become Patient-Centered Medical Homes and to use health information technology to provide the most excellent, cost-effective, and satisfying patient care.

January Sun

2012-01-08T15:13:00.002-05:00

I am sitting at home on Sunday afternoon, enjoying the final dregs of egg nog (expiration date: 1-13-12) mixed into decaff coffee, with my cats perched on the ledge of an open window. The days are getting longer, and this weekend has been a reminder of spring.

I am pleased to be living up to a few New Year's resolutions already. I have been working in an hour of exercise whenever possible, and that has greatly improved my feelings about winter (helped by the recent unseasonably warm weather).

Friday afternoon, I met with the Delmarva Foundation to discuss ways we can partner to improve our measurement and reporting of quality measures with the use of Health Information Technology. Quality measures are reported on a population basis, not involving any identifying or individual patient information. A couple of years ago when I did a practice improvement project as part of board recertification, we had to gather data from patient charts, one by one. At that point, I was reminded of a dislike for research. So much tedious work was involved in finally obtaining enough information to put to some use... all with the realization that the same tedious process would need to be repeated several months later. It wasn't as if there was nothing else to occupy my time. Now, through major advances in IT, we are able to extract and organize vastly more data than ever before. Now I like research!

We have been hard at work, finding ways to ensure that we have good quality data. Accurate numbers are key to improving patient care. Amy and I spent yesterday morning at the first gathering of the MMPP eClinicalWorks users group. Representatives from 5 practices, a member of Discern Consulting, the director of the Maryland Learning Collaborative, and our practice transformation coach were all in attendance. We had a productive three hours, sharing strategies of obtaining clinical quality measures through the software and using the new care plan feature. Though we come from diverse practice sizes and types, we all shared similar challenges with tasks at hand as well as the hope that we will be able to engage eClinicalWorks in helping us achieve our goals.

I spent the rest of yesterday in DC with one of my best friends, Tami Ritsema. It was a beautiful day. We spent some time soaking in art at the National Gallery and serendipitously happened upon a curator's tour which was focused upon Italian Renaissance works. Since each of us had spent time in Italy in 2011, it was great to hear the stories while looking at beautiful art by painters whose works are also scattered throughout the Uffizi - Boticelli, Raphael, Bellini, Titian. The balmy weather beckoned us outdoors again for a long walk around the Capitol and the White House, with a great dinner at Jaleo in the middle. The best part of all was having a real conversation with someone I love. Tami and I can talk for hours on a variety of deep subjects, and that I treasure.

My hope is that in the coming months, I will achieve enough balance between my professional and personal life to allow for more writing. It felt good last week to decide upon and implement 1-2 administrative hours every Tuesday afternoon. This will help me regain free time on Fridays. The early week had become too much of a "tyranny of the urgent", allowing the to-do list to get a bit unmanageable. I am looking forward to seeing what other outcomes the change might bring.

From 2011 to 2012

2011-12-31T11:06:00.000-05:00

(subtitled: Reflections and Resolutions)
I am sitting at my usual Saturday morning spot, my neighborhood Starbuck's, and it is 10:30 am. My usual pals have come and gone, and now it is down to me and my little Windows 7 Acer Iconia tablet netbook. This is the third netbook I purchased in 2011, with one as a present and another to serve as our digital EKG/spirometry computer at the practice and the third as a my work laptop.

With so much "in the cloud" these days, it is truly possible to get by with the most basic and hence less expensive computer. I really love this one. I love computers I can touch to make things work, including smartphones. While this computer is no iPad, it shares many of the cool features. 2011, among other notable mentions, was the year of the tablet. These new tablets are a lot smaller and faster than the tablets I first started using in my old practice in 2005. They have come a long way. What is not to love?

Also reflecting upon this year:

2. 2011 was the year of the beginning of our PCMH Pilot (our new practice model as part of the MMPP), bringing Amy's arrival to the practice (thank God!) and countless other positive changes

3. 2011 was the year of meeting Phase I Medicare requirements for Meaningful Use, which was no small feat despite my early adoption of electronic medical records technology

4. 2011 was the year of Twitter

5. 2011 was the year of a timely trip to Tuscany with friends

6. 2011 was a year of rediscovery for me: that I really do appreciate having my own practice and having my own space at home, that I am not wired to work with or live with bossy people

7. 2011 was a year of staff transitions and growth of the practice from a total of two people in January to five in December

8. 2011 was the year of the revolution in the Arab world and elsewhere

9. 2011 was the year the Iraq War ended

10. 2011 was the year the Iraq war ended

2012 holds many aspirations for me. With 10 resolutions, I won't lose sleep if I fall behind on one or two of them.

1. to grow in my IT skills

2. to stabilize the staff and grow Green Spring Internal Medicine further along the pathway of Patient-Centered Medical Home transformation, to become leaders in small practice PCMH

3. to regain Fridays off (real days off) by introducing administrative time during my work week.

4. to find more time to write

5. to hand over bookkeeping

6. to deepen friendships

7. to learn new recipes and make healthy modifications to old favorites

8. to grow a deeper understanding of the whole gospel, with all that it means in terms of justice and mercy, and to let my thought life transform my actions

9. to take a few key trips to be with family

10. to meditate and pray more, to sync my heart more with God's

Yuletide blog

2011-12-24T09:31:00.001-05:00

Wishing you and yours a happy Christmas and/or Hannukah and/or holiday-not-otherwise-specified and a joyful 2012! For more of my reflections upon Christmas this year, please click here.

Teamwork

2011-12-20T21:41:00.001-05:00

2011 keeps trying to end like a whirlwind, like the hurricane of earlier this fall, with November slipping by like a breath. Even so, I am kind of against getting caught up in the craziness of the holidays this year. With Mom and John here for Thanksgiving, I really intentionally slowed the pace. I wanted to be sure to spend time with them. It was great to take the time and enjoy a few of my Baltimore traditions like hosting the "Thanksgiving orphans", a Thanksgiving Day hike, and antique shopping in Ellicott City. I also began rehearsing for the FCF Advent Concert, working with a group of five friends to arrange and rehearse an a capella version of "Angels We Have Heard on High" which was sung with such heart and beauty that I found myself not just singing but listening to my fellow choristers and reflecting upon those words of anticipation.

Despite all that Christmas has become in the American culture, Advent is really about the first coming of Jesus, who was born in a most awkward place and in a time of great uncertainty, homeless in a small town, to a single mother and a fill-in dad. It wasn't the most obvious way for the Messiah to appear, yet there were those who "got it" and stood ready to welcome not just a precious and delicate newborn baby but One who would be called Holy and King. That is deeply stirring to me. I am reminded that God is near to the broken-hearted.

I feel that I have finally emerged from a season of great hardship. Just a year ago, I was pretty burnt out. As a primary care doctor, a patient, and a small business owner, I felt that I had just about reached the end of my rope. I was considering career changes, because I could not imagine having to continue to work so hard and yet remaining under financial stress and being unable to afford bringing in another professional. I had applied to become part of the Maryland Multi-Payor PCMH Pilot Program and had waited for months to hear the news, only to find out that we were rejected in January. Many other hardships piled up in January, including stalemates in negotiations with insurance companies, the loss of a key employee, and tough business decisions. I weighed options and struggled. Then, in a strange turn of events, our MMPP PCMH application was reconsidered. In March, we were offered a place in the program.

Here is my month-by-month, just related to the practice:

January-February: working the equivalent of two jobs, single-handedly trying to put pieces of the Patient-Centered Medical Home together on my own and scrambling for ideas on how to accomplish it without funding; a first meeting of the Green Spring Internal Medicine Advisory Board

March: attending the National PCMH Summit Conference in Philadelphia, then finding out about our acceptance to the MMPP Pilot

April-May: our biggest and most challenging software upgrade since launching in 2006! interviewing and hiring Amy Luebehusen, CRNP, our amazing care manager and nurse practitioner and hiring Kweisi (CMA)

May: the MMPP Learning Collaborative - meeting with over 50 other Maryland practices to discuss what
PCMH is all about and learn more about what the NCQA application would entail; working with our software company on ways to capture data to improve patient care

June: preparing the launch of our PCMH, my first true vacation in years (2 1/2 weeks in Italy!)

July: the official 5 year anniversary of the practice and the launch of our PCMH and pre-visit planning via daily huddles, initiation of monthly staff and transformation team meetings and countless other policy and workflow changes, Kweisi's resignation

August: hiring Chanel (admin asst), conference calls, working with Amy and Laura (our practice transformation coach) on putting together the vastly extensive NCQA application, meeting with Wavelength MSO for help on preparing to attest for Meaningful Use with Medicare

September: a quick trip home to Aspen for rest from work on Labor Day weekend, more meetings and conference calls about PCMH and ongoing work on software glitches and changing our practice workflow, hosting a tour of the practice/reception for key partners in our work

October: submitting our NCQA application, thanks to Amy for the difficult details, working on preparing to certify for Meaningful Use, lots and lots of software challenges, Chanel's acceptance to college! Hiring Sara (CMA)

November: the MMPP Learning Collaborative meeting #2 which was greatly encouraging - meeting together with the other 50+ practices in our program, Amy giving a great talk and my brief summary of our history and progress, encouragement via shared values of others at the conference; the redesign of our front desk position, finding a new way to track documents and tests

December: running a successful test to submit vaccination report to the State of Maryland, finally working out enough of our software kinks for me to attest to Meaningful Use, 6 months of bookkeeping, Chanel letting us know that college was starting in January and preparing for that staff change, fixing breaks in the software to allow us to capture data to measure quality, organizing a software usergroup start-up meeting in January, staff party tomorrow, on the train Thursday, being closed for the next two Mondays, and finalizing the books by December 30th!

In less than a year, Green Spring Internal Medicine has gone from 1 doctor and 1 staffmember to a team of 5. We call our PCMH transformation team "the Early Adapters." After Chanel moves on in January, we will be hiring another team member. Everyone has pulled together, adjusting to the many changes we have had to make to meet the ideals and expectations of a small-practice Patient-Centered Medical Home. We have had a great deal of support from the outside. One insurance company just gave us a 10% raise, while still others stand in the way of progress.

Our patients have been key team members and have been pleased with the changes. We were grateful to be able to continue to participate with most of the major insurance companies this year, thanks to the Pilot Program. We have had the ongoing work of communicating to our patients and reminding ourselves what the Patient-Centered Medical Home is all about. Thanks to Amy, our care is better coordinated. Thanks to the staff, our charts are now more complete with notes from specialists, colonoscopy and mammogram reports, and other test results. Our visits are more organized, and we are working more collaboratively with our patients toward their best health. I feel so full in my heart, knowing that we are practicing better medicine as a team than I was ever able to practice on my own or in old models of care. Sometimes we find ourselves weary and hit what has been called "change-fatigue". Other times we are more inspired. We are working harder than ever, yet we are also seeing the results and reaping the benefits of sharing the labor. I now even have guarded hope for the future of internal medicine.

Feasting

2011-11-24T09:59:00.001-05:00

It is always tempting on Thanksgiving to write a list of all of the things I am thankful for. I could be inspired to start from the top of my head to the tip of my toes or go from floor to ceiling. Even that reflection could take quite a while. There is so much to be thankful for. Even though the relationships that began so long ago when Native Americans saved colonial ancestors from starvation did not end so well, it is still interesting to imagine how they might have related to one another over a feast.Whenever I am in town for Thanksgiving, I love to host Thanksgiving "orphans". I was impressed from my youth by Thanksgivings at my grandmother's house. It was never just our own family, but often out-of-town guests, houseguests of my grandmother, and a variety of other people were present. Bent, the Norwegian, comes to mind. Some family friends came year after year. I will never forget one Thanksgiving. The table was all set, and everyone was seated. Before I knew it, I tipped over my water glass and it spilled. "Thank God, a new twinkletoes!" exclaimed Uncle Loren. He had been dubbed the family twinkletoes, but now I was in the running for the title.During hard times like our present era, perhaps especially at times like this, it is so important to gather together and feast. Thanksgiving is a feast of sharing this year: John bringing the green beans, Frank bringing a bottle of wine, Megan and John bringing mashed potatoes, Rachel bringing a blueberry pie. This year we have the special treat of my parents' company. They are presently tidying up downstairs. I started cooking yesterday, not necessarily health food but certainly savory: slow-cooked sweet potatoes, rosemary cornbread, apple-sausage stuffing, a soon-to-be-dressed orange-sage turkey, and orange-marmalade cranberries. We even have a gluten-free pumpkin pie from Sweet Sin. Unlike others, I truly look forward to leftovers after Thanksgiving and hope they last for days. It is my favorite meal of the year.There have been a number of other "feasts" lately. Amy, our nurse practitioner, and I attended the Maryland Multi-payor Patient-Centered Medical Home Pilot learning collaborative meeting in early November. 53 practices were in attendance. I was able to share a brief presentation on our progress as a practice and how the learning collaborative has helped us. Since I only had a few minutes, it was a fast-forward version of our history since being accepted to the program through the present time. The changes in our practice have been exponential. As the underdogs of the program, we were pretty excited to be able to highlight the landmarks. Amy gave a presentation on the role of the care manager in the Patient-Centered Medical Home, and people kept coming up to me afterwards praising her for the excellent job she did. It was so encouraging to be in a room full of health professionals and staffmembers who share values on patient care. We experienced a feast of ideas.I am also in the midst of a feast of family: a trip to Aspen for Labor Day weekend, parents visiting for a couple of weeks, an upcoming trip to my sister's family in Connecticut for Christmas, and travels to Mexico for Cousin Tommy's wedding in February, my parents' return visit in the late Spring, and hopefully a weekend venture to Aspen for the 4th of July.There has been a feast of friends this year: a mini-reunion with dear college friends in January, travels in Italy and a stay in Tuscany with Baltimoreans in June, a little retreat with my dear friend Dede this summer, impromptu overnight visits with Tami, Sarean coming through, a weekend trip to Charlottesville to be with Lynne, and joining up to sing a Christmas carol in a small ensemble of friends at the FCF Advent Concert in a couple of weeks.

A New Song

2011-10-28T11:04:00.001-04:00

"I will sing, sing a new song." - U2 "40", paraphrase from Psalm 40

Some of us have been singing the same song for a long, long time. "How long?" keeps being the question. For many, this is a song of suffering that has found no relief, a song emanating from a "miry pit." Personality type and neurotransmitters may have to do with the durability of that old song. Sometimes old songs are sung from wounds that run deep, pain from a past that was never healed or perhaps healed with a scar that pulls, pains or misshapes.

We are living in an angry culture these days, and that is reflected in traffic and in the grocery stores, sometimes at home and at work. In the balance, there is much to complain about: financial injustices, an education system that is failing many of our youth, political disunity, somewhat of an unedited rude style that pervades the media and popular TV shows, people living selfishly who should be contributing their share, and on and on and on. It is an old song that reminds us of the Fall. The imperfect world we live in has muddy trails, pitfalls, impassible routes, and final and certain death for all of us. This weighs heavily in our hearts and we sing a dirge. We look around the swamp and struggle to find the positive. It just seems that at every turn, roots are everywhere to trip us up and send us into muddy water.

Like so many others, I actually love blues music, partly because it rings so true and sings that song on my behalf. The Shakespeare tragedies can be as entertaining as the comedies, because human nature is understood and reflected outside of ourselves. There is the reminder that someone else always seems to be worse off than we are, or perhaps more laden with awful tendencies? Though often we see ourselves in even the worst of characters. We struggle and sing the old song in a minor key.

What would a new song sound like? Jesus is the one who gives me my new song, and the next new song, and the one after that. A new song is a song from the garden, a place of fruitfulness and joy, a place of living out our perfect design without fear of the future. A new song is sung from a place of security that knows perfect love and is not afraid. It is a song that leaves behind anger and bitterness, because old wounds and resentments lose their importance when we know that we are perfectly loved and forgiven and that nothing will ever get in the way of that. A new song is other-minded, not a solo, best sung in community, because together with others we are not impoverished. We grow in joy as we share the redemption story, and we know how the story ends.

It is hard to sing a new song in a world full of pain and suffering. All around us, every day, are reminders of hardship and sorrow. There are lots of songs everywhere, some old songs and some new songs. The song we sing flows out of what exists within our hearts. Our hearts are deeply in need of transformation, of a turn in the trail up out of the swamp and to higher ground. We are unable to struggle our way out on our own, but thankfully we are not on our own.

Last Sunday, I went hiking at Gunpowder off of Bel Air Road. As I went along, I was struck by how well that trail seemed to represent all of life at just this time between seasons. For a moment, I mused at what it would be like if fall were followed by spring. Yet winter always comes. The trail had a rocky ascent amid the trees, with views of fall colors deep into the woods, especially toward the top. There is a pine forest at the top that is so orderly and stalwart, like classical music, a reminnder of all that is good when things are in perfect place.

The trail went on to a scrub brush section where the leaves had fallen off of deformed weed trees, and all appeared barren. At one point, I was distracted by the view from a ridge and tripped and nearly fell over a rock that was underfoot. Thankfully, though clumsy, I have a good righting reflex and seldom actually fall. Tricky river crossings multiplied in front of me, and there were patches of inevitable mud, making things messy. All said, the most remarkable thing happened. As I neared the top of the highest ridge, I heard sounds of birds with jungle-like resonance. Before I knew it, hundreds of birds flushed from the valley below and went first one way and then another before turning upward and landing on tree branches above me. "Not even a sparrow goes unnoticed by our heavenly Father."

I had never before witnessed such a spectacle, a bird migration, with many voices but unified direction growing out of the movement of a few determined leaders it seems. I thought of the great encouragement that grows out of commmunity, how we are never really alone. One of my friend's brothers took his own life last Saturday. The old song drowned out the new, as he struggled with deep and deadly depression. Sometimes there is nothing to be done, nothing that can pull someone else out of the mud and mire, yet there are new songs still to be written. We have just got to sing the new song to one another and "sing, sing a song, sing out loud, and sing out strong."

The Love of $

2011-09-23T18:02:00.000-04:00

It is popularly misquoted, "Money is the root of all evil."

What was really said in that all-time bestselling book is, "The love of money is the root of all evil." I have known those who, for richer or poorer, were relatively happy people. In plenty or in want, they got by just fine. Money was a tool and not an obsession, a necessary commodity but not an idol. I am grateful to have grown up with those values.

I have to credit my grandmother, Phoebe, as the best investor in our family. Born before 1920, she joined others of her vintage in getting married rather than finishing college. She had many channels for her intellectual energy: architecture, civics, world politics, art, and theater. She was most brilliant in choosing to move to Aspen, Colorado, in 1973 after by grandfather's death. Having visited Aspen on family vacations, she was ready to leave the rural outskirts of Chicago for the Wild West old silver-mining-town-turned-ski-resort.

As the story goes, she bought her 3 bedroom house with solar panels and a jacuzzi for $79,000. She went on to dream of, and even design models, of a family apartment above the driveway so that the rest of us could come and join her there. That was not to be. We were happy to enjoy the views from Independence Pass to Sopris Mountain during family gatherings, of course, a view that would ultimately be worth $2 million about ten years ago. By Aspen standards, the sum was a mere pittance, but I have to hand it to her for scoring a 25 time return on the property alone. After she moved out, a great big house was built in place of the original. She was able to give generously to her 6 children and how many was that? lots of grandchildren and still have enough to live out her days comfortably. Her legacy, as well, is that none of us in our family quibble over money, and we all still talk to one another.

If we ever did squabble, my grandmother sometimes called us "selfish shellfish"!

Other families struggle a lot more over money. I have witnessed heated arguments over bills that are due, how to manage debt, and how to control spending in times of want. Even so, the most unbelievably awful wars over money seem to occur in families of great means. It is as though the Prodigal Son story is played out over and over again. The righteous good son got so little for being good, and the runaway rogue was lavished upon by that unreasonably gracious and forgiving father. That dad would have been called out in the modern world for enabling. What could he do? His kid was starving and begging for help, and he had compassion.

But isn't there a time and place for tough love? Of course there is, in certain circumstances. We ought not encourage someone's bad habits or over-and-over again abuses. I've got to admit that I have had to learn some of the subtleties of tough love. I have seen families break apart, unable to speak to one another or even sit in the same room, all over flimsy paper with green printed sketches of long-gone old white men.

I heard a stark commentary on NPR this week which cited that about 1 % of Americans are millionaires; in contrast, 244 of 435 (46%) of our lawmakers in Congress are millionaires. As our country gears up to suffer through yet another economic crisis stand-off, I am sure that many are groaning just as much as I am. It is almost like the worst kind of family feud ever, one that occurs in public and thus only encourages exaggerated statements and last words, like two 17 year old sisters fighting in the car. Most of us middle class Americans are left to sit back and wonder whether or not these elected lawmakers. who will never-ever enact campaign finance reform so that a few more non-millionaires can be elected, will ever lay personal financial interests aside. Will our leaders ever be able to show tough love where needed, in situations of abuse, and yet still have compassion on those most vulnerable to starvation in the downturned economy?

Legacy

2011-09-15T20:50:00.000-04:00

"I want to leave a legacy. How will they remember me? Did I choose to love?" - lyrics from a song by Nichole Nordeman

Legacy seems like a pretty big word and makes me think of what will last for a long, long time. I think choosing to love is one way to build a lasting legacy. Those in our immediate spheres of influence, particularly those whom we parent or mentor, directly observe our choices, our attitudes, our language, and our demeanor. They see the passions that drive us and often follow in our footsteps, whether we would want them to or not. A child observes gentleness and grace in a parent and grows up to become gracious or witnesses anger and resentfulness and learns to be bitter. They see what we choose to give our lives to, for as Bob Dylan put it, "You Gotta Serve Somebody." Are we pointing to God? To success? To brilliance? To money? To political power? To beauty? To things?

"Good Night, Irene"!

2011-08-27T15:44:00.000-04:00

Is it possible that Irene used most of her twist and shout energy in the first dance and spun herself right out of energy? She has fluctuated between Category 3, 2 and 1, according to the local news-listeners at Starbuck's this morning. Maybe she is fizzling out, defying expectations of her greatness. Or perhaps she is resting up before catching her second wind. At any rate, she cut into my Saturday night plans. At least this wasn't my wedding day, as it was for a sad North Carolina couple who were forced to evacuate. I'm sure the Maryland State Fair is taking a hit, with many disappointed kids who had hoped to get on the rides, milk a cow, and see the baby animals.

With the news of the coming of Hurricane Irene earlier this week, I kept hoping she would spin out to sea. As the days go by, it has become clear that many are hoping and praying harder than I am. Over 300,000 people were told to evacuate low-lying areas of New York, and my sister and her family are housing another evacuee family in coastal Connecticut tonight. They are prepared for days without power, having already survived a week without electricity this past March in 50 degree weather.

Here in Baltimore, more inland, we are expecting a tropical storm tonight. I made little preparations last night: taking the compost to the backyard pile, moving patio chairs and waste bins into the garage, clipping the hedges (after all, would disaster befall such a well-kept property?), and charging my laptop and cellphone. I also put the solar flashlight and solar radio in the windowsill to charge up.

After some consideration, I also made a run to the office today to rescue the vaccines from a potential power outage there. With no back-up generator and no way to remotely assess the power status at Green Spring Station, it finally became clear to me that having the vaccines here at home was a better idea. This way, I can measure the temperature where they are kept and put them in an ice cooler if the power goes out. I thought about running to the store for candles, but I really do have plenty at home. It may be better to just get extra rest anyway if we lose power. I don't know, though, it just seems this storm hopefully will not be as disastrous as the news stations predict. Public anxiety does seem key to news ratings.

Swing!

2011-08-25T21:46:00.000-04:00

I found my way back to a long-term love, this past weekend: swing dancing. I had only been dancing one other time since March of 2009. A confluence of events had conspired against my return to the dance floor: breast cancer treatment, knee injury, and other detours. Now that I am in my 40's, driving home from DC in the middle of the night is a bit too much; though for months I have caught myself tuning into NPR on Friday nights fondly listening to jazz for hours. Then a few weeks ago, I happened upon an e-mail from Charm City Swing highlighting upcoming workshops with world class Lindy champions and dances with a live band, all for just $100 and here in Baltimore just minutes from my house. I had to sign up.

Returning to swing dancing last Friday night, I bumped into many people I have not seen for the past couple of years. Most of them had no idea as to why I had been gone for so long but were matter-of-factly glad to see me back. As I took a few turns, I realized how much joy dancing brings. After five hours of workshops on Saturday and then another dance, I was also reminded of which muscles are more uniquely used for dancing than other more recent activities. I have been known to overdo it a bit.

I think one of the greatest treats was a musicality class taught to us swing dancers by the band members (the amazing Boilermaker Jazz Band). We were reminded that musicians count to 4 whereas dancers count to 8. They played three different versions of Honeysuckle Rose: a 20's style, 30's style, and late 40's style. They highlighted the various accents of the drums, bass and guitar and discussed the overall structure of typical jazz swing - AABA. If dancers get it, then we are able to hit the breaks with cool moves. There are also certain signature sets of notes or structures that end a song; though, of course, the band can play a trick ending. One thing became clear to me, that the 30's style jazz is so much more sophisticated and beautiful sounding and more dance-inspiring than the boogie-woogie beats of the next decade or two. I am sure that this is a matter of preference. I would not be sad if I never ever heard another boogie-woogie song in my entire life. Swing music, on the other hand, is a joy just to listen to and even more joyful with a little movement. I can keep on going for three hours without even realizing it's exercise.

How much a part of my life will swing dancing now become? I don't think I will get back to three nights a week, like it was in my late 20's. Hiking, biking, soccer coaching, and community-building have all occupied some of the space that swing dancing used to occupy. Perhaps it'll be a dash of dancing!

Quirky

2011-07-30T17:19:00.001-04:00

When things don't totally add up in the usual way, that may mean that it's a God story. I had one of those happen to me yesterday, at least yesterday was when the story became the God story. I was born with a birth anomaly, among others, called a coloboma. This condition involved my right iris and pupil and caused my optic nerve not to grow in properly. As a result, I have had one-sided or monocular vision since I was born. The little vision that I had from the "bad eye" was only of movement or color, but I could not distinguish any objects clearly. Lacking depth perception, I was never much good in the ball sports, having tried out for softball and basketball without making the team. Thankfully, my chosen sport, horseback riding, was unaffected. I was able to drive, because my left eye vision was perfect and the brain has adaptations in the setting of monocular vision. Due to plasticity, or rewiring of neurons in early childhood, I have a heightened sense of size and shadow, helping my perspective on distance. 3-dimensional movies have always been lost on me, and some optical illusions as well. One doesn't miss what one has never known, at least not much. I was not destined to be a surgeon either, always told that I cut the knots "too short" or "too long" when I assisted as a medical student in the operating room.

More recently, I had been told that a cataract had grown in that eye but not to bother correcting it. About three years ago, a brownish spot started floating along the center of my vision, and I thought it might be a floater. My eye exam only showed a cataract and the need for computer and reading glasses. Strangely enough, over the past two years my computer and reading vision improved, so that I no longer need glasses.

Then, this past winter, I began to notice that my "bad eye" seemed to lag. In photos, this created a zombie effect that was noticeable. Of course, with the history of breast cancer, I worried for a moment; however, consulting Dr. Guyton at the Wilmer Eye Institute and the internet, it became clear to me that this is a common problem when one eye does not see well and the other does. I had also been working 10-14 hour days, including Saturdays, while gearing up for major work projects. I looked into having the problem corrected surgically, but when it became clear that it would amount to general anesthesia, I had to resist. I have had so many surgeries in this short life, including 4 in the past 2 or so years. After vacation earlier the summer and fewer hours at the computer, this problem has become less pronounced.

I went to see my eye doctor yesterday, also a medical school classmate of mine, and described all of these things. Eye muscle weakness could have been worse with fatigue. My vision may have improved with better control of dry eyes and allergies. What was hard to explain, though, was that the previously noted cataract could not be found, at least not at first. In addition, my right eye vision had improved to the point that I was able to count fingers! Dr. Castelbuono asked whether I had had eye surgery, and I said that I had not.

Then he went looking and, lo and behold, the lens that had been affected by the cataract had moved out of position and was sitting in a parking spot at the back of my eye. My right eye, essentially, no longer has a lens at the front. The rods and cones on the upper portion of my retina (vision and color producing cells at the back of the eye) also looked healthy. Thus that would explain why my vision in the right eye had improved. Maybe science, maybe God, or both? Neither he nor his resident had seen this before.

Anyway, since yesterday, I have been trying out the right eye and find that it allows me to grab the phone or my computer mouse on the right. Not like I will eventually be reading with that eye, but I think it's time to try to strengthen the muscles now that my "bad eye" sees a bit more than before, so that I really can avoid surgery. Who knows whether or not that would really work, but it's interesting to try.

As I was exercising at the pool today, I was thinking of the metaphor of "the scales falling off" of my eyes. Maybe I should marvel even more at how my perspectives have changed over time. Some things I had failed to see before have become apparent. I am grateful for the process, both in the case of my eye and in the case of my life perspectives, that the vision changes have been none too sudden nor traumatic and have been for the better.

At some point, I may blog on my trip to Italy, but for now I am just grateful for having had the rest and now having the arrival of reinforcements at the office. Amy, our nurse practitioner, has been a most welcome addition to the team and is doing her part in sharing the labor and joys of the transformation of our model. I am confident that our patients and we will reap the benefits of all of the hard work and creativity that is going into our Patient-Centered Medical Home.

Letter to Patients

2011-06-15T18:50:00.002-04:00

GREEN SPRING INTERNAL MEDICINE, LLC
2360 W JOPPA ROAD
SUITE 210
LUTHERVILLE, MD 2109
410-583-2890, FAX 410-583-2891
www.greenspringmed.com

June 15, 2011

Dear Patient,

Thank you for entrusting us as your internal medicine practice. As such, we are committed to providing you with the highest quality service, access to your health information, and streamlined transitions between healthcare settings. Since the practice was founded in 2006, we have been committed to excellence and have successfully implemented eClinicalWorks electronic medical record and practice management software. We are at the forefront of a major movement in our area. Because we strive to be the best, we are taking our next major step as a practice to improve our model of care and are sending this letter to extend the invitation for you to join us in this endeavor.

We are writing with the great news that Green Spring Internal Medicine was chosen as a pilot site for the Maryland Multi-payer Patient-Centered Medical Home Program! We were selected competitively from among many applicants to participate. Under the direction of the Maryland Healthcare Commission, the Program was recently launched in partnership with other primary care practices, consumer groups, health insurance companies, the Maryland Department of Health and Mental Hygiene, Johns Hopkins, and the University of Maryland, among others. We believe that this pilot program will provide key resources and tools to enable us to better address your medical needs at no additional cost to you. We are thrilled about this opportunity to partner with you in the process.

Being selected as a pilot site allowed us to remain in network with CareFirst and all of its products (at least through December 2014), contrary to a letter some of you recently received from CareFirst or BlueChoice in error.

What is a Patient Centered Medical Home? ”A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety. ”

- definition from the American College of Physicians web site on the PCMH concept

At a recent staff meeting, we came up with a mission statement for Green Spring Internal Medicine’s Patient-Centered Medical Home: an evidence-based approach to equip, encourage, empower, and engage patients. You can read more about PCMH on my blog at www.drhollydahlman.blogspot.com

What will change and how will I benefit?

Team-based care: We are re-designing our staff and provider team roles in order to better serve your needs, using our software as a tool to assist us. We are blessed to welcome Amy Luebehusen to our team. She is a highly qualified, experienced Nurse Practitioner from Maryland. A graduate of Western Maryland College who completed advanced nursing training at Penn, she will be able to see patients for urgent visits and when my schedule is full. She will be taking new patients. I am pleased to add another provider to the team. She will be serving part-time in the capacity of care manager, reaching out to our more vulnerable (or in some cases less frequently-seen) patients in order to proactively assist with care transitions and promote better health. She comes highly recommended. Kweisi (pronounced kwa-EEE-suh) Vines has also recently joined our certified medical assistant staff and will assist Erica Reese, who has been a devoted staff member of Green Spring Internal Medicine since 2008.

Collaboration with you: We are working toward launching Patient Focus Groups, which will meet periodically and allow patients to network with one another to share health resources and work toward common health or disease self-management goals. These groups will center on diabetes, hypertension and weight management. Please let the staff know if you are interested. We will also seek feedback and suggestions from patients by way of surveys and a Patient Advisory Committee. We are also hoping to work more closely with family and caregivers in circumstances such as dementia, realizing their role as part of the medical home. We would like your feedback. One way to give us feedback is to click on the Survey Monkey icon on our website: www.greenspringmed.com.

Communication: Our practice has always valued sharing information with patients. To that end, we have implemented the Patient Portal. Exciting new features have been added: view lab results from Labcorp and other select labs, view portions of your chart and messages from the office, and even schedule your own appointment! It requires only a basic amount of computer knowledge to take advantage of this wonderful feature. We hope you will sign up soon, if you haven’t already. You can now enroll online by going to our practice website: www.greenspringmed.com and clicking on the Patient Portal link. Our practice website also has a link to the eLibrary which has helpful resources including interactive websites. We hope to post more health material and even smartphone health apps on our Patient Portal in the future.

Improved access: Starting in July, we will expand appointment hours as follows: Monday through Thursday from 8 am – 7 pm and on Fridays from 8 am – 5 pm. Phone hours will also expand to 8 am - noon and 1 pm - 4 pm on weekdays. Same-day appointments are available for urgent needs, and we encourage you to call the office to arrange an appointment. Because Green Spring Internal Medicine is your medical home, we highly recommend that you schedule a visit to come to us rather than heading to Patient First, the ER or other urgent care facilities. As always, if you have a true emergency (such as stroke symptoms, chest pain, shortness of breath or heavy bleeding), then please call “911!” We are working with local ER’s and hospitals to ensure that we are notified promptly if you have been seen or admitted. If you do not hear from us after an ER visit or admission, then please call the office at your earliest convenience. Our desire is to make transitions between healthcare settings more seamless.

Pro-active approach to long-term health: Our team will be monitoring your medical needs and may call you to schedule visits or tests that are due and will assist you in arranging consultation with other providers. As well, we will work to ensure that specialists are communicating with our practice and with you in a timely way. Please do not forget to ask other providers whom you consult to fax notes to our office 410-583-2891. This way, we provide a central location for your medical records. Our aim is to improve coordination of information between our office and labs, radiology centers, hospitals, and other facilities and to have important information available at the time of your visit. The Patient Portal allows you to view your medication list, according to our records, as well as the date of your last visit.

Shared responsibility: We will work together with you to create a specific plan of action at each visit. By giving you a copy of your note at the end of every visit, we have been able to communicate clearly, but now we will be asking for your health care goals. We hope to engage you more in the dialogue – listening and coaching rather than “preaching at you”.

Efficiency: You may notice changes in staff roles that allow our office to work more smoothly. As before, please bring a brief list of your concerns and an up-to-date copy of your medication list to your appointment. Please think of refills you may need. In addition, the Patient Portal allows you to answer a set of questions about your recent health in advance of your appointment. You can also update demographic information on the Portal.

Health information and practice updates: Find links to websites on our eLibrary linked on our practice website or additional health information on the Patient Portal. We are also gathering a list of health-related smartphone apps from our patients to share on the Patient Portal. Let us know if you have one. For more real-time updates, follow us on Facebook (Green Spring Internal Medicine) or on Twitter: @GreenSpringMed.

It is our strong desire that every patient in our practice benefit from this Patient-Centered Medical Home. This will allow us to continue to offer the best care possible. We believe this model represents the future of primary care practice in the

United States

What do I do next? If you are interested in partnering with us in this endeavor, then all you need to do is continue as a patient at our practice. If you do NOT want to participate in the program, then please cut and paste and then print the opt-out form below and mail it back to us by August 1, 2011. If you choose not to participate, you are still welcome to be our patient and to receive care as you have in the past.

With sincere regards,

Holly Ryerson Dahlman, M.D.

Green Spring Internal Medicine, LLC

OPT-OUT FORM

Dear Dr. Dahlman:

I understand that the Maryland Multi-payer Patient Centered Medical Home Program services would be provided to me at no additional charge; however, I choose not to participate in the Program. By opting out of the Program, I understand that I may be relinquishing the additional services outlined in the letter I received. I also understand that this decision may preclude future participation in the Multi-payer Patient Centered Medical Home Program.

I have made the decision to opt out of the Program in a completely voluntary manner and not under the influence or direction of any other person or entity.

____________________________________________

Patient signature* Printed Patient name

_____________________________

Date

_________________________

Parent/Legal Guardian Signature***

___________________________

Printed Parent/LegalGuardian Name***

****Documentation of guardianship required

_______________________________

Date

Blazing the Trail in EMR

2011-06-08T22:07:00.000-04:00

Click the title above. That will link you to an article I wrote for the Chesapeake Regional Information System For our Patients (CRISP). The article is a bit technical but tells the story of our practice, the first five years. It also highlights our dual goals for the next phase: to achieve "Meaningful Use" according to Medicare standards and transform into a Patient Centered Medical Home.

Progress Note

2011-05-28T15:55:00.001-04:00

It has been a busy few weeks, accelerating Green Spring Internal Medicine down the runway and into the air, as we rise up to the challenge of Patient-Centered Medical Home transformation. I have been to a series of conferences and webinars and am even presenting a webinar for CRISP on electronic medical records (EMR) implementation in small practices. I am excited to be in a role of championing the cause of EMR, having been a trailblazer all these years and continuing to blaze ahead. An article published online and in print this week, in the newly minted Maryland Physician Magazine, features our practice.

I just finished writing and submitting an op-ed article to the New York Times on healthcare driving forces, so keep your eyes out! If I am rejected, I think I will recover. After all, I am not a full-time writer. Still, I do have a heart to translate the high-stakes issues to common folk so that we can all better understand and push for what is good in healthcare delivery.

I have been working long hours, smoothing out some of the wrinkles of our eClinicalWorks Version 9 upgrade. Having set our system up in 2006, there are many features we still need to customize in order to maximize the use of the software and to prove to Medicare that we have achieved its "Meaningful Use." One of the greatest new features is the upgraded Patient Portal. We will soon be able to offer online scheduling and pre-registration for our patients. Already, patients are able to go to our Portal to see their lab results when they have gone to Labcorp. The same will soon be true of Quest lab results. We have also been reaching out to Johns Hopkins and Sinai Hospitals to put together interfaces and to streamline communication between our entities when patients are admitted. Through CRISP, we will soon have the ability to have radiology results arrive in our patients' records as soon as they are available. This degree of efficiency is of life-saving magnitude.

By far, the best news of all is that Amy Luebehusen (pronounced loo-bee-hoo-sen), CRNP, has agreed to join our practice in June. Amy is a Marylander and did nursing school and training at University of Pennsylvania. She has extensive experience in clinical practice and chronic disease management. Most importantly, her heart is in the right place about primary care and building longterm relationships with patients. She will come on board partly in the capacity of our Care Manager, a role defined within the Joint Principles of the Patient-Centered Medical Home. She will also serve in the capacity of primary care provider and will be filling in for me at the end of June during my vacation. Her official start is at the beginning of July. She and I will share more complex patients, and she will also establish a panel of her own patients. Though certified nurse practitioners and physicians have different root training, our skill sets are complementary. For example, Amy also has a lot of experience in women's health including gynecology, which has never been my forte. CRNP's bring a lot to the table in primary care, and they will need to fill some ranks since there is a nationwide shortage of primary care physicians. A part of the PCMH design is to have everyone in the office operating at the top of her/his license or skill set.

We were also blessed to bring on a new Certified Medical Assistant, Kweisi (pronounced kwa-eee-suh), who joined the staff in early May. Kweisi is organized, skilled, and eager to assist our patients. She has been a much-needed addition to the practice after Samantha's departure in January. Erica has remained a dedicated and steady staffmember, helping countless patients with countless concerns, and almost never complaining even in the midst of a crisis.

In addition, more help arrived in the form of Wavelength MSO, a company that will be working with our practice and with eClinicalWorks to make sure that we are ready to attest to "Meaningful Use" with Medicare. This will result in receiving the long-awaited EMR bonus for hard work of the past 5 years. This will greatly help us, as there are many pieces that still must be put into place this year. Thankfully, those pieces will also be of great benefit to patient care and will help us achieve our PCMH transformation as well.

I am fast at work, putting together a letter that will go out to the entire practice, highlighting features of our PCMH program and giving patients an opportunity to opt out if they wish. Of course, we are hoping that everyone will participate, because it is going to be great for patient care. Having all of these projects has been like an extra job, pretty much since January. It is almost like starting the practice all over again. That has me plum tuckered, at times, though the hope of a better future for primary care does drive me onward. I will be graced with a vacation to Italy soon and then will arrive back on July 5th, exactly five years since the practice started up, ready to implement phase II of Green Spring Internal Medicine, LLC.

East Coast Whirl

2011-05-08T17:04:00.000-04:00

Mom and John just arrived in Baltimore for their annual East Coast tour. I am glad they are back in town, as so many people have been asking about them and waiting for their arrival. Thankfully, Mom has been totally healthy and John has overcome his own health blips this year. For being in their seventies, they are quite spry, I'd say.

I had a bit of an East Coast whirlwind tour myself, running up to NYC on a train before 6 am on Friday to attend the eClinicalWorks Northeast Users Group Meeting. Penn Station to Brooklyn, then at the end of the day from Brooklyn to Grand Central to Greenwich, CT. I had a chance to stay overnight with my sister and brother-in-law and two nieces. The turn-around was too quick, because by 6:39 am, I was back on the train to NYC Grand Central to Brooklyn. After the conference ended, Brooklyn to Penn to Baltimore to meet Mom and John at BWI where they had flown in yesterday afternoon - all in a day-and-a-half!

The eCW Northeast Users Group Meeting was quite an encouragement as the New York City doctors are pretty far along in implementation of Meaningful Use features and the Patient-Centered Medical Home. Thus, at the conference a lot of presentations and questions that were asked were at a more advanced level. It is a blessing to know that, over 5 years ago when I chose to go with eClinicalWorks, I picked well. The software company has been very forward-thinking and adaptable. I came away from the conference with a sense that the company is truly in tune with doctors and is most focused on helping doctors in the frontlines to manage increasingly large and varying amounts of data. In other words, eClinicalWorks has vision. I was particularly impressed when I spotted the CEO at the back of the room during several presentations. He was willing to field questions and did so with great respect and kindness.

I was able to meet many people from the company and share our story with them. I am hopeful that we will be able to connect with eClinicalWorks on a more personal basis and work with them to iron out some of the wrinkles we recently experienced with our Version 9 implementation. Most of the time, our issues have been with communication, knowing who our go-to person is, being able to reach them, and being sure the information is coordinated. As I thought about it, our software company organizing our practice's IT pathway is much like me organizing my patient's healthcare. Seamless transitions are the ideal, but often not the case.

Finally, it was good to have fellowship with other providers who have struggled at the forefront of electronic medical record and practice management technology. We put in time, energy and elbow grease long before there was any promise for financial return. The reason? It is best for patient care. Hopefully, like Medicare, the insurance companies will start recognizing the commitment and cost put forth in accomplishing best practices and reward practices for our work. I know that our goal to become a Level 3 Patient-Centered Medical Home would not be feasible without a system like eClinicalWorks.

Crosses to Bear

2011-04-22T22:31:00.000-04:00

As a doctor, I am no stranger to suffering. As a person, I have had just about my fair share. I am always impressed when I come across an individual who has turned suffering into a growth opportunity or found some other redemptive story in the midst of it. A couple of years ago, I was in the midst of chemotherapy for Stage I breast cancer. I still kept 80% of my normal work hours and pressed on with a number of major commitments. There were times when I was worn out, times when overwhelmed. During "one of those days", a patient of mine came to visit who is an ophthalmologist from India and a fellow Christian. He asked how I was doing and got the honest answer, "I am suffering."

To this he replied eruditely, "It is always so interesting when we find ourselves surprised by suffering. Becoming a Christian is almost guaranteed suffering." Of course, Christians do not own the lion's share (no pun intended) of worldwide suffering, but we do happen to worship a God who suffered on our behalf and let us know that His desire was for us to become like him. Not a lot of Christians really look like Jesus, though I am pretty sure He uses our moments of suffering to make us more like him. I really had to brew what my patient had said that day. Finally, one day, I actually wrote a song. It truly emerged from meditation on suffering. Here are the lyrics:

Don’t be surprised when you suffer,

For it is the way of the cross.

The pathway of pain

Seems a place of such loss,

But in the end it is Jesus we gain.

We proclaim that we want to be like Him.

Do we really mean what we say?

So many blessings He brings in the things we didn’t ask for,

God’s ways are not our ways.

Blessed are the poor in Spirit,

For theirs is the kingdom of heav’n,

As they mourn they find comfort,

As they meekly receive

The righteousness they’ve ever longed for.

Not a lot of Christians are, like the Apostle Paul stated he was, trying "to be like Christ in his sufferings." Some try to avoid suffering at all costs. Nobody I know desires to be crucified. We don't have to go looking for suffering; it is a part of life. It shouldn't surprise us, even though it often does. It is not unusual to react to suffering by questioning God's love or somehow feeling punished. I think it is true that we sometimes suffer because we have done wrong or have not done what we should have done. Most of the rest of the time, we have no exact sense why we are suffering. One thing is for sure, we are not alone. I used to think the poem "Footprints in the Sand" was so schmaltzy; yet, I remember praying on the way to work back in 2009 for God to carry me through what seemed to be an impossible time. I still struggle when things don't seem to be going well, still surprised and still needing to grow and not just fall apart. Let no suffering be wasted!

CareFirst Still Alive

2011-04-18T22:09:00.000-04:00

If you are one of many of our patients who received a letter signifying our resignation, please know that we have rescinded that resignation. My previous blogs have some highlights of our dialogues with CareFirst and other insurance companies. Thanks to the Maryland Health Care Commission's invitation to our practice to join the Multi-payor PCMH Pilot Program as a site, we were able to re-engage in business with CareFirst. We are hopeful that the health insurance companies will see the wisdom of supporting best primary care practices, including the use of health information technology and interfaces between healthcare settings. We are seeking to smooth the transitions between care settings for our patients, reducing medical errors and redundancy, and improving overall efficiency in the process. I, for one, have been working very hard to put new pieces in place that will further improve communication between our patients and our practice.

We just updated to eClinicalWorks Version 9 which will qualify us for the Medicare Meaningful Use bonus, but more importantly it will add important new features to enhance patient care. On the newest version of the Patient Portal, we will offer open scheduling, allowing patients to choose the open appointments which best suit their own schedules. We will also be able to post lab results from Quest and Labcorp which individuals can securely review online. Many other processes have been streamlined, including automatic appointment confirmations. This will free up our personnel and providers to server patients in a more personal way.

Finally, we are working on hiring a nurse practitioner to assist us with care management while building a panel of her/his own patients. I look forward to the arrival of a colleague who shares our vision for the Patient-Centered Medical Home.

We apologize for any distress the CareFirst letter may have caused. We rescinded our resignation in early March; however, CareFirst had set a process in motion that could not be interrupted, even a month in advance. Thanks for understanding! Please contact your insurance company if any further questions arise.

Home in the (neighbor)Hood

2011-03-26T15:23:00.001-04:00

Coming home to Baltimore from the PCMH Summit in Philadelphia, I have to confess that I had to recover. The conference honestly overwhelmed me. It was as if 1000 people with my personality all got together in one room. What would you do with a room full of visionaries? What impressed me even more was how much more idealistic they were even than me!

By the end of my first day back to the office, I had over 100 documents to review and about 50 phone calls to make. The next day was only a little less hectic. Finally, over the weekend, I had a chance to sit and reflect, journalling through my thoughts. As I did so, I realized how big this project is and how the patient-centered medical home extends so far beyond me and so far beyond the walls of Green Spring Internal Medicine. There are certain features of patient-centered care that we would not possibly be able to achieve on our own; thus, we are going to have to tap into community resources. Most of all, we are going to have to involve patients in the process.

As thoughts flowed, I sketched a diagram of what the PCMH would look like. It was a daisy! This struck me as neat, because in my doodles and sketches in my journals throughout the years, I have often sketched daisies. It was a "eureka" moment for me, to think of our PCMH like this! In a rare artistic burst, I put this together later in the week to show exactly what I mean.

... and furthermore, a friend pointed out to me at church last Sunday, as I was sharing the story with her, that I was wearing daisy earrings. At that moment, even though it might seem so little, I felt the warmth of heavenly affirmation. I have to admit that I have relied upon God moments like this over the past 5 kind of scary years, the reminders that He is in it. It gives me a bit more bravery.

I thought about how we, Green Spring Internal Medicine, would be a home with a number of rooms in it: patient focus groups, care coordination, a nurse practitioner, medical assistants, community educators, nutrition, maybe even a psychologist, all overseen by me but all taking part in an ongoing team dialog and team effort focused on what it means to be patient-centered and what it means to be a medical home.

Hopefully, we will become a beautiful home, much like this beautiful row home I photographed while walking through Philadelphia last week.

Our medical home will exist in a medical neighborhood. What I like so much about the row home concept of the medical neighborhood is that rowhomes are attached to other homes in their community. Through care coordination and health information exchange, it will be possible for transitions between medical settings to become much more seamless for patients.

As in other neighborhoods, I am sure there will be a certain amount of "keeping up with the Joneses." In addition, some medical neighbors may need to be encouraged to get up to speed and fix the broken windows. There is increased safety and strength resulting from joining forces, and many lasting relationships are fostered by neighborliness. It is interesting to think of how these ties will form between entities who will invest in patient-centered care.

Hopefully the end result will be a much more relational than informational approach to healthcare. Research shows that certain patient populations especially value "affective" or more emotionally-connected interactions with health providers, as opposed to the traditional information-giving. With the internet, it is now more common for patients to come in full of information they've read on the web about issues affecting their health or the diseases that afflict them. Patients with rare diseases often know a lot more of the details than I do. An empowered patient has more charge over her/his health destiny; thus, the role of the health provider changes from analyst/director to compassionate coach. The word "compassion" has Latin roots. "Com" means "with". The Latin "passio" means "suffering". For many, staying in good health involves suffering. For others who are affected by chronic illness, there is a daily cross to bear. By putting a better model in place, a model that lessens the hassles of healthcare delivery, we are able to relieve unnecessary pain.

Transformation

2011-03-16T11:41:00.000-04:00

I can cite a variety of transformational events or periods of time in my life:

- coming to faith in my youth
- moving to Aspen the summer after freshman year in high school
- going off to college at Mount Holyoke
- starting med school at Hopkins
- becoming an internist, through training in the Osler Medical Housestaff and early years in practice
- joining a group practice in 1999
- a shift in thinking on politics, largely driven by my experience as a doctor in the frontlines of the U.S. healthcare crisis
- leaving the group practice to start Green Spring Internal Medicine, LLC

When Green Spring Internal Medicine opened its doors nearly five years ago, we were ahead of most of the other practices in our neighborhood in terms of the use of health information technology. Namely, we fully implemented eClinicalWorks as our electronic medical records and practice management system. From scheduling, to note-taking during office visits, to ordering labs and diagnostic tests, and tracking disease processes, we have utilized various features of the software as they have been developed and have eagerly awaited the new versions. Version 9 is especially anticipated, as it will help us to achieve "Meaningful Use", a set of well-conceived standards for utilizing computer systems to assist in patient care. Medicare will provide a bonus to practices that achieve this over the next 4 years. We are also looking forward to SaaS (:software as server") hosting which will allow me to securely access my records whenever I am away like I am now.

I am sitting in a large conference room at the Loew's Philadelphia Hotel at the National Patient-Centered Medical Home Summit. It is the last day of a 4 day symposium focused on transforming the healthcare delivery system in primary care to the Patient-Centered Medical Home. This model has proven success at improving patients' access to care, engagement in health, and patient satisfaction. There are also some studies to suggest increased provider and staff satisfaction. Perhaps most importantly, "Medical homes reduce costs through relationship-building." stated Jeffrey Brenner, MD just now.

If any of you have really talked with me lately, you must know that the current status quo is not sustainable. I have been seeing an average of 80 patients per week, bearing the challenges required of primary care mostly on my own shoulders with the help of a very small staff. It has been too much, and there is need to change; however, the current system of fee-for-service healthcare has driven the speed of the treadmill up with no increase in compensation for my ever increasing pace of practice. The faster the pace, the more impossible it is for me to achieve what every patient needs from his/her primary care office:

- a relationship with a devoted, undistracted personal healthcare provider
- cultural sensitivity and communication in a language that is understandable
- a listening ear, with adequate time to express concerns
- access to urgent appointments at reasonable hours
- screening for risky lifestyle choices
- screening for disease
- evaluation and management of acute issues
- thorough physical examination, at least periodically
- time to be heard when in the midst of a crisis
- mental health screening and counseling
- ability to provide feedback to the practice - complaints or suggestions
- thoughtful prescribing avoiding drug interactions, while reducing costs through generics
- authorizing necessary tests and medications
- access to lab and test results
- a written care-plan at the end of every visit
- coordinate healthcare, scheduling appointments and processing information from every entity related to health
- knowledge that the primary care provider has been communicating with specialists
- help negotiating the complex health insurance atmosphere
- ready access to specialty care when needed
- preferred methods of communication with office staff and providers
- ready access to community-based and internet-based health resources that are interactive and culturally sensitive
- ready access to medical records
- ready access to referrals and follow-up of the results
- a smooth transition to outpatient care after being hospitalized
- a way to state goals at the end of every visit and seamlessly report on success before/at the next visit
- a team-based approach to ensure that important information never slips through the cracks

The above is basically my job description, with the help of Erica and Halie. Research studies suggest that a primary care doctor doing his/her job in total would work, on average, 21 hours per day! I must say that I am not working 21 hours a day; yet, I cannot deny the impact of bearing responsibility, even though we have added tremendous efficiency via eClinicalWorks.

What is the solution?

Our transformation into a Patient-Centered Medical Home!

What is it?

Well, it has taken me the past 4 days at the conference to try to figure that out.

Patient-centered: the idea that care revolves around the patient and not the doctor, focused on what is of greatest benefit, involving patients not only in their own care but also in how the practice works, finding ways to connect patients to one another in order to support health initiatives, empowering patients to actively engage in every aspect of his/her health

Medical: pertaining to every aspect of every patient's health in the context of his/her family, community, and the larger population

Home: a place for gathering... gathering of information, gathering together with one another. It is a place for being in close relationship not only with the provider but with a whole team focused on care including family members and other sources of support to each patient, What "home" does NOT refer to is an institution or a bureaucracy. It is kind of like a "home page", and nothing like a "nursing home".

In the patient-centered medical home, the patient stands at the center with our practice team standing at his/her side, advocating for the best possible care and serving to translate, facilitate, and communicate.

We will be supported in our transformation process by the Maryland Healthcare Commission's Multi-Payor PCMH Pilot Program. We have been selected as one of approximately 60 sites in the State of Maryland, varying from small practices to large group practices, from independent practices to hospital-owned practices, from private groups to community health centers. Without becoming part of the pilot, I believe we would have lacked the leverage with insurance companies and would have been unable to afford the cost of the new model. We long to become part of the solution and not remain part of the problem of unsustainable rising costs of the U.S. healthcare system. The current system is unsustainable, and noone knows this better than primary care physicians; though, the government has lately taken notice. Large businesses, like IBM, have also recently taken notice and are partnering in the process of transforming payment models. Insurance companies need to engage in this process as well, because most practices will still have to function on the fee-for-service treadmill model while moving in the direction of the PCMH.

The most important partners I have are my patients. I am looking forward to inviting patients into this process, not just by staying with us through the transition but also by providing valuable feedback to us. We created an easy SurveyMonkey link on our practice website: www.greenspringmed.com. We have also assembled a GSIM Advisory Board comprised of patients. Other future opportunities include participating in health groups which will probably focus on diabetes, obesity management, and smoking cessation.

After 4 days of ideas, there is still much to process. I am looking forward to the change, inspired by the possibilities, somewhat daunted by the task that lies ahead, but borne up by the certainty that this is the right thing to do.

Win-Win-Win

2011-03-09T22:39:00.000-05:00

I am happy to report that I have rescinded my resignation from CareFirst. CareFirst was happy to accept me back into the network on the terms previously agreed upon; although, there may be a few snafus with respect to the CareFirst Maryland products which were slated to phase out this Friday. This is what was to have been:

"3-11-11 Out-of-network takes effect with: NASCO, Bluecard, CareFirst of Maryland (provider # 2228)

4-11-11 Out-of-network takes effect with: Bluechoice, FEP R prefix, XIC, XIK, XWR, XIA, XIJ, KWY, XIP, XIL, XWP, MHIP, FEP Maryland providers (provider # 4108-0001)"

Carefirst representatives informed me that they expect the CareFirst of Maryland plans to be integrated into the regional plans (that are listed as those affected by the 4-11-11 date). Because this change in plans is at the 11th hour, there may be a few hold-ups in the process. It is possible, for example, that my BlueChoice patients may receive a letter of notification of my resignation. Hopefully, that won't happen.

In this case, I believe it is not just a win-win situation (i,e the Maryland Health Care Commission Pilot program bringing about acceptable terms of business between Green Spring Internal Medicine and CareFirst). I believe it is a win-win-win situation, because hundreds of my patients will now not have to go scrambling for a new doctor.

It is possible, through the Patient-Centered Medical Home, that internal medicine doctors and other primary care providers will be able to convince insurance companies to join us in the common goal of keeping patients healthy: lowering costs, while still valuing the frontline of healthcare providers as professionals. Keeping patients healthy and helping sick people stay out of the hospital by managing their conditions proactively - shouldn't that be our common goal? It costs less and is the right thing to do. Wouldn't that be amazing? That doing what is good would be rewarded, who could argue against it?

The bottom line issue in the primary care workforce shortage is that the doctors who practice as generalists must be valued as professionals through fair compensation, recognition of the value of our services, and acknowledgment of the fact that those of us who promote our patients' best health must also achieve a reasonable work-life balance and financial security for the sake of our own health. Otherwise, we would be hypocrites who should be disregarded, whose message becomes discredited by our actions.

On the Brink

2011-03-04T22:03:00.001-05:00

"We worship an on-time God." - Bill B, worship leader at my Baltimore church

As I drove to work this morning, I started thinking about how on earth I was going to break it to about 800 of my patients that I will no longer be in network with CareFirst (BlueCross/BlueShield). The decision to resign my contract came after much distress, more like "cognitive dissonance". Back in January, after receiving a rejection letter from the Maryland Health Care Commission, I started feeling like the writing was on the wall. I had reviewed numbers from 2010, and it turned out that CareFirst had only paid 1/3 of what was charged. We took a close look at denials and realized that many denials were due to policy changes our patients were not aware of. The biggest of these was lack of coverage for annual preventive visits (as if preventive medicine doesn't save CareFirst oodles of money, they just seemed to want their cake and to eat it, too!).

One claim from last spring was denied because I neglected to document the last menstrual period for a 60 year old woman!?! At times like this, one is tempted to growl "WTF!"; however, my mother did school us never to swear, as swearing is uncivilized. I started coming to the conclusion that there was a strategy involved, based on the "learned hopelessness" experiments involving rats in mazes. It is unfun to be the rat in that situation, especially when relying upon the insurance companies for bread. It was kind of extreme to have taken a pay cut last year despite working 20% more hours.

Getting paid sub-professional wages is one thing; but it is truly the illogic of it all that kills me. Why on earth would doing good not be rewarded? Maybe because evil exists, or is it perchance simply laziness or myopia on the part of the insurance companies not to see that good doctors, even the most devoted, are on the verge of burnout? I knew I was in trouble when, last Christmas while sitting at a fireside with my brother-in-law, I started talking to him about the possibility of leaving medicine altogether. I think the pressures of being a doctor, a small business owner of a recent start-up, and a patient all caught up with me.

I have been financially stressed for the past 5 years despite a really thrifty lifestyle. It is true that most of my clothes are from second-hand stores. When I needed a new car last year because I couldn't drive my stick-shift while recovering from knee surgery, I bought a 2003 used car rather than a 2010 model. I drive a Honda Civic, true that it's a hybrid, but I even save on gas. I haven't left the country on vacation since 2008, and I don't have a golf habit. I pay my credit cards off in full every month, and I don't like shopping. So why should I have less than a month of expenses sitting in my bank account?

On the productivity side, I can't imagine seeing more than 80 patients per week. I am not interested in doing botox as a side business and have been too tied up lately to think of other cash revenues. But why should I have to? I should simply be paid as a professional. I don't need a lot, really.

As I drove to work this morning, I kept thinking of the image of the woman who fell into quicksand, struggling to grasp at a slippery edge, slipping into the mire. That is what it has felt like to deal with CareFirst and the other insurance companies from whom I have resigned contracts over the years. Various statements insurance companies have told us over the years:

"Internists in your area are a dime a dozen."

"We don't negotiate with small practices."

"There are plenty of internal medicine doctors in your area to replace you." (last year)

"Why should we make an exception for you?"

"If you were a larger practice, we would negotiate with you."

What should follow all of this? "If you were a man, we would negotiate with you"? After all, recent studies have shown that women doctors are paid less than their male counterparts, even correcting for work hours and within the same specialty. It is time, again, to demand "equal pay for equal work." I have joined the ACP Health Policy Committee and recently wrote a bunch of resolutions about equality; however, traditionally the general practitioners have lacked political clout, as our organizations are not as generously funded as the AMA. After all, generalists are underpaid and thus have less money to contribute and are overworked and thus have less time to contribute.

Pretty much, all of this was in my head for the first few hours of the day today and for most of the past few months as well, especially after the bad news in January. We found out then that we weren't chosen by the Maryland Health Care Commission as a Patient-Centered Medical Home Pilot Program site this January. The arrival of the rejection letter coincided with the departure of my last hope for a favorable option. I was crestfallen. I sent my resignation to CareFirst the next day. I later wrote the MHCC asking for advice on how, now, to negotiate with insurance companies. How, without the State's backing, would I possibly be fairly compensated for pushing forward with the model of excellence I have so wanted to pursue? Turns out, my first letter went unanswered. I rewrote the letter and sent it up-the-chain to the head of the selection committee.

To my surprise, he replied and asked whether or not I was still interested in the Pilot Program, as some of the selected practices had opted out. Of course, my answer was a resounding "yes!" He told me that the committee was planning to invite a few more practices after more decision-making. Having faced huge disappointment with the first go-round, I dared not hope very much. He promised to look into things. I followed up. I even wrote a letter to the Selection Committee highlighting my commitment to the Medical Home Model. I'm even going to the PCMH Summit Conference, on my own dollar, in Philadelphia from March 13th-16th. What's not to love about me? I sent my letter a couple of weeks ago and had really stopped thinking about it.

Then today, around noon, I thought of contacting him. Or would a letter come in the mail? Maybe best to wait. I moved on to other projects. Then around 3 in the afternoon came a phone call from the MHCC. Had I received their e-mail? No. Perhaps it bounced? Well, turns out that they were calling to let me know that our practice was selected!

This is totally crazy.

God's timing is totally crazy, and even though it does say in the Old Testament, "My ways are not your ways, saith the LORD," I am still having a hard time believing the timing. Turns out that my CareFirst Maryland contract is set to expire on March 11th, and the rest of the CareFirst/Blue Cross contract is set to phase out on April 11th.

What to do? I guess I have a pretty big decision to make. The MHCC Pilot Program incorporates a favorably negotiated contract; though, CareFirst was still my lowest payor. In my heart, though, I really want my patients to have me as their doctor. My patients and I, many of us, have been a team for years. I have put a lot of effort into patient care and a lot of heart into those relationships. I still feel devalued by CareFirst, though, and it runs deeper than just me. I feel that CareFirst is not on board with recognizing internal medicine as a profession. I have felt disrespected. I could just work with the other MHCC-sponsored insurance companies who seem more reasonable. Is the MHCC deal sweet enough to re-engage in negotiations with CareFirst? Will it be in time? Should I rescind my resignation? Tune in for more, or if you can't sit still, then write them a letter.

Partners

2011-02-24T07:06:00.000-05:00

(Blog post started 1/21/11)

As my brain was trying to pull off a second sleepless night in the span of three days, I lay in bed this morning with my mind full of thoughts and ideas. Surprisingly, they were not thoughts about the present crises in my life but rather a stream of ideas about how to survive the future waves of change in the practice of medicine. It is much like my friend, Hye Yong, remarked last weekend, that the technology industry has vastly outpaced other industries in rate of change. Even so, I believe it is technology that will facilitate my adaptation to the very averse present healthcare climate. Conversations of last weekend became springboards for new ideas, a wide range of considerations, and many reasons to be hopeful. Thank God for friends!

Laying in bed this morning, I began to connect the dots and came to the realization that I have more than a dozen business partners who have made Green Spring Internal Medicine possible. This was so suddenly reassuring, because it helped me realize that I have not been alone in what I have been up to, even though I don't quite have another doctor or health provider to practice with yet. Even as I seek to build community in my private life, I am relieved to know that I also exist within a community in my work life. Here, I will tell the story of the companies with connections that knit together to make our practice possible. I will include weblinks to the companies I reference.

Once upon a time at my first practice, The Health Associates, I was a young graduate of the Johns Hopkins University School of Medicine and the Osler Residency Program in Internal Medicine at the Johns Hopkins Hospital. Though we had limited electronic records and computerized order-entry at the hospital, I had enjoyed the benefits of computerized processes. I asked my old associates if they were going toward electronic records, and they told me they were thinking about it. Fast forwarding five years, I attended the Pri-Med conference in Boston and heard all of what was new in the health information technology world and my heart was won. It was at that conference that I first met salespeople for eClinicalWorks . I was a little intimidated at the idea of adopting a software whose home was up in Massachusetts. How would there be any help, if something went wrong in Baltimore. I started investigating different EMR systems as soon as I got home to Baltimore and also launched my first practice website. Soon thereafter, I bought my first Toshiba tablet and created my own rudimentary documenting system. It made a big difference in my practice of medicine, reducing the mental clutter that paper charts had always caused me. I created "Requests for Proposal", by this time planning to leave my old group and start my own "paperless, wireless" medical office. The research involved took longer than expected and circled me right back to eClinicalWorks!

I worked with the Johns Hopkins Medical Management Corporation on securing office space at Green Spring Station, shortening my commute by 15 minutes in either direction. Their help was a godsend, and I designed a beautiful office space with the help of NFD, Inc, built by MacKenzie Contracting. We set up internet connection via Comcast, which remains a great deal to this day. The front office and back office desktops and servers all came to us via Dell, which was reputed to have great customer service... at least reputedly though faltering in real-time. We bought an additional three Toshiba tablets, since I had another doctor and a physician assistant working for me at the start-up. As well, we purchased an amazing Fujitsu scanner which has kept up-to-snuff for nearly 5 years, the workhorse behind converting about 2000 paper charts from my old practice to electronic records. Our digital ECG and spirogram are from Midmark.

Our medical supplies have been care of McKesson Medical-Surgical and office supplies have come to us from my local Staples. I always feel like such an entrepreneur going in and out of there. Recently, we have been ordering vaccines from Sanofi Pasteur, which has proven to be the most reliable source of flu shots.

Of course, we have had countless partners from among the specialists, doctors and other providers who have taken the time to teach me about disease recognition, approach to diagnosis, and how to interpret test results. There is so much learning after medical school, especially since generalists have responsibility to understand a little bit about everything that affects people.

Clearly my most important partners are my patients. I work one-on-one with over 2,000 patients who are invested enough in their own health to come and see me. I am fond of saying that my patients are their "own best scientist", as they are able to gather the most data in real time. When they come to me with information, I am able to help them to interpret it and use it. Even though the medical literature is pessimistic about lifestyle change, I am so impressed by my patients. Time and time again they prove to me that it is possible to re-orient diet, activity, and habits and to step into the way we were designed to live. People desire good health. They desire to be empowered to manage challenging health conditions, and eClinicalWorks has equipped me with the ability to give my patients the information they need and to coordinate their care with other providers. I love inspiring people and equipping them with the information they need to succeed. My web designer, Cari Kramer, also helped me put up an eLibrary with helpful interactive health links for my patients on www.greenspringmed.com. I often say, "Living long is only as good as living well."

Dream Job

2011-01-16T17:24:00.000-05:00

This past week brought the disappointing news that Green Spring Internal Medicine was not selected as a Maryland Health Care Commission Patient-Centered Medical Home Pilot Program site. The news broke my heart, mainly because we so strongly desire to move forward into this new model of care; however, I have no idea how I will possibly be able to accomplish it without outside funding plus a guarantee of appropriate compensation by the health insurance companies. The Patient-Centered Medical Home has been established as a model of healthcare delivery that improves quality of care while reducing the overall cost of healthcare. This model has been widely adopted, with great success, in the state of New York. South Carolina has also demonstrated positive outcomes through implementation of the Patient-Centered Medical Home, through programs designed by CareFirst. This fall, CareFirst in Maryland sent out an invitation to practices to join their pilot program; however, to small practices, there was an added requirement. Practices of fewer than 5 physicians were required to assemble a "panel of 5" providers from the same region to sign on to the program together and agree to compile financial data for analysis by CareFirst. I was taken aback by this requirement, such a taxing expectation for small practices that often run (like ours) with no office manager. It was not feasible for us to sign on. Now we are left with a dream that makes so much sense, but seemingly no reasonable way to achieve it. Sad.

Even though I had anticipated this as a possible outcome, it was hard to prepare for switch of parachutes in the midst of the "free fall" that the practice of internal medicine has come to feel like. What plan will save us now? How will it be possible for me to bring another physician on board, in the midst of such uncertainty. I desire to move forward and adopt a more multi-disciplinary approach and more fully implement the technology that is available; however, the current model of care that I have felt constrained to is not sustainable either with or without the efficiency and safety added by the technology we are utilizing. I was recently annoyed when a clinic director of a local "Accountability Care Organization" run by a hospital in our area visited my practice and told me that there was no way that I could become a Patient-Centered Medical Home as a small practice all on my own, that sooner or later I would have to work for a hospital. I was annoyed, because it felt like a veiled threat, and I really do believe he intended to make me feel insecure. Ok, so it worked for at least an hour after I had ushered him out of my office. I am also still annoyed, because I do not feel that every patient is best served by seeing a doctor whose prime loyalty is to a hospital system. Isn't it our job to keep patients out of the hospital? Non-option #1.

Another non-option for me is concierge medicine. I have previously written my defense against this model.

So, where is the hope? I am left wondering actually. As an inherently joyful person, I have found myself too often complaining of late. What is it that is sapping my joy, singeing me at the edges of burnout? It just seems that so much stands in the way of what is right and good in the current healthcare system, and I am just not so sure that the healthcare reform that passed will really result in enough change, if it is even allowed to stand by the 1st session of the 112th Congress.

The prime reason why I left the Health Associates, PA, in 2006 was a value conflict. According to Peter Drucker, a value conflict is one of the greatest impairments to workplace happiness. He wrote a beautiful article called "Managing Oneself" in The Harvard Business Review (January 2005) that continues to be life-changing to me. In analyzing my present workplace problems, I was surprised to find out that though I officially work for myself, I have a multitude of value conflicts. To name a few:

VALUE CONFLICT versus VALUE CONSISTENT

insurance company greed versus access to affordable healthcare for all
asking impoverished patients to pay their bills versus extending grace in certain situations
financial stress versus having enough not to think a lot about money
"Medicine as business" versus "Medicine as healing art" - do I hear an AMEN?
workaholism versus strong work ethic lived out with balance
little incentive to do good versus reward for doing what is right
inability to travel/take vacation versus flexibility of schedule
facing big business risks versus being able to grow because we are creative
faltering systems versus technology-assisted organization (which we need outside help to implement)
status quo versus the Patient-Centered Medical Home
being solo versus practicing among colleagues

I guess I am going to have to talk to the boss about how to get from value-conflicted to value-consistent practice of medicine! Of course, I don't really just work for myself. In part, I work for my patients and in part, I work for insurance companies. Far and away, the driving force behind my long set of value conflicts is the insurance companies' approach to my profession. It seems that the insurance companies are our society's chosen means of obtaining healthcare access; however, having insurance is not the only means of having access to a good doctor. Believe me, I am considering this matter with all seriousness. It makes me feel heavy-hearted. It is surely better for me to be in practice than to burn out. At least, I think so for now. I still love internal medicine and patient care.

Thankfully, my inspiring college friends, Lynne and Hye Yong, visited me this weekend and encouraged me to dream again. It is amazing that we have now known eachother for more than half of our lives, and it seems that those who have known us from our younger years know us the best somehow. True to Mount Holyoke women, our parting words this morning were, "Change the world!"

Just for fun, I sat down at a local coffee shop this afternoon with a blank sheet of paper and brainstormed about my dream job, putting down goals in a symbolic cloud. "All things are possible..."

Heroes

2011-01-09T17:29:00.000-05:00

Who are your heroes?

I asked that question of a group of friends lately and one of them cited Amy Carmichael, who was an Irish missionary to India and lived from 1867-1951. She opened an orphanage and rescued many young girls from the fate of being forced to become Hindu temple prostitutes. She is quoted, "One cannot give without loving, and one cannot love without giving."

Another friend shared that his father is his hero. His father has stood by as the main supporter of his mom, caring for her throughout her struggle to fight cancer. It has been over five years. Recently, that fight has become a losing battle. At the recent family gathering, his father stayed positive, remarking, "She's just getting there before we are." This comes home to me today, as a friend of mine was just diagnosed with lymphoma and faces harsh treatment (the kind which brings back bad memories for me). He is married with a beautiful wife and three young children including a baby. Those who suffer from cancer are often heroes, but so are the people who are most closely connected to them.

One of my friends shared that Martin Luther King, Jr. was his hero. He has recently read a multi-volume biography of King as a class assignment. He remarked that King, though struggling with fear and succumbing to infidelity, though an imperfect hero, still pressed on in his work for justice. Martin Luther King, Jr., bravely applied a gospel-centered approach to confronting his enemies, I might add, choosing to apply his faith rather than working only through political avenues in his work for social justice. He chose non-violence in a violent era, which was a dangerous thing to do; yet, he overcame fear and pressed on.

What made me ask the question of my friends is that I am in the midst of reading Bonhoeffer: Pastor, Martyr, Prophet, Spy by Eric Metaxas. This New York Times Bestseller is truly a page-turner, as are so many books about the Nazi era. It is hard to imagine the evil existing in Bonhoeffer's day and the dilemmas he faced. He stood early on during Hitler's rise to power, opposing discriminatory policies enacted toward the Jews and challenging fellow Christians to hold to the true gospel rather than caving to the "Fuhrer principle". Though clear-headed about the risk of doing so, he returned to Germany from work abroad and spearheaded an illegal seminary. Though pacifist by conviction, he ultimately joined in a plot to assassinate Hitler but was captured, imprisoned and ultimately executed less than a month before Germany's surrender. I have been so taken by Bonhoeffer's strength of character, his integrity and his resolve, that he has become a hero to me. One of my other heroes is Corrie ten Boom, a Dutch woman of that same era.

Recently, my housemate suggested middle names for my cats so that they could be called their full names whenever they disobey. I decided to choose positive and heroic middle names for my dear feline companions. Though they do find frequent opportunities to bend the rules, I prefer to use their new full names as terms of endearment: Wilberforce Bonhoeffer Dahlman and Aliceanna Corrie ten Boom Dahlman. They each seemed quite pleased when I informed them of their new names.

Of course, I have other heroes as well. I went through a long spell of life, feeling too cynical to come up with any heroes. 2010 was a bit hero-challenged, as far as public figures are concerned. If one looks hard enough, though, there are heroes all around us. As time tells their stories, I happen to have fallen in love with at least three heroic men: William Wilberforce, Eric Liddell, and Dietrich Bonhoeffer. All of them were men of deeply rooted conviction who stood strong in the midst of tremendous pressures. They remained faithful to God and to their callings. Loving these men does seem to challenge my dating life, especially since all three are dead and gone and would be over 100 if they were alive today! It may not be possible to marry this kind of a guy, so maybe I will just have to emulate them. As the lion from the Wizard of Oz proclaimed, "Courage!"

(Some have said that I set a high standard man-wise. I say that I am too often bored on a date. As an idealist, I do love to live inside the world of ideas and am most impressed by those who have the greatest accomplishments of the heart. I'm not too good at talking football and would rather spend a quiet Sunday afternoon reading a good biography.)

Joy!

2010-12-20T22:07:00.001-05:00

Please click on the title of this blog entry for a little "Merry Christmas" from us to you and yours. Happy New Year, too!

Primary Care Crisis

2010-12-03T14:32:00.000-05:00

I decided to write to Maryland's Health Care Reform Coordinating Council today, in order to express my concerns about the primary care shortage. My letter is included here:

To Whom It May Concern:

Greetings and happy holidays! My name is Holly Ryerson Dahlman and I just spoke with Joyce Meyers at your office. She pointed the way to this opportunity to weigh in on the health reform issue. Whereas, I would love to attend public forums, my time is limited as I am a private practice general internist in solo practice.

First of all, I would like to applaud the Committee for its heart to expand access to affordable healthcare to all Marylanders. It is not only the right thing to do, but it is the fiscally responsible thing to do. My comments on health care access can be found in an Op-Ed I wrote in the Baltimore Sun last October.

I am writing the committee now primarily to express grave concerns about the state of affairs in the primary care workforce. Since starting in practice 11 years ago, I have watched disturbing trends in my profession. When 3 out of 6 of my former partners in practice announced that they were pursuing concierge medicine, I decided to branch out and start my own practice. I stand morally and ethically opposed to concierge medicine and dislike the model for practical reasons as well. Yet, I have been somewhat surprised to watch one colleague after another who was originally opposed to the model succumb to its temptation. This trend is the direct result of the tremendous financial pressure that primary care physicians have been under for many years.

With a flatline in insurance compensation for our services in the face of rising business expenses, primary care doctors in small practices face the likelihood of being driven out of business altogether. Some physicians have met the crisis by refusing to sign contracts with insurance companies. Others are joining hospital-owned practices, which enjoy more negotiating power but also pose conflict of interest and may encourage increased healthcare spending. Others, like myself, are trying to tough it out and do the right thing in our hearts and participate with major carriers. The problem is, our profit margins are too narrow to sustain crises like the 9 weeks total of Medicare non-payment this year. Being so close to the edge puts us at risk for burnout or choosing other career alternatives.

It is my understanding that the Committee aims to address the primary care workforce shortage by offering loan repayment. I applaud this effort, as it is a necessary step in the right direction. It is necessary, but not sufficient, however. In order to sustain the existing primary care workforce, the payment structure needs to be revamped. The current payment system has resulted in a tremendous salary gap between primary care and specialty care and encourages performing expensive procedures rather than thoughtful prevention and approaches to disease management which are cost-saving. As for salaries, the average internal medicine salary is approximately $150,000; whereas cardiologists and gastroenterologists enjoy $300,000 to $350,000 average salaries. I am grateful to my colleagues who are specialists and am glad they exist; however, their services are not worth more than twice the value of my services. Primary care practitioners face the ever increasing complexity of keeping metastable, chronically ill patients out of the hospital. We are treating many, many diseases in the outpatient setting that would have been grounds for hospital admission ten years ago.

Models like the Patient Centered Medical Home make a whole lot of sense but will only be possible if they are adequately compensated by insurance carriers. The CareFirst PCMH model is a farcical non-option for practices of fewer than 5 physicians due to the tremendous administrative obstacle posed by their "Panel of 5" requirement. The 12% increase in compensation only barely catches up to increases to primary care physicians that CMS is finally enacting next year. It will not be enough to cover the upfront cost of implementing this model, even though the model has proven to save healthcare costs in other states where it has been implemented. I tried to negotiate an alternative, but they will not engage in negotiation with small practices.

Now, as I stand waiting to hear whether the MHCC will select my practice for their PCMH Pilot Program, I wonder whether or not I will really be able to stay in practice. I am unable to hire another physician with the confidence that they will feel appreciated and well-compensated. At the start of my new practice in 2006, I had hired a PA and another internist to work for me part-time. Though I paid them a competitive internal medicine starting salary, both left the practice within 2 years wanting to be paid more. While I took this personally at the time, I now realize that they should have been paid more. I should be paid more for what I do. It is wrong that a PA who is working 40 hours per week at a local ER, with 10 hours per week of administrative time, earns more than I do. I work my tail off to practice with excellence, to keep my patients healthy, and to address the needs of many sick patients. I want to care for them all, but sometimes doing so has meant working without vacation and working through an interval of serious personal illness last year.

Our state will need to have a more robust primary care workforce to meet the increased demand for healthcare as people become insured. Believe me, having a frontline of thoughtful doctors is necessary to stem the vast expenditures that could result from people seeking primary care at the specialists' offices. Besides, I don't think the specialists want to do my job.

Please do not hesitate to contact me if any questions should arise.

Professional regards,
Holly Ryerson Dahlman, M.D.

Giving Thanks

2010-11-24T23:17:00.000-05:00

In the weeks running up to Thanksgiving, I have hardly had much of a chance to sit and meditate upon what I am thankful for, even though it is such a good yearly exercise. I found myself suddenly in the midst of major work projects this fall, gearing up for the launching of the Patient Centered Medical Home model in my medical practice and taking additional steps in preparation to establish "meaningful use" of our electronic medical record system to Medicare this January. In addition, I joined the Small Practice Advisory Committee of CRISP, an organization working to promote the implementation of computerized medical records and the connectivity of hospitals and private practices throughout Maryland. I also felt compelled to join forces with the Maryland ACP Health and Public Policy Committee which is an arm of my medical organization concerned with issues affecting internal medicine doctors in our state. After 9 weeks of not being paid by Medicare and numerous roadblocks in negotiations with insurance companies, I felt that it was time to take action. Joining a committee is better than forming a one-woman picketing protest outside the CareFirst headquarters; though, that idea had crossed my mind.

Even in the midst of the busy season at work, I found myself back on the soccer field again, coaching young kids from Pen Lucy and even able to play in a few coaches' games at the end of the season. I am grateful for nearly complete recovery from knee surgery this spring and am happy to report that I am playing soccer better than ever. It may be partly owing to all of the World Cup games I watched over the summer. I had extra fun this year, figuring out that the best way to motivate my kids to work hard in practice was to name a team captain every week. The best way to motivate them to play hard and play together during the game was to name an MVP. My team was the Eagles, so I taught them how to recite Isaiah 40:31 with a resounding "Eagles!" right in the middle of the verse. At the last practice, I folded up two paper airplanes - one was a dud and the other had at least some aerodynamics. The take home point was that when we fly according to the way God designed us, we soar. When we fly according to our own designs (our sinful nature), we flop.

This past weekend, the community organization associated with my church (PLAN), held the 2nd annual "Buck-a-Bag/Health Fair". Unlike the year before when the Maryland Food Bank provided the majority of the food items, this year the majority of the contributions came from our own congregation. I was blown away by the generosity of so many people in providing abundantly more food than I would have imagined, enough to provide a bag full of groceries to over 100 families. Then, Panera Bread donated two large bags full of bagels and baguettes. We had a box full of huge McIntosh apples from the food bank, and a trunk load of fresh produce from the Waverly Farmer's Market. Then, on the health fair side, we had the generous contribution of nearly 150 flu vaccines from the Baltimore City Health Department. It does seem that more work needs to be done to convince Pen Lucy residents of the benefits of the flu vaccine. I did my best. Dr. Anne Bailowitz, the Chief Medical Officer of the health department did manage to convince our pastor to get his first ever flu shot. One of the most amazing aspects of this event was the sight of all of the volunteers, ranging from high schoolers to retirees, helping out in almost every way. One of our volunteers even took the time to carry the groceries home for a lady who suffers from disability.

It is said that it is better to give than to receive. I think this is true on multiple levels. Certainly, I think it is better for our souls. The Native Americans who brought produce to the near-starving earliest European immigrants changed history through their generosity. They were also in a position to give, even though the same folks they saved did not return the favor. It is so ironic that the phrase "Indian giver" ever came about. I caught myself saying it the other week, and thought about how wrong that phrase really is.

After nearly two years of medical crises and in spite of all of the adverse economics of primary care practice, I am grateful to be able to give my time and energy and resources to others. I am thankful for the restoration of energy and good health. It is also a privilege to be surrounded by friends and colleagues who are committed to do what is good and loving and right. "He has shown thee, oh man, what is good and what the Lord has done for thee - but to do justly and to love mercy and to walk humbly with thy God." Micah 6: 8 If that is all I accomplish in this life, I will be glad. Easier said than done, I must say.

"Praise is fitting for the upright", says the psalmist in Psalm 33:1; thus, it will soon it will be time for all sleepers to rise and shine, give thanks, and cook that bird (or whichever side dish one happens to be contributing)!

Sanity

2010-11-03T22:28:00.002-04:00

Why did 215,000 or so of us turn out to "The Rally to Restore Sanity and/or Fear" this past Saturday? Of course, Jon Stewart has quite a following as the one newsguy who has helped many of us to laugh and not cry through these hard times. Stephen Colbert humors us as well, allowing us to survive the almost unendurable scare tactics of the media by calling them out, one goofy newsclip after another. Certainly Glenn Beck's ill-timed and ill-placed rally deserved a counter-rally. I think the biggest reason most of us showed up, though, is that we believe in reasonable dialog when it comes to differences in opinion. The public marketplace of ideas should be a place ruled by an ethic of mutual respect, where we use (as Colbert put it) "our inside voices," and where facts are upheld. With reasonable exchange, it is possible that we Americans could all discover that we have much more in common than we thought, namely a desire to be healthy and live at peace.

As I prepared to go to the rally last weekend, I thought of what I would like to demonstrate about because even though this was a Comedy Central-sponsored entertainment event, free to the public, with big name appearances, I still felt there were a few things I wanted to say as an American. The setting of the National Mall in DC inspires political statement; though it is used on weekday afternoons for Ultimate Frisbee. There is so much to say, and most of it won't fit onto one poster. It's hard to sum things up in a few words, but here's what I came up with.

Thankfully, my friend Tami was happy to go along with my idealistic sentiments and help me hold up the "LOVE" sign, stylized to my vintage, the 1970's. I felt like all of that anti-healthcare reform rallying of last year deserved my own peaceful and quiet counter-rally via a quite unarguable sign, "Health for All." You'd have to be a meanie not to desire the health of everyone else; though, certainly many seem to have such a hard time connecting health to healthcare, health of individuals to the health of our society, or moreover health of our healthcare system to the health of the overall US economy. The low cost of prevention compared to the high cost of catastrophe management? Not rocket science, folks.

The rally also amounted to my coming out as a pacifist. Yes, I really do want to make the statement that going in a direction of loving our neighbors is better than regressing to the historical approach of settling conflicts or pursuing our economic passions through war. I'm wearing my "Obama" T-shirt because he did at least get troops out of Iraq on time, but I would also challenge him to get us out of Afghanistan ASAP! I don't really think the U.S. has fought a "just war" since World War II. Even the famous pacifist, Dietrich Bonhoeffer, joined a plot to try to assassinate Hitler. I think I would have as well, given the options of that day; however, I can't really understand why we have become involved in any of the wars since WWII. Ok, I'm not naive. We are gluttons for oil and our economy might have died without it, but does the end justify the means?

Just to connect my two thoughts, the cost of the Iraq war, as per a recent Washington Post article well exceeded $3 trillion. Even the conservatives cite the short-term costs of overhauling the nation's health care system at $1-1.5 trillion, less than half the cost of the war. Sweeping health care reforms are necessary to stem the burgeoning cost of healthcare in the U.S. and ultimately, it is estimated that health care reform will result in billions saved. So who, might I ask, are the big spenders? Barack Obama did not shipwreck the U.S. economy. The deed was done when he came into office.

"The United States has the highest homicide rate of any affluent democracy, nearly four times that of France and the United Kingdom, and six times that of Germany," and firearms were involved in 2/3 of the cases in 2008, states Jill Lepore in a recent article in the New Yorker. Urban youth are disproportionately affected by gun violence, yet we sent our soldiers nearly halfway around the world to depose a despot for killing his own people and possibly hiding terrorists (while, of course, interfering with our oil interests). Of course, because of doing that, there is simply not enough money left over to fund decent schools and give kids an opportunity to choose life and opportunity rather than violence and the street drug industry. How is it that we so easily ignore the war on our own streets. Why not have reasonable gun control laws? Isn't it time to disarm?

What bugs me the most is that Christians are so often the ones leading the fray: warring against foes rather than loving them and praying for them as our own scripture mandates; suggesting that America get back to roots as a Christian country, even though the founding fathers fought the Revolutionary War in part to defend religious freedom; supporting gun "rights" even though one of the 10 Commandments is "Thou shalt not kill." Worst of all, Christians have supported and defended people who take great license with the truth who, when they are not doing that, are outright lying! So, that is why my rally signs had to proclaim, first of all, LOVE. Love rather than war. There are countless ways to solve conflict, other than going to war. Finally health for all. That is a reasonable human desire. It is sane to desire your neighbor's health, lest in ill health he should sneeze on you!

Safety

2010-10-01T18:17:00.000-04:00

I had just read an article about violence in the healthcare setting the week before Dr. David Cohen was shot in the abdomen in the halls of Johns Hopkins Hospital while disclosing medical news to the son of an elderly cancer patient. For hours, East Baltimore took on the characteristics of a war zone, with the stationing of SWAT teams and news helicopters hovering over the scene. Friends of mine experienced the lock-down on the campus while safety measures were enacted. In the end was the astonishing but also sad discovery of a patient shot to death in the back of the head and the suspect having committed suicide by firearm.

Raised up through medical school and residency in East Baltimore, I experienced some concerns for my safety. I moved to Baltimore after graduating from Mount Holyoke, a small college nestled in a country town in New England. I was far from accustomed to the sound of sirens, helicopters overhead and even gunshots at night. When I interviewed at Hopkins, we were invited to attend a couple of medical school classes. There was an announcement about a student who had been raped during daylight hours, after parking her car north of campus. One of the attending faculty members was carjacked in the parking garage on campus. I wasn't sure whether I was safe or not safe at various times and in various places between the dorm building, the main hospital and the lecture building; though, I was never the victim of violent crime. I did have a stethoscope or a wallet stolen from the hospital here or there. We took care of quite a few patients who have criminal records, I'm sure, but none of them nor any of their family members ever threatened to harm me. As it were, violence in the city is mostly suffered in impoverished communities. We hear about it on the news when a doctor is shot.

Johns Hopkins was caught by surprise; though, it may have only been a matter of time before something like this shooting was to happen. I don't think it came from an expected direction. The suspect was not the kind of guy one would "profile" as being prone to violence, a devoted son and a good neighbor. Many have surmised that he must have been mentally ill. It seems to me that he must have been very, very stressed. Overattached? Possibly. He might not have slept well, staying overnight the week before to watch over his mother who was having surgery. He may have brought her to Hopkins, hoping for a miracle cure. It is not that friendly of an environment. Did he feel isolated, the hospital too far for friends to visit? There may have been deep-seated anger and frustration that had boiled up, even for entirely different reasons. Many Americans are angry these days. Living with the outcome of her illness may have posed an intolerable dilemma. I think we will never know.

Certainly, as this is unpacked among nursing staff, support staff and among physicians, I am sure there will be a lot of talk about how to recognize stress among family members, how to listen, and how to address questions in ways that defuse anger. The hospital is an unusually intense setting, and some people can be very anxious or disturbed without outward manifestation. Care of family members is part of the role of the healthcare team, even though our prime responsibility is to the patient. Are there warning signals we should detect? Are there questions we should ask? I think expectations are very high when patients are transferred to an institution like Johns Hopkins Hospital. Does institutional pride play a role in setting expectations? Informed consent involves the listing of potential adverse events that may result from a medical intervention, but are patients and families really prepared for when bad things happen? The unexpected, unwelcome outcome is understandably upsetting.

Most of us have experienced the unwelcome unexpected in hospitals. I find it hard, as a doctor, to hold back criticism when a family member of mine is ill. They say that the best thing to do in a hospital is to get out, and I happen to agree. I do not think hospitalized patients are highly at risk for violent death, nor are their family members or their doctors. They are more at risk for other things happening: infections, complications of procedures, falls, blood clots, etc. Hospitalized patients are probably endangered most by medications that are not prescribed when they should be or medications that are prescribed when they shouldn't be. This is why patients should keep these safety measures in mind when heading to the ER, or even to routine doctors appointments:

- keep a medication list that includes the generic name and brand name of all of the pills that you take and includes dose, frequency and the reason the medication was prescribed

- make sure the medication list matches what is in pill bottles at home or what nurses are administering in the hospital. If not, ask what medication is being administered and why

- make sure to check prescriptions picked up at the pharmacy to be sure that the details match your list

- ask for copies of notes, lab results and x-ray documents from the doctor's office or hospital that generated them, keep them in a secure personal file, and share the information with your primary care physician

- if you are over 65, avoid sedatives or tranquilizers, anti-histimines (often in cold medications), strong pain medications, and especially benziodiazepines (which are known to cause prolonged confusion in the elderly)

- be sure to include herbs, vitamins, and alternatives on your medication list as these especially may affect blood thinners and thyroid medications and may have other interactions or side effects your doctor may advise you about

- bring a copy of your last primary care progress note to visits with specialists and be sure the specialists always fax a note or copy of their recommendations to your doctor

- share your advance directive or living will with your entire family and with your doctor, to be sure that your wishes are honored at the end of life

- read up on your disease process and ask lots of questions to be sure that you understand the treatment plan, the expected outcome, and alternative options

- write a list of questions to set the agenda for the visit; however, also recognize that your provider may not be able to tackle more than a few issues in a single visit and follow-up may be needed

- work with your doctor toward your healthcare goals and share responsibility for the details of your care and treatment decisions.

- if you are caring for a family member who is hospitalized, be sure to sleep at home at least some of the time and to eat three meals a day. Caregiver stress can be very overwhelming.

- if your loved one is confused or forgetful, be sure to attend appointments with him or her or send a caregiver who knows the details

- if things are not going well, either with patient care or communication within the hospital setting, ask to speak with a charge nurse or patient services representative.

- have a primary care doctor whom you trust, who communicates well with you, and share care

"I'm going to live until I die." Quote from 89 year old patient I saw this week.
"You're in great shape for the shape you're in!" Quoted my predecessor and mentor, Dr. Jerome Koeppel.

"Activity"

2010-09-10T09:04:00.000-04:00

I have always advised my patients to get "3-6 hours of cardiovascular exercise per week". 3 hours of brisk walking per week, or more vigorous exercise, is enough to cut the risk of diabetes and the risk of a heart attack in half for both men and women. Research has also established that people over 65 who walk regularly fall less often. Exercise seems to be a bad word for many people, however, while others seem to have developed immunity to the advice to exercise. After viewing a web video from the CDC on "increasing physical activity", I thought I might rename exercise as "activity" especially to certain patients. Of course, most of my patients know what I am onto. Our bodies are designed for activity. For the vast sum of human history, people have labored by necessity, except for certain kings, queens, and tribal leaders. I always feel better when I am exercising closer to 6 hours per week rather than 3. This is probably because more exercise is what our design dictates.

For those who do not love exercise, "activity" may be the answer. The seemingly official website for zumba proclaims, "Ditch the workout, join the party!" Swing dancing is even more fun. It has been my sport of choice for the past 10 years; though breast cancer treatment and knee surgery have kept me away from this love over the past year and a half. Hopefully I will be cleared to get back to it later in the fall. Another great form of recreation that disguises exercise is hiking. Because of the glory of God's creation, hiking provides wonderful distraction from sweat and sore muscles. Plus, there is often the reward of a fantastic view from the top of the trail, especially if it is in my favorite state - Colorado. Hiking is lower impact than running, hence easier on the joints. Other outdoor pursuits like canoeing, gardening, swimming, and cycling can also pass as activity.

Back during college, my week's activity mostly involved working at the Dopkin Ranch, saddling up and riding horses, grooming, cleaning tack, and doing barn chores. In later years, I taught riding lessons as well.

In my early swing dancing years (bordering on swing addiction) my week's activity looked like this:

Thursdays: dance class for an hour followed by two hours of recreational dance

Fridays: 3 hours of dancing in Chevy Chase (yes, I drove an hour to and from)

Saturdays: 3 hours of dancing at Glen Echo (another hour-long commute for a pursuit)

More recently, in autumn, it would look this way:

Thursdays: swing dancing
Saturdays: soccer coaching for three hours, sometimes followed by yardwork
Sundays: a long hike

And on my vacations home in Colorado? Hiking, walking the dog up the hill, or skiing just about every day of the trip.

After breast cancer last year, I never quite got back to swing dancing in the fall and then injured my knee skiing. Currently, I have been in a pattern of alternative activities and the last 2 weeks looked like this:

Sunday: trail jogging and hiking at Cromwell Valley Park
Tuesday: weight lifting, then half hour of aquajogging, followed by 20 minutes of swimming
Saturday: 6-7 mile hike with friends near Harper's Ferry
Sunday: 2 hour hike with a friend at Oregon Ridge
Monday: 24-25 mile bike venture from Monkton to the Mason-Dixon line on the NCR trail
Thursday: 30 minutes cycling on my trainer at home, followed by light weights
Friday: physical therapy half an hour from now

I am not expecting to be cleared to coach soccer until mid-October but will be there at the field next Saturday helping another season kick off. I am supposed to be running in order to get in shape, but I hate running! That is how trail jogging came into play the other week, nowhere near as painful physically or mentally but still great "activity"!

(End of) Summer Reading

2010-09-05T20:07:00.000-04:00

I decided to put aside David Copperfield and dig into some non-fiction this summer. I have always had a love for literature, especially Russian and English writers. I had read many of Dickens' novels, but somehow got stuck on page 292 of this book. Even though it's my friend Bobby's favorite, I just never really got into it. I understand that Dickens got paid by writing episodes which then became novels. Evidently, he had quite the cult following, people who could hardly wait for the next episode to be written. Long books resulted! Unlike Dickens, I wind up blogging whenever inspiration strikes since I am not paid for 32 pages of output. Lately, I haven't been sure that I would be able to write anything fruitful, because I have felt so frustrated. Rather than complain about the healthcare crisis, Glenn Beck, BP or Wall Street, I thought maybe I should just write about the books I am now reading. How it happened, I don't know, but I am actually reading seven books!

1. The Bible: it has been a consistent international bestseller and has been worth reading and re-reading. It is the only book that I have been reading for the past 30 years. Even skeptics like Joseph Conrad appreciated the Bible as a work of literary inspiration. So many people have so many different interpretations of it. Since I can't read it in the original languages, or perfectly interpret the various genres, will I ever really understand it as a whole? Even so, I think we are in an era of many false prophets (including Mr. Beck for sure) who are invoking God without really knowing Him or at least not the God of the Bible. Jesus said, "You will know them by their fruit." Matthew 7: 16. At least some of us have to know the Scriptures well enough to call these people out.

2. The Language of God by Francis Collins who was head of the Human Genome Project and Director of the NIH. This book brings some sense to the debate between "Creationists" and "Evolutionists". In the end, it is impossible for a truth-seeking individual to rule out evolution. It is also impossible for a truth-seeking individual to rule out God. Of course, belief in an artistic God is not a new way of seeing things (Ephesians 2:10). We humans are increasingly witness to the splendid beauty and glory that God, in His wisdom and creativity, brought about through evolution and possibly other processes as well. My faith is, in no way, diminished by recognizing evolution as a scientific truth.

3. Quarks, Chaos, and Christianity by John Polkinghorne who is a quantum-physicist-turned Anglican priest. This book complements Dr. Collins' book by highlighting the complementarity of science and religion rather than the conflict between them. Recently, another famous British physicist, Stephen Hawking asserted that there is no reason to invoke the existence of God in order to explain how the universe began. The law of gravity explains it all. Of course, the law of gravity cannot explain why the Universe began. Back to the realm of theology.

4. The Call to Joy and Pain by Ajith Fernando whom I recently heard give a weekend seminar and also heard years ago at Urbana. One of my patients reminded me of an important truth last year, in the midst of my trial. He said, "I don't know why Christians are so surprised when we suffer. Becoming a Christian is almost guaranteed suffering." After all, Jesus was known as the "suffering servant." Ajith Fernando's book is a reminder to find joy in the midst of suffering. I find it particularly important to find joy in the fight for justice, as it can be so discouraging when the bad guys seem to be winning and when doing good doesn't seem to bring reward.

5. The Republic by Plato. I am interested in knowing how Plato influenced Western thought, particularly how his philosophy may have had an impact on the founding fathers. Our country was founded as a Republic, after all. The founding fathers have gotten roped into much of the recent political dialogue. One of the fundamental questions asked in The Republic is, "What is justice?" This is one of the most fundamental questions Americans should ask as well. Most will answer along economic and racial divides. Much of my reading and thought life over the past 10 years has centered on the topic of justice. Understanding it is key to racial reconciliation.

6. A People's History of the United States by Howard Zinn retells American History from the perspective of those who were not traditionally given a voice. Could it be that our cultural mythology has spared us so many of the bitter details? Should it be that schoolchildren are kept safe from certain terrible truths about our foundations as a nation? As an adult, I have the opportunity to relearn and reframe, in some cases.

Adaptability

2010-08-15T21:37:00.001-04:00

The slogan, "Adapt or Die" is not new and seems to refer to anything from technological innovation to becoming more accustomed to the weather. An MSNBC articles reads, "With the world losing the battle against global warming so far, experts are warning that humans need to follow nature's example: Adapt or die." The newspaper industry has said it of themselves; hence the proliferation of online news, letters to the editor, and blogs by famous people. A recent catchy Gatorade jingle, "If you want a revolution, the only solution: Evolve, evolve," seems to say it all. Evolve or Die: Seven Steps to Rethink the Way You Do Business, reads the title of the book by Robin Crow. It was published this past April. With the number seven in the name, it sounds almost Biblical or lucky at very least. I am finally convinced this is true of my own profession. We must evolve or die.

As in most evolutionary processes, we should not "throw the baby out with the bathwater". It doesn't mean starting from scratch. To evolve implies building upon strengths while moving away from what works poorly or is non-functional.

The greatest strength of general internal medicine is that most of us are in it, heart and soul. We were attracted to medicine due to its intellectual complexity, the challenge of sleuthing out the diagnosis with careful history followed by physical examination and analysis of data. We admired our professors of medicine for knowing something about almost everything. We form an idea and then confirm or negate our suspicion. We care for individual conditions in individual patients who are part of a family and part of a community, who are global citizens and have a global impact. Counseling and screening according to best research serves an important role in prevention and treatment of disease. Ultimately, this is of benefit by reducing healthcare spending, thus contributing to the health of the overall economy.

What is working poorly is the system of compensation. Under the influence of the AMA, the Centers for Medicare Services has progressively adopted a system of compensation for physicians' services that is based on procedures (called CPT codes). Other insurance companies use these codes as well to determine physician payment. Procedures have become increasingly valued, whereas "Evaluation and Management" services (or the thought processes of doctors) have become devalued. Partly for this reason, we have one of the most costly healthcare systems in the world, even though we have left 50 million people uninsured. I am not ungrateful for procedures, having been a patient as well; however, it is a little bit unreasonable that the average gastroenterologist's salary is more than double the average internist's! Sometimes, just pausing and thinking about a case may prevent a procedure from being done; however, there is more reward for going ahead and doing the procedure. With the rising cost of practicing medicine, it is hard for primary care doctors to survive. Some have simply left medicine, others have dropped insurance contracts, and still others are "going concierge."

Concierge medicine represents a maladaption. Disgruntled colleagues of mine became distressed, looking at an ever-decreasing bottom-line. Solicited by an attorney-run company called MDVIP, they decided to place stake in longterm relationships with patients who trusted them. In this model, doctors charge their patients a $1500 membership fee which is inclusive of a thorough annual physical examination and associated costs, giving patients 24x7 access to their own physician, and a CD containing health history. Additional visits are usually charged to the insurance company. Concierge doctors agree to limit their practices to only 600 patients. I have received several mail solicitations from MDVIP this year, alone, in addition to e-mails. I wish they would just give up!

Concierge medicine is of ethical concern, because it disrupts the doctor-patient relationship. The doctor-patient relationship is inherently unequal; hence, medical societies forbid doctors to date their patients. The doctor graduated from medical school and finished medical training whereas (in most cases) the patient did not. The doctor has knowledge the patient does not. In the concierge model, however, there is an exchange of power. Even though the doctor still has more medical knowledge, the patient may demand his or her will. The most concerning case is in the over-prescription of antibiotics. A patient with a cold may come in to the office and demand, "I want my z-pack. Now, please." The concierge doctor, who is essentially employed by the patient, is then coerced to prescribe the antibiotic even though conventional wisdom dictates against prescribing antibiotics for a virus. Unnecessary prescribing of an antibiotic could result in a severe or even life-threatening allergic reaction or secondary infection like C. difficile colitis. It may also result in a resistant strain. Over-prescription of antibiotics is largely responsible for the presence of MRSA and resistant E. coli in non-hospitalized patients.

It is not as if the concierge doctor went back to medical school or somehow became smarter. The decrease in case load reduces the doctor's exposure to learning experiences. My clinical acumen has increased over the past eleven years through the practice of medicine. Caring for an economically and ethnically diverse practice full of patients has given me exposure to a wide range of conditions that a textbook could hardly teach me. When I am unsure of the answer, I will pick up the phone and call a specialist. Through an extensive network of colleagues and an adequate caseload, I have learned a great deal of medicine. Taking care of the poor is especially instructive, as they often present with a host of conditions requiring close attention. It is not only instructive to care for the needy, it is the right thing to do. It is not only the right thing to do, it is a blessing. Concierge doctors are missing out, in my book. Besides, they are contributing to the primary care shortage.

Still, there was something deeply broken in the old paper chart model of practicing medicine. It was unsustainable. In my old practice, I spent much of my best energy shuffling papers. It felt like an endless cycle: seeing a patient, phone ringing, dictating the note, secretary at the door, phone ringing, signing the prescription, seeing a patient. I finished countless 11 or 12 hour days clearing my desk of the tornado of documents and charts, phone messages and prescription refill requests. I began to feel as though my career was competing with future happiness. I wasn't too happy in the present, either. Many nights, I would return phone calls on my cell while driving home. The practice model was inefficient, with 28 staff working for 7 doctors. My patients likened it to a factory.

In October of 2004, I attended the Pri Med Conference called "Practice Solutions" in Boston, Massachusetts. The Red Sox had just won the World Series and there was a great big party in the streets. It was a turning point for the Red Sox and marked a turning point in my career. At the sessions, I learned about the many benefits of electronic medical records and practice management systems as lecturers talked about "the paperless, wireless" medical office. I might as well have been at a tent revival meeting. I was sold, totally convinced that this was what I had to do.

I returned to Baltimore with plans to implement this model. I was already making plans to leave my original group when the lease was up in 2006. Though I was approached by a couple of other medical groups, I wasn't convinced that they were wholeheartedly committed to the computerized medical office. Soon it became clear that, in order to live out my vision, I would have to start my own practice. Though fearful, through prayer and meditation, research, and a lot of elbow grease, the pieces came together for Green Spring Internal Medicine to open in 2006.

In many ways, Green Spring Internal Medicine hasn't been everything I expected it to be. In some ways it has been more. More beneficial to my lifestyle, more excellent, more fulfilling and more joyful. Yet it has also been more emotionally and spiritually taxing, more unpredictable, more financially costly, and more unsettling than I predicted it to be. Despite our efficiency and thriftiness, it has been hard to make it. After some analysis, I do not believe it is because of a faulty business model nor because we need to see more patients. Of course, there were some unpredictable personal turns. All said, primary care doctors are simply not paid enough in the current model. It has been hard to be starved out of our own profession! Even with healthcare reform, and a 10% increase in compensation of primary care doctors scheduled for January of 2011, it is too little and too late. It is time to "adapt or die."

This time, the pathway for adaptation has been laid out for us. Medicare has given us a mandate to take electronic medical records to the point of "meaningful use" and will even pay us to do it! Thankfully, we are already about 75% there, and our software company is working on getting us the rest of the way. We have been working on updating the Patient Portal and hope to have the new practice website up and running soon! In addition, we are working on transitioning to become NCQA certified as a patient-centered medical home. This will enable us to receive recognition for much of the work that we already do, in addition to providing our patients with increased access to additional services both through our practice and outside the office. It should also pave the way for better compensation and, hopefully, the addition of another doctor to the practice. We are excited about the prospect of becoming a patient-centered medical home, as the idea has been endorsed by the American College of Physicians and the American Association of Family Practitioners. Besides, it is a really good idea! Our hearts are in it.

Here's to change for the better! To life!

Risking the Good

2010-08-08T18:50:00.001-04:00

Lately the news has been full of stories of bad behavior, from BP to Goldman-Sachs, Bernie Madoff to Mahmoud Ahmadinijad. Locally, there have just been 14 murders in 14 days in Baltimore. Each murder touches the life of a family and community indelibly; though with the common loss in our urban neighborhoods, there is risk of apathy. How can this be? Life is so precious, people! With 238 homicides in Baltimore last year, we had the third highest homicide rate among cities over 250,000 population. Our homicide rate was six times higher than New York City and seven times the national rate in 2009. I wonder how 2010 is going to close out. With this much bad news, it is hard to come by reports of anyone doing anything good even though good works are not actually that uncommon. It seems that in order for the news to report about people doing good, something bad has to have happened to them. That was the case with the above article.

Tom Little, an optometrist from New York, had devoted thirty years of his life to the people of Afghanistan. He was among a team of doctors and technicians who hiked 10 miles of rugged terrain to provide medical services to villages in Afghanistan. Dr. Karen Woo had given up her private practice work in London for humanitarian work in Afghanistan. Each of the ten individuals who were killed had a personal story and loved ones who were left behind. Each of them risked his or her own life to do good, to help others, and to bring good news to a war-torn country. They traveled unarmed and were gunned down. Though the Taliban intended to keep this team from spreading the good news through good works by killing them, it is likely that this brutality will have the opposite of its intended effect. When violence is used to take down a peaceful mission, the world takes notice. The Romans brutally tortured and killed early Christians before large audiences in the Colosseum and the number of believers increased. What made the world take notice was a faith worth dying for. Unlike the suicide bombers or military action, this act of sacrifice involved laying down one's life without resistance rather than killing one's opponent. In laying down their lives, these Christians have followed perhaps most closely in the footsteps of their master.

Some have suggested that war is the answer to the Taliban. Certainly the Taliban draws little sympathy from my corner. I am not a fan of any group that seeks to take away the freedom of any other group. I just don't believe that war is really going to deter them. I think it is possible that if these medical missionaries had been travelling with armed guards, they might still be alive today; yet, how the story would have changed. Perhaps the rest of us will be able to honor them by working to "overcome evil with good." Many of us who are committed to doing good risk our prosperity and security, but most of us only in some small way. Do we have courage to lay down our lives for the sake of others, in order to have the "beautiful feet" that bring good news?

Aquajogging and Other Local Trips

2010-07-25T18:09:00.000-04:00

Like all Baltimoreans, I have been working on ways to cope with the heat. We have experienced a heat wave that seems to be the longest ever. I think it started in May! I have lost count of the number of days in the 90's with nearly 100% humidity and a heat index above 100 F. The newscasters even came up with, "A heat warning will be in effect for today, with a heat index of 105. Tomorrow, there is a heat watch, with the heat index expected to rise to 110 degrees," or something like that.

I am utterly grateful for my Hopkins gym membership. All that tuition has been paying off in an incredibly inexpensive gym membership which has been invaluable in the process of rehabbing my knee after ACL reconstruction. I've been lifting weights and have found a new favorite cardiovascular workout in aquajogging. I can hardly believe I like it so much, since I find the treadmill incredibly boring. Perhaps it is because it is a total body workout, with resistance through almost every movement. I think it is also more meditative than the treadmill, since there's no risk of falling off. Apparently, it burns more calories, too. While aquajogging, I will find a letter or a number on the wall and allow that to prompt me to a thought or a prayer. I would see an F and pray for FCF church or a 5 and pray for my pastors and their families, as both of them have 5 kids. This past week, I even noted the H and prayed for myself, especially that I would have a pure heart and attitude. I think aquajogging has definitely helped my prayer life.

I hate to say it, but I complained a lot over the past week. I know that I should pray more than complain, but I had stress in a friendship and we were short-staffed on Monday. Then I fell ill with a sore throat on Monday night but had to work anyway, because I have to keep up my practice. I am almost never call in sick. I had an extra-intense set of clinical problems to solve in what seemed like too little time. This recurred on a daily basis this past week. In addition, it has been hard to see so little in the bank despite working very hard. In recent times, the adverse nature of the business of internal medicine has been coming to a head. There is no way that I will ever pursue the concierge model, but something has to give. We have been paid the same amount for our services for the eleven years that I have been in practice, while every expense continues to rise: malpractice insurance, health insurance premiums for our small businesses, staffing costs, rent, etc. I haven't contributed to my retirement in 4 years and took a $1000/month paycut this year after Medicare stalled payments. The government was indecisive about correcting the 21% paycut to physicians and, after a series of temporary fixes, has only fixed the problem this time until November of this year. It is a shame that this has happened in the year that landmark healthcare reform was passed, as it casts doubt upon the future. These delays have been very taxing upon the psyches even the most altruistic doctors, because it is hard to take out a loan to pay the government taxes when the government is owing you. The other scary thought is whether the insurance companies will follow suit or learn other bad behavior patterns from Medicare. I know it sounds paranoid, but this has happened before.

A couple of months back, I began to think of ways to increase revenue. Some have suggested learning to "do botox"; however, I do not want to profit off of people's insecurities. I am not really keen on selling beauty products or unproven vitamin therapies. Maybe travel medicine? That's a more likely possibility but would still require some energy. I even considered forming a non-profit organization to raise a grant in order to improve our practice and hire another physician. Problem is, I hate asking for money. So, I started looking into other options. One of the most appealing facets of healthcare reform is the "Patient Centered Medical Home" or "Advanced Primary Care Model." These ideas are the outgrowth of the work of major medical organizations over the past few years. Not only would the model revamp the primary care compensation structure, it will also serve to improve the quality of patient care by increasing the level of coordination of services. I am hoping that I will be able to implement this model in my practice, doing what we are already doing with electronic medical records and adding more services including increased use of our Patient Portal, targeting certain diseases such as diabetes and hypertension for ongoing case management, and increasing web resource availability to patients. One of the most important elements for me will be the addition of another health care provider to the practice, hopefully within the next year, with the goal of adding another over the next several years. With three providers at Green Spring Internal Medicine, I believe we will have grown to the ideal size. I look forward to a long vacation overseas someday.

Meanwhile, I have been making the most of staying local on a low budget this summer. My 100 day progressive birthday party has gone on, loosely including two outdoor Shakespeare performances, a couple of mountain ventures, watching the "Princess Bride" on Federal Hill with about 1000 other cult fans of that great movie, dinner with friends, bringing lunch to other friends, a "slumber party", the Friday concert at Belvedere Square, and an upcoming adventure on Assateague Island. Thank God for central air conditioning! I am reminded of one ill-fated Baltimore summer during medical school. It was a heat wave, and I hadn't bought a window unit yet. I lived along a west wall of a row house with a north window that received very little breeze, especially with the heat hanging thick. I actually woke in the middle of the night with the most vivid nightmare of my life, believing that the house was on fire! It took my housemates a few minutes to convince me otherwise. Apparently Doris, my nextdoor neighbor who just turned 100 today, only had her window units installed yesterday. She wouldn't let her son do it until then! I think she might have died this weekend without A/C, except that she's done a pretty good job living all these years and still lives on her own in her great big house.

"Unforgettable"

2010-07-14T19:58:00.000-04:00

"Unforgettable, that's what you are.
Unforgettable, though near or far,
Like a song of love that clings to me,
How the thought of you does things to me,
Never before has someone been more

Unforgettable in every way
And forevermore that's how you'll stay.
That's why darling, it's incredible
That someone so unforgettable
Thinks that I am unforgettable, too."

Nat King Cole, 1951

July 3, 2010 around 9 pm there was a pregnant pause in the concert. Those of us sitting on the grass outside the Aspen Music Festival tent wondered if something had gone wrong on the technical side. Maybe the sound system? In actuality, Natalie Cole had taken a chair, overcome with emotion before the start of this most meaningful song that she re-recorded as a duet with the soundrack of her late father singing his great hit. After a time, she pulled herself together and the song began, with the big band backing her, and slides flashing on the screen, photographs of the young star-to-be and her famous father. I hadn't really thought of that song as a father-daughter song before; however, that Natalie Cole was born in 1950, a year before the song became a hit, does make one wonder. Nat King Cole died an untimely death in 1965, from lung cancer. Hearing Natalie Cole sing "Unforgettable" as if singing it to her father (and he, as if singing it to her) made me think of all of the memories that had never been created in order to be forgotten, because he died when she was only 15 years old.

Legend has it that Nat King Cole smoked Kool cigarettes, believing that they kept his voice low. He was 45 when he died. Incidentally, tobacco is currently the leading cause of preventable death in the U.S. AS the Harvard professor put it last summer, "95% of lung cancer is due to smoking, and 95% of those diagnosed with lung cancer will die of lung cancer." Cigarettes kill 450,000 Americans annually, and not one tobacco company executive sits behind prison bars. On the other hand, there are plenty of folk jailed for far lesser crimes. Where is the justice? Someone told me last week that the tobacco companies have taken on the strategy of handing out free cigarettes to adolescents! What will they think of next? Meanwhile, our society would rather pay the costlier price to imprison drug addicts than pay for rehabilitation programs. Go figure.

Natalie Cole, herself, struggled with her own health problems and underwent rehabilitation for cocaine and heroin addiction in the 1980's. In 1991, she released the "Unforgettable" duet. I wonder if it was part of her restoration. She still sings impeccable jazz, even after a recent kidney transplant and the struggle with hepatitis C which was a longterm result of past drug use. In my estimation, she is one brave lady.

It has been an unforgettable summer for me thus far. My 100 day progressive birthday party is going along well. I had a great weekend in West Virginia with my hiking pal, Emily. Then, just two weeks later, I was off to Aspen. It felt like a real vacation, even though I just got out there for a long 4th of July weekend. My stepdad, uncle and I went on a scenic hike. Then we were treated to Gil Shaham playing a Brahms violin concerto at the Aspen Music Festival. My mom threw a birthday party and invited the family. We caught up with friends, watched World Cup games and headed to the hometown 4th of July parade. Then we had lunch at Boogie's diner. The Sunday afternoon concert at the Music Festival won my heart to a new favorite classical symphony - "The New World" by Dvorak. It was wonderful to be in the mountains, to feel the cool air, without a care in the world. I even started a little art project my mom has been asking me to do for the past 5 years. I left it as a work in progress for her to finish, so that it will be our collaboration in the end.

I was also able to raise a toast vicariously, as Spain won the World Cup last Sunday, since my niece Elizabeth is studying in Spain for the summer. I am grateful for the joys in life, big and small, and for the energy to celebrate.

100 Day Celebration

2010-06-10T21:50:00.000-04:00

This is the day the the LORD has made, let us rejoice and be glad in it. Psalm 118:24

Since 1970, my birthday has been in August. Those of us with summer birthdays know not to make such a big deal of the whole thing. We are accustomed to the fact that our friends have headed for the hills or for "down'e'ocean" or simply have other things to celebrate such as summer itself. I think the last really big birthday party I had was my 21st. My mom threw a fiesta at my grandmother's home in Aspen. The view was beautiful. My gorgeous friend Joel brought along a bunch of his handsome friends (yes, all of them gay as I pretty much already knew). My cousin made a great cake decorated with flowers, and we had sumptuous sangria (my first, of course). The view from the deck was fantastic. It was definitely memorable.

I'm not really a great big party person, though. I would much rather get together with a smaller bunch of people and have good conversations or do something interesting. As I thought about my big birthday this year, I started to feel a little bit stressed about it. How could I possibly enjoy a party with all of the friends who I would want to invite but who probably don't know one other? I wouldn't want to count anyone out, but wouldn't I feel distracted away from really catching up with people if I were the center of attention? I am sure this happens to brides and grooms at their weddings. All said, I think that a lot of people want to be in on the celebration of the fact that I'm alive and restored to a clean bill of health after last year.

Somehow it came to me. I am planning to stage a 100 day-long progressive party, starting 50 days before the birthday that rhymes neither with "flirty" nor with "nifty". I have always been more of the long distance runner than the sprinter anyway. The standard progressive party is all in one night, which would be much too exhausting at my age. The newly respun 100 day progressive party will hopefully involve a whole variety of events and circles of friends both near and far. The first day is tomorrow, coinciding with the kick-off of the FIFA World Cup.

Parenthetically, how cool would it have been if I had arranged that party, but it has been going on since 1930, which is the last year that the U.S. placed in the top 3. They stand a chance this year, and that would be a great and unexpected early birthday present for me. I have decided that if the U.S. falls out of contention, I am going to root for Spain since they are a great team and also since my niece Elizabeth will be spending the summer there. Apparently, the World Cup final is the most watched sports event in the whole world, even more popular than the Olympics.

Party plans from tomorrow through mid-September are to include outdoor theater, a trip to West Virginia with my hiking pal (yes, hiking since Dr. Cosgarea just gave me the go-ahead today!), getting out to Aspen for the 4th of July, an August trip to Assateague, and a hymn sing in September. Of course, I have other ideas: coffee dates with friends, art ventures, outdoor films, and an appearance or two at Belvedere Square. If all goes according to schedule, I will also be singing on the music team at FCF Church on my birthday. Sing joyfully to the LORD, you righteous. It is fitting for the upright to praise Him. Psalm 33:1. Like the Martha Munizzi song lyric says, "I was created to make His praise glorious." I think she was paraphrasing from the book of Ephesians in the New Testament. I hope that I will always live my life "to the praise of His glory", even though I know that I am imperfect so much of the time. The passage of Ephesians 1: 11-14 reads:

¹¹In him we were also chosen,^[e] having been predestined according to the plan of him who works out everything in conformity with the purpose of his will, ¹²in order that we, who were the first to hope in Christ, might be for the praise of his glory. ¹³And you also were included in Christ when you heard the word of truth, the gospel of your salvation. Having believed, you were marked in him with a seal, the promised Holy Spirit, ¹⁴who is a deposit guaranteeing our inheritance until the redemption of those who are God's possession—to the praise of his glory.

It's Organic

2010-05-31T15:13:00.001-04:00

"Organic - 1. of, related to or derived from living organisms... 5. constituting an integral part of the whole, fundamental 6. Law - denoting or relating to the fundamental or constitutional laws and precepts of an organization of a government or organization."

The American Heritage Dictionary of the English Language, Fourth Edition 2000 by Houghton Mifflin Co, Updated in 2009

It's been awhile since my last blog. Though a Mother's Day meditation had crossed my mind, I never quite got it together. One of the reasons is that I have been getting back my usual busy life. This is the least exciting but best current news I have. As I burn tracks, leaving knee surgery and breast cancer treatment behind, I've regained energy and at least a few activities. I'm not quite back to swing dancing. Most of my cardiovascular exercise has been at the pool or on my stationary bike. The latter has afforded me the opportunity to watch a lot of clips and documentaries on Hulu, especially since I've been taking a break from TV for the past year.

I just watched a documentary entitled "The Future of Food." Already aware of the presence of genetically engineered food on grocery shelves and in my shopping bags, I was still surprised by the film. I had no idea as to the extent that the food market that has become dominated by patented, engineered food products. The movie was very eye-opening to me even though it came out in 2007. I had heard about famines caused by the reduction of diversity of food crops, such as the Irish potato famine that killed a million people in the mid-1800's. Decreasing the variety of food crops increases risk of famines due to diseases that affect one type of food and not another. The production of genetically engineered food has been subsidized by taxpayer dollars, masking the overall cost of producing it and driving other markets out of business. The movie also highlighted how the patenting of seeds has affected U.S. and international farmers. Not only so, but the effects of genetically engineered foods on human health have not been studied in unbiased fashion. It no longer seems possible to contain the cross-pollenization of genetically engineered crops with home grown crops.

Robert Kenner discussed his movie, Food, Inc, on PBS Now . In the interview, he retold the story of the fast food industry controlling the overall direction of food production in our country through values of "uniformity, conformity and cheapness". (I first read about the McDonald's business vision in Eric Schlosser's book _Fast Food Nation_ years ago). Kenner argued that the cheaper manufactured food may not, in fact, be cheaper, because it causes expensive illnesses like diabetes. In addition, the way that food is mass-produced poses increased threat to public safety. One hamburger may contain meat from a hundred different cows; thus, tracking an E. coli outbreak to its source may be impossible. In addition, the agricultural industry dictates whether or not a recall should be enacted.

Hearing about this reminded me of a story on NPR from earlier this week about a "phantom recall" by Johnson and Johnson, whereby a private company was hired to mass-purchase faulty pain pills in order to get them off of the shelves a number of months before a voluntary recall took place. Can corporations be trusted to recall dangerous products when such recalls threaten their bottom line? Now that corporations are being treated as individuals with respect to the funding of campaign finance issues, perhaps corporations will be held morally responsible as well. We are talking about human lives at stake! To my knowledge, tobacco company executives were never thrown in real jail for committing murder after knowingly adding nicotine to cigarettes to make them more addictive, knowing that cigarettes cause cancer. As recently as 1994, they were still publicly denying nicotine's addictive effects. What kind of message does this send to us? Can it be that it is alright for companies to kill us even though an individual is put in prison for killing another individual? Whether they are held accountable or not, moral wrongs abound in corporations. The preservation of freedom to pursue prosperity is an important American value, but that freedom should have limits when it harms others.

It is so important to maintain diversity in biology, through the preservation of varied farm crops. We should also hope to preserve intellectual diversity, by funding academic research that is independent of industry influence and by ensuring that federal regulatory committees are not unduly influenced by corporations. In addition, we need market diversity to preserve capitalism. Large companies should not be allowed to monopolize the U.S. food production. Many of us feel helpless against the onslaught of labeling and information when we buy food. What is often absent on the label is whether or not the food was genetically engineered, what the cows were fed in order to make the beef, or just what "all natural" actually means. In 2005, Congress voted to uphold the USDA "National Organic Product" rules, helping preserve the truthfulness of the "organic" in our friendly neighborhood supermarkets. Unfortunately, the integrity of the organic label is now being questioned from blueberries to baby formula, and there seems to be reason for concern.

My mind is just about to flood just writing this blog! Too many details, to hard to sort it all out. So, what do I plan to do?

I plan to start purchasing more produce at the local farmers' markets (thank God for living in Maryland).

I'm going to ask my friends what they know about "Sustainable Agriculture" and "Community Supported Agriculture".

I'm going to keep on growing some food of my own on my lil' 1/2 acre, including the thyme and peppermint plants that I just bought today. I'll take any hints on how to grow tomotoes, which I've never really succeeded in doing.

I'm going to try to cook more from whole food ingredients. It's possible to junk out with processed food even from my beloved Trader Joe's.

I'm going to try going organic, "-ing" being operative since many of my beloved brands aren't. The label isn't perfect, but perhaps the stores I patronize will prove reliable in supporting truly organic choices

I'm going to try to be more aware of the source of meat and fish that I purchase (grass-fed beef and ocean-caught fish are examples).

I'm going to keep on avoiding fast food, which isn't actually cheaper in the end, since it threatens my most precious good health.

I'm going to vote for lawmakers who will hold industries accountable for products affecting human health.

Lofty thoughts

2010-04-23T21:43:00.001-04:00

Finally brothers, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable - if anything is excellent or praiseworthy - think about these things. Philippians 4:8

As I sat awaiting my breast MRI this morning, a song came on the radio in the radiology suite. Unexpectedly, it was a popular Christian song called "God of Wonders." As I sat and listened to it, my eyes glistened with tears, and I sat for a moment and meditated. "Lord of all Creation, of water, earth and sky, the heavens are your tabernacle, glory to the Lord on high." I traveled in my mind to the mountaintops of my life - the top of the Dolomites, the Vancouver area, Pyramid Peak, Old Rag, ski hills in Aspen, Peru. I also imagined beautiful spots in the woods along various hiking trails and other beautiful places I have been. These peaceful thoughts carried me all the way through the MRI, as did faintly-heard classical music. I was glad to be able to overcome the ominous overtones of the machine, with its whirs and beeps and Buddhist monk-like droning.

At the beginning of chemotherapy last year, I quipped to my oncologist that it would "take 9 months to birth the chemo baby", since the total duration of treatment would be about that long. I think I imagined a great big celebration at the end, but instead I dealt with bouts of "post partum depression." It wasn't a consistent low, nor did it stand in the way of daily functioning, more it was just a somewhat disconnected sense of grieving when I should have been rejoicing. Getting out to Aspen for Christmas was a real bright spot, but then the knee injury knocked me down again. I tried to talk myself out of being too upset by my ACL injury. After all, it wasn't recurrent breast cancer or anything. It was entirely fixable. Yet, this present ordeal has entailed just as much of a lifestyle change as the breast cancer did. For one, I truly miss regular cardiovascular exercise.

Exercise is one of my main stress relievers, and a lot of my social life is wrapped around physical activity. It has been over a year since I last went swing dancing. My last hike was sometime back in November. Even gym exercise has been strictly limited. I find myself grilling my orthopaedist with questions at each visit. Most of them center on the "when can I?"'s. The reply has mostly been, "Not now." He mentioned that many people with this injury go through a bit of depression. Yeah, I'm feeling it. I pretty much chalk it up to lack of endorphins; though it has also been hard to face my human limitations, to feel that turning 40 might amount to rounding the bend, to confront my own unattractive jealousy when my friends scoot off to the high trails and I can't go.

I guess it was nice for a moment today to recapture memories of all of the amazing place I have already been. Thinking of those places gives me the hope that I will reach many more mountaintops in my lifetime. I realized that many of my most pleasant memories are of mountainous places. Perhaps I will live in the mountains again some day. I went on from thinking of past places to the imagination of future ventures to places I have yet to visit like the Arctic, Norway, New Zealand and Costa Rica (or are those hills?). It may be time to book plane tickets for the 4th of July weekend in Aspen. Having something to look forward to has always helped me find joy.

Another boost was the news that the breast MRI was completely normal! This news, which I received from Dr. Schultz this evening, adds to a recently normal mammogram, soon after the anniversary of my diagnosis. I am so grateful. It really is time to celebrate!

Career Path

2010-04-13T20:35:00.006-04:00

Last week, I received a call from Dr. Michael Weisfeldt who is the Chairman of the Department of Medicine at Johns Hopkins. He asked whether I would be willing to join Dr. Chuck Angell and Dr. James Porterfield, speaking to the Osler Housestaff (internal medicine residents at Johns Hopkins Hospital) on the topic of my career path. It was my honor to do so. I am posting the essay I wrote in preparation.

Some have career paths as straight as the interstate between Iowa and Nebraska; however, I’m from Colorado and my career path somewhat resembles a mountain road with various turns in the road, steep uphill climbs, and scenic overlooks which have offered perspective. My career path was a bit unusual to begin with, since I decided to become a doctor at age 3. I give credit to my childhood pediatrician. His strategy for melting my terror was to seat me on his examination table and address me directly. “Holly, what do you want to be when you grow up?” Quickly, I learned that the correct answer was, “A doctor! A doctor!” Fast forward to college, I knew that I needed to fulfill pre-med requirements but chose a liberal arts education at Mount Holyoke College where the humanities shared an equal part with the sciences. My academic interests were varied, and I loved dabbling in various disciplines.

Interviewing for medical school at Hopkins involved one 15 minute interview with a faculty member as well as a group interview with other applicants mingled with members of the admissions committee. I remember it well. The somewhat austere faculty member asked the basic question as to my field of interest and I replied, “Family medicine or pediatrics”, to which she replied, “You know there is no family medicine program at Hopkins.” Breaking out in a sweat, I think I replied something like, “Well, I just want to train at the very best institution no matter which field I choose.” I left the interview laughing, certain that I would never be accepted. Imagine the surprise when I got the call inviting me to become a member of the Class of 1996.

Coming to Hopkins was really humbling. After all, my classmates included Harvard and Purdue valedictorians and two women with PhD’s in science. My idea about going into family medicine was challenged by the sheer and vast amount of information flooding my mind. I started to think that a more refined approach might be to pursue med-peds. I bumped into Dean of Students, Dr. Catherine DeAngelis, at the Monument Street entrance one day and ran it by her. She said something like “Don’t do both, Holly. It’s simply too hard to be excellent at both.” Another mentor suggested that I would most likely choose my career based on similarity to my colleagues rather than who the patients were. When I did my pediatrics rotation, I realized I was no pediatrician. I wasn’t up on the latest kids’ movies and was certainly not going to wear a Sesame Street tie. When I hit the O on the Barker firm, I came to the realization that internal medicine was it. I loved the detective work involved in the H&P and the broad concepts of pathophysiology. I admired the interns and residents and was thrilled to be allowed to stay here and train on the Osler Housestaff.

I came back to the O as an intern on the Thayer firm, pretty much undecided on my future career. I knew that internal medicine would be a great base for a variety of choices. Research was not that appealing to me, and I already knew I was not a bench scientist. I liked infectious diseases. After working 100 hours per week for the first year and 80 hours a week after that, I found that I was a bit burnt out on patient care. Urban medicine challenged my patience with its limited resources, illiterate patients not knowing which medications they were on, a 50% clinic show rate, and paperwork. I began to question whether I was really cut out for clinical medicine. By my third year, I thought I might pursue public health. I applied for a job at the CDC called the Epidemic Intelligence Service, where I could train in studying outbreaks. That became my “plan A”, and I hadn’t thought too hard about a “plan B”. In December of that year, I was in the middle of my geriatrics rotation. As part of that rotation, I worked with Dr. Durso in his efficient private clinic. Suddenly, I found my heartstrings plucked as I took care of gracious older patients. I even wondered if I should reroute and apply for a geriatrics fellowship. I had also just started dating a guy in Baltimore. Right around then, I had the job offer from the CDC. There was a decision to be made. I finally turned the CDC down and started applying for jobs, way late in the game.

I had never before considered entering private practice, having a bit of a negative image of “private slicks” wearing fancy suits and driving nice cars. Shouldn’t I be serving the disadvantaged? Could I live with the country club image? Even so, the best job offer I received was from a group in Northwest Baltimore. They were nice guys, and we negotiated a contract that involved equal call schedules and a $100,000 starting salary with benefits. Within two years, I was offered partnership and thought I was sitting pretty since I was billing over $200,000 per year. There were two critical points that went unnoticed:

1. only about 2/3 of what was billed ever came in as income (due to insurance company adjustments)

2. the overhead in that practice per physician was $200,000 per year

I wound up paying back $30,000 that the practice had overpayed me because I wasn’t making enough money to cover the salary I had made as an associate (that is, before partnership). It was a very harsh awakening to the business realities of medicine. Though this will not sound right, I had to learn how to make money in my profession. I had to see a certain number of patients at a certain level of complexity every day in order to cover overhead and generate enough of a surplus to take home a professional salary.

The next challenge involved a change in the direction of our practice. Three of my six business partners decided to pursue the concierge model of medicine, which involves charging patients a membership fee of $1500/year to remain in the practice in exchange for longer visits and more availability. At around that time, my parents were facing insurance premiums that comprised around half of their income. I could not live with the notion of no longer taking care of patients like my own parents, who could never afford added costs. The ethical conflict with my partners was a major drain on my energy, so I decided to part from the practice when the lease was up in 2006.

I had never been very happy with the way the old practice ran, in the paper chart model with 28 staff working for 7 doctors. The office was busy and noisy, and my patients compared it to a factory. The model was inefficient, and I had to field complaints frequently. By then, I had a full practice of around 2000 patients. The flushing of patients out of my partners’ concierge practices resulted in a flood of new patients into mine. I spent one to two hours per day, clearing the clutter of paperwork off of my desk, arriving home too tired to call a friend or go to a movie. Most of my days were 10 to 12 hours long, especially when I had patients to see in the hospital. I began to see my career competing with future happiness. Something was going to have to change. I decided to leave my partnership in the old group when the lease was up and had two years to come up with a new plan.

Just then, I attended a PriMed conference on Practice Management Solutions up in Boston. At that conference, the use of electronic medical records and computerized practice management systems was emphasized. This was my “Eureka!” moment. I was completely sold on the idea of starting a “paperless, wireless medical office.” After the conference, I returned to Baltimore and began putting together ideas. Two other practices invited me to join them; however, those practices were not wholeheartedly committed to electronic medical records. Then came the somewhat terrifying realization that I would have to start my own practice in order to accomplish my goal. I was already well familiar with the difficult business of medicine, having learned most of my lessons the hard way.

After two years of planning, my practice opened in 2006. There were a lot of unexpected turns, including computer challenges and a high staff turnover rate. Finally, I came up with the two nearly perfect staffers who work for me now. Last year, I was finally getting my head above water financially when I was diagnosed with Stage I, triple negative breast cancer. With added news that I was positive for BRCA 1, I pursued a course of lumpectomy followed by bilateral oophorectomy, then chemotherapy for five months, followed by 33 rounds of radiation therapy, all while working and running the practice. Following my oncologist’s strong advice to cut back my schedule by 20%, I was just able to survive financially. On top of it all, I was up for recertification by the ABIM which required not only a boards exam but also practice improvement projects which I hadn’t yet begun. Thankfully, by God’s grace, I passed the exam at the end of November, that month also marking the end of all of my treatment. Then in December, I went skiing in my hometown of Aspen, Colorado, and tore my anterior cruciate ligament on the last day of my trip. I just underwent ACL reconstruction 6 weeks ago and have 6 more months of rehab.

The past year has brought the full pressure to bear upon what it means to be a primary care physician, a patient, and a small business owner. It also happens to be the year of the great national debate on healthcare reform. It has become increasingly difficult to attract the best and the brightest to the field of internal medicine, even though we need smart doctors to handle the increasingly complex host of illnesses affecting our aging population. When I went into general practice, I was told that I was signing up for boredom. “You’ll see the same thing every day, and manage the same conditions over and over. Your brain will atrophy.” Funny, but I find that what I do is just the opposite, and no one day is the same as another. Especially since moving over to electronic medical records, I find my career more satisfying than ever, and it is just the right fit for me. One of the funniest realizations was that I actually do “family” medicine after all, it’s just that none of my patients are younger than 16! There are so many non-monetary rewards in my field. My patients love coming to my quiet, efficient office, and I am practicing with excellence. Thanks to being computerized, I work one to two hours less every day. Hopefully, in the future, primary care physicians will be compensated more on par with the rest of our profession, especially since prevention, early detection, and aggressive disease management stand to save the healthcare system so much money.

Resurrection

2010-04-04T21:48:00.000-04:00

It seems only fitting for a week that began with a Passover seder to end with an Easter celebration. No set of holidays bring Judaism and Christianity closer together, both in theme and proximity. My life is in parallel, transitioning from a season of hardship to a season of living again. I am so grateful to have made it through the season of breast cancer, the boards, and knee surgery. Now that the worst seems to be over, I have a deep down feeling of starting a new life. I have almost wanted to keep this a secret.

Nothing dramatic has happened, no stones rolling away from the grave, yet it does feel like a resurrection of sorts. My minister's wife wrote a wonderful book entitled A Thousand Resurrections, and I remember wondering what she meant by the title. The book was a biographical sketch of her own family as they took on the challenge of working in urban ministry. Through countless challenges and disappointments, God was faithful in bringing about new life to so many individuals through their work. It is remarkable how God uses our suffering to multiply his work.

I feel like I have grown a lot through my hardship. Certainly, I have a much better handle on what it means to be a patient as an adult. It is very different to have all of the responsibilities of being an adult, like working and managing a household, handling bills and dealing with insurance companies, all while fighting an illness. This is important for me to understand as a primary care doctor. It is also important for me to be "near to the brokenhearted," that is, to have compassion on those who suffer. When we prosper, it is sometimes hard to stay in touch with the needs of those around us who are enduring hardship. It is very hard to ask for help, even when we need it. In our time of need, though, we then realize the depth of community.

I feel very blessed to be part of a very rich and diverse community of friends and family here in Baltimore and can honestly say that I have never gone with needs unmet. I do know some who have, though. Having been in a position of needing help lately, I now want to take the time out to help others in turn and as my level of fitness permits. Tami Ritsema and Larry and Beverly Stappler have been great examples to me of helping others. I would also like to continue to connect others within the community. Sometimes we are too individualistic as Americans. Being isolated is overrated. As with Thomas Merton's book title, No Man is an Island.

Like I said, my resurrection this year is none too sudden. Even doing physical therapy 2-3 times per week, with home exercises twice a day, it will be six more months before I am able to return to most of my favorite sports. My knee immobilizer has been replaced with a less frumpy athletic brace; however, it still has a way of requiring tightening throughout the day. It has definitely slowed me down. There have also been some funny moments, with the brace falling down my leg at inopportune moments but thankfully not during the Easter service. Today's celebration was a reminder of present and future hope, always my most joyful and favorite holiday.

Spring!

2010-03-23T15:41:00.001-04:00

I am now into the second week back to work following ACL reconstruction. My schedule is reduced to 2/3 of the normal with my hours distributed across five days rather than four. Last week, I was "plum tuckered", getting back in the saddle after ten days on my backside with my knee elevated. Being the model patient right after surgery, I have enjoyed recovery ahead of expectation with reduction in knee swelling and pain to the point that I am now only taking naprosyn. I believe that God added His healing mercy, in answer to many prayers, also helping me to rest well. Though I do not usually excel at sleeping through the night, by Friday of last week I headed to bed around 9 pm and woke up after 8 in the morning. Then on Saturday night, I slept another 9 hours. I still rested for the better part of Sunday and slept well again on Sunday night.

Finding spiritual rest has been a bit harder. Though I intended to have all kinds of time for prayer and meditation during my week at home, I never quite arrived there. Besides having a lot of adjustment to the new routine and the lovely distraction of visitors, my heart just wasn't in the right place.

It took Glenn Beck's outrageous comment (or one of them) to get me back into reading Scripture wholeheartedly. Though Mr. Beck rarely captures any of my attention, several friends made me aware of his judgment on "social justice" last week. He basically asserted that churchgoers should be aware of certain buzzwords which were used by both Communist and Nazi regimes, including the phrase "social justice". Funny, because that is a major theme emphasized by my wonderful church. If Christians aren't concerned for the poor and oppressed, who will be? I wonder if the vacuum of the church's involvement in these issues over the past century hasn't been a major contributing force to the government's imperfect handling of poverty and justice issues.

My heart was moved to simply reread the Gospel of Matthew to try to get a handle on what Jesus was really about. Not only was Jesus concerned about the false religious attitudes of his day, He also demonstrated compassion by bringing healing to broken people and by interacting with individuals who were rejected by religious people. His most famous Sermon on the Mount emphasized not only a higher standard of righteousness than the Pharisees prescribed but then Jesus highlighted that the only way to achieve this standard was through faith in Him, by being "poor in spirit", knowing that we can't do it on our own. Jesus may not have coined the phrase "social justice" but He was clearly concerned about it.

The past few weeks have brought lessons for me. Being unable to drive or to walk very far has helped me to identify more with the poor who often lack transportation and have physical difficulties. I have had to rely more upon my community and have had a chance to reflect upon the little things that I can be thankful for. Time has slowed down, giving me more opportunity to spend time with others and to share stories. I had a chance to talk with one of my best friends for a couple of hours on Sunday. Finally, I have had the chance to restore prayer and meditation, thanks to the Book of Matthew, which has reminded me of who and what to pray for and even how to pray. The LORD's prayer is part of that book, not just a prayer to memorize and recite as quickly as possible, but one that serves to focus the heart and the mind to fall in line with God's priorities.

I'm not about to leave my church, with its heart for social justice. Faith Christian Fellowship has been what I would call "my gospel workshop", where I have been able to work out what is good and right in this world and how to follow Jesus. I hope the rest of Christendom manages to either ignore or confront Glenn Beck. As one of my friends put it, "I doubt that he has ever even read a word that Jesus said."

If you want risk becoming a radical, please consider coming to this event:

Faith Christian Fellowship Church

Easter Celebration

Sunday, April 4th

10 am

Goucher College

Kraushaar Auditorium

free to the public, onsite parking, Gospel choir, Mark Meadows on piano, refreshments following

Movin' On Up

2010-03-13T11:55:00.001-05:00

It is hard to believe that a week has come and gone since surgery, what I have proclaimed to be my last surgery ever. Of course, I can't exactly presume upon the future, but there's nothing wrong with hope. After staying overnight at the Stapplers on Sunday, they brought me to the first follow-up visit with Dr. Cosgarea on Monday afternoon. Ice, compression, elevation and twice daily home PT exercises I had been doing obviously paid off, because he told me that I had achieved the range of motion he would expect a week from then. I was thrilled to find out that I was a week ahead in recovery! I believe those prayers for quick healing are being answered.

Monday night, the Stapplers brought me home for the changing of the guard which amounted to the arrival of my dear friend Tami. Though she lives in Northern Virginia, she came up to town for work-related reasons and stayed overnight with me, returning Tuesday afternoon through the evening just to hang out with me. It was great to catch up. I managed my first night by myself with the help of various devices we had set up downstairs where I have been staying.

Wednesday morning, Vernette came early to pick me up for physical therapy. After returning home, Lisa came by with her 4 month old, Elinor, and 21 month old, Jacob. Jacob had a wonderful time chasing Wilberforce around the house, my cat happily and coyly playing along in their usual game, while I held the baby. It was good to visit with Lisa who has come over on a number of similar visits since last year, though before Elinor was born. In the evening, Emily and Kirstin and Kristina came with a wonderful veggie chili with cornbread and chocolate covered strawberries for dessert. Needless to say, I have felt well-loved.

On Thursday my Afghan friend, Khadija came for a visit. We spent the whole afternoon and evening catching up, watching a movie and dining. It was good to see her and catch up. She has lived here for about 5 years and is considering various schooling and career options, most intent on becoming a filmmaker. She is also full of stories from Afghanistan as well as reflections on living in America now.

Friday morning began early, with Vernette's faithful arrival to transport me to PT visit #2 where a big part of the session involved "gait training." Who would think that I would need to learn to walk again? But there it was. No more shuffling and dragging my feet. Heel first, then to toe, even wearing my great big football-player-sized knee immobilizer. Let's just say that my gait is far from normal right now, even after training; however I have semi-graduated from crutches. I have become more and more comfortable with stairs to the point that I think I will try to sleep in my own bed tonight rather than on the couch. I think my back will appreciate the move, and this will start to help me feel like I am getting back to the usual routine before heading back to work on Monday night. I will have better access to my computer and DVD player up here, and it's warmer!

As part of getting back to normal life, I'm hoping to make it to church tomorrow morning. I even have a dinner date planned for tomorrow night. That will be a big adventure after spending most of the week within a 50 foot radius. Thankfully, I am no longer under the influence of strong pain medications, except at bedtime.

Post-Op

2010-03-07T13:43:00.000-05:00

It is hard to believe that the big day has finally come and gone. My ACL reconstruction is over, and I am now sitting on the couch at home, typing away on my sister's iBook laptop computer. I haven't yet ventured up or down stairs yet, pretty much camped out on the first floor. I am so grateful that Katie arrived the night before surgery. She adventured down with me to the Johns Hopkins Outpatient Center where we checked in at 8 am on Friday morning. While in the waiting room, a doctor garbed in white coat over scrubs came out to discuss a surgery with family members, bearing with him a specimen container. Thankfully, we were sitting a little too far away to overhear the details.

Since we come from a family of fainters, I was quick to advise Dr. Cosgarea not to bring a specimen container out to my sister when it was all over. He brought photographs instead. I have yet to see them, but were very fascinating according to Katie. The new ligament looked "all robust and healthy".

I awoke from surgery in the post-operative area, unaware of having been extubated, which is always good. Pain brought me into consciousness, and I found that my shin was hurting and not just the knee. The outpatient surgery nurses may be a little bit reluctant to give pain medications, because the goal is to get patients up and out; however, I had to sound my discomfort. Finally when it came, I received tylox to swallow and fentanyl in the IV. It seemed simultaneously, and off I drifted into a long winter's nap. I do believe that an old friend, Ralph, dropped by. He works at Hopkins and was down in the post-operative area picking up supplies. Dr. Cosgarea dropped by as well and mentioned having repaired the meniscus as well. When I saw him later, I think I asked the same exact questions. Anesthesia not only treats pain and sedates, other forms of it cause amnesia. At least I remember little bits and pieces.

The first 24 hours post-operative were pretty rough. Despite maximum pain medications, I still had a throbbing, especially in the shin area. I figured out that the ice pack, when filled with icewater, was ramming up against the shin. It felt better getting my knee out of the immobilizer which was adding to that pressure; however, I'm not supposed to sleep or walk without the immobilizer. I finally called the resident with the idea of using one of my shin guard from soccer to keep my shin from being pressed by the ice machine. He did not object, and so I unlayered my dressing a bit and got down to business. Afterwards, there was much improvement. I have required much less in the way of pain medication today.

I am so grateful that the surgery is over! I'm voting that this be the last surgery for me ever. Thank God for modern techniques that are able to replace torn ligaments, and for the devices and medications that assist in the healing process. I am working on physical therapy exercises already and look forward to getting back on my feet again. There is no way that I could have managed this weekend without my sister, Katie. She has been a fabulous nursemaid and companion, having come with her usual wonderful sense of humor. When she leaves this afternoon, the Stapplers will take over. They are whisking me away to their home tonight through tomorrow where I'm sure I will be showered with TLC. Then, tomorrow afternoon I will visit with Dr. Cosgarea for the first post-operative appointment. Over time, they will allow me to bear more and more weight on my leg, and I may even graduate from crutches in a week. Tomorrow night, Tami is coming to stay with me, planning to work at Hopkins the next day. It will be great to have time to hang out with her. I am looking forward to other visits throughout the week, as well as some downtime to read and watch movies. I'll find a little time each day to take care of needs at the practice.

Many thanks to Drs. Michael Rudikoff, Tamara Sobel, and Ellie Goldbloom for being willing to see some of my patients this week!

Preparations

2010-02-18T19:18:00.000-05:00

March 5th is coming quickly. Besides being my brother's birthday, it is the date we have set for my ACL reconstruction. On one hand, I am bracing myself for yet another surgery. On the other hand, I am really looking forward to greater knee stability. As it happens, most of my sports involve the "plant and pivot" motion which is supported by the anterior cruciate ligament. The ACL is critical to swing dancing, soccer and skiing. Reconstruction has a 95% success rate, and I can hardly wait to get back to my sports. I haven't even been able to go hiking. Snow exercise (aka shoveling this past week) did add variety to my usual regimen of riding the stationary bike and lifting weights at home. I have finally regained almost all of my pre-injury range of motion, and my knee no longer hurts. The swelling is gone. Dr. Cosgarea seems pleased.

My to-do list is now running through my mind. I need to catch up on bills and bookkeeping, arrange coverage for my surgery date, and set a schedule for my recovery week. Thankfully, Samantha and Erica have been very flexible. I will be out of the office from March 8th-12th, returning on March 15th, which also happens to be Mom's birthday. The weeks of the 15th and the 22nd, I will be seeing patients from 9 am through 3 pm, Monday through Friday. This will be a bit of a change from the normal schedule but will allow me to work shorter days and keep my knee elevated for most of the time. Keeping knee swelling to a minimum is the key to recovery during the first few weeks after surgery. In addition, I will need to regain the ability to straighten and bend my knee and bear weight on it. My lovely physical therapists at St. Joseph's are poised and ready to assist in this endeavor. With physical therapy, "no pain, no gain." I expect that I will need to devote a significant amount of my free time to rehabilitation over the next 6 months.

Before the big day, I will need to stock the shelves of my fridge and pantry as if "Snow Apocalpse II" were coming soon. I won't be able to drive for three weeks, but a number of friends have already offered to help. My sister, Katie, will come down on March 5th and for a few days after, so I have to prepare the guest room. If I'm good, I'll buy flowers and have a chocolate or two on her pillow. Then, there's preparing a stack of books. During that week at home, I'm sure I will occupy time by reading one after another. Thanks to Larry Stappler, I am itching to read the next Robin Cook novel. I am also gathering up some movies to watch. After last week, I rediscovered introversion. I'm definitely somewhere in the middle personality-wise, yet I find myself content to spend long periods of time by myself. I'm sure that I would eventually go crazy without people, like the Tom Hanks character in "Castaway"; yet this will only be a week and not a month, and I'm sure visitors will drop by. Besides, there will be calls to return, labs to review, and other organizational aspects of medical practice that I will be running from the home office while keeping my knee above the level of my heart.

Blitz or Bliss?

2010-02-10T10:13:00.000-05:00

Blitz or bliss, this blizzard of 2010? I am sure there is great variation in perspective, and that there are age-specific cohorts in each camp. I would bank on the joy of those 12 and under, though the teenagers may be getting tired of shoveling the driveway and are most likely to declare themselves bored. Adults are more likely to perceive this as a blitz, and more so with each ascending decade I should think. My Uncle Chico, who lives in Oregon, has already commented on the storm's unnecessary effect on the U.S. economy. I'm sure that thought has occurred to so many of us. Like one of my old business partners declared, "The most expensive part of your vacation is not being at the office."

I did find myself tempted to worry about my business this week, a worry that was somewhat assuaged by 11 hours of patient care which we accomplished yesterday. This is a year of vacation time that is already spoken for. Perhaps this is God's way of proving to me that three weeks of vacation is actually possible. It is true that I had to trade in my 1998 standard Honda Civic, because I wouldn't have been able to drive it after surgery in March. Thankfully, the 2003 Civic Hybrid which I purchased in exchange at the end of January has already stood the first several tests of snow driving, not to mention being a really cool car. I haven't even gone through a half a tank of gas since January 29th when I brought it home.

I also anticipate having to regrade my property and replace plumbing pipes in the Spring. A few trees will need to be removed, and I will need to have landscaping. Somehow, this seems to be another year of trusting God with my finances, which is one of the hardest areas for me to have faith. Even so, He has always provided for me. Sometimes our lives get trimmed down, like Gideon's army, just so that God can show that it was His strength and not ours. At times like this, it comes down to the choice to trust or to worry. The former is the more adventurous attitude.

So, how have I passed the time? I think one of the major themes has been rest. For the first time in nearly a year, I think the dark circles may disappear from under my eyes. Extra sleep has boosted my recovery from breast cancer treatment and my knee injury. It has been great to have a few days without lugging around the knee brace, since I've been set free from having to wear it at home. I have had some good reading and writing time. Perhaps the most fun has been cooking time. I have enjoyed Alpine-inspired cuisine including chocolate chip pancakes, goat cheese and tomato toast, and black bean soup.

On Sunday, digout day # 2, my neighbors showed up with a snow blower. That totally took the edge off of shoveling. Before I knew it, the end of my driveway was cleared down to the asphalt and my car emerged from under its igloo shelter. Grateful, I offered to have them over for dinner; however, since it was Superbowl Sunday and I have no TV, I brought soup over to their house. We put it together with their freshly made bagels and cornbread and watched the game. Neighborliness, without fail, shows up in snowstorms around here.

On Monday, I caught up almost all of the bookkeeping, read medical journals, and watched a movie. I also had a chance to witness an X-games style athletic feat by Wilberforce. I have a couple of nearly empty boxes in my home office, one of which is a banker's box with the top panels open. Instead of pulling the panel down to jump into the box, Wilby leapt straight up in the air, flipping before landing inside the box. These are moments we miss when away at work. Today, I am captivated by the scene outside, the wind causing snow-laden tree branches to wave and gusts of white dust to kick up all around. I may be inspired for more snow exercise by the late afternoon. Until then, more quiet time.

"Snow-pocalypse"

2010-02-06T19:58:00.001-05:00

When I first saw the term "Snow-pocalypse" on MSNBC.com this morning, I had to laugh. The way the media usually cover snowstorms around here, it should be no surprise that this one took on an epic pseudonym. There was even a quickly-invented Facebook event called "Snow Apocalypse". By noon today, over 100 people had joined in. Is this a "Snow Apocalypse"? In the balance, I would more likely say "It's no Apocalypse!" The word "Apocalypse" would tend to imply catastrophe, or at least "the end of the world as we know it" as the REM song goes. The buzz about the movie "2012" had a lot of people referencing the Apocalypse, including Saturday Night Live's very funny parody "Sarah-pocalypse". I understand that the movie had much in the way of special effects and little in the way of plot. I haven't quite seen it yet. To me, the earthquake in Haiti must have seemed far more apocalyptic than our blizzard and probably still does for those who are still living through the aftermath. True that there were power outages, and East Coast life has come to a screeching halt.

To me, though, the snowstorm has not held that negative connotation. It is a message from above to slow down. I am grateful for it, having come through a frustrating week. A couple of grumpy people, a hectic schedule, and insurance hassles were all enough to throw me into a rut. It is amazing how quickly I fall to self-pity, even though I have so much. A year ago this week, I discovered the lump that would be diagnosed as Stage I breast cancer. I am so grateful that I was able to continue seeing patients through my illness, especially since both my livelihood and insured status depended upon it. 2009 had so many challenges! Thank God, breast cancer is solidly a thing of the past.

I am still in the process of recovering from the ACL tear. Having stayed on track with physical therapy, I have almost healed enough to be able to have surgery. I initially considered postponing surgery until the week before Passover; however, that seemed too far away. The surgery date is now March 5th. It is time to get on with it. I am hoping to heal quickly enough to be able to coach soccer this fall. In addition, I have been restricted from almost all of my favorite activities including hiking and swing dancing. Most of all, the surgery and recovery should mark the last major steps to end the medicalization of my life. To be sure, I will always be a doctor. I am simply looking forward to ending this stretch of being a patient. It is hard to be both; though, I know that I have gained a great deal of perspective.

Having a snowstorm slow me down is good. This weekend's pause is giving me a chance to process a bit, something I don't often do these days.

After sleeping in this morning, I made some coffee and nestled on the couch, reading a book with Wilberforce snuggled on my lap. After lunch, the outdoors beckoned and I dug out a pathway from the house to my car which was parked near the street end of the driveway. Though it looked like 3 feet of snow from inside of the house, I think the final depth was closer to 2 feet. When I finally got to my car, I made a snow angel and then headed inside. I caught up with friends and talked to Mom for about an hour. Later on, I finished the book _The Hiding Place_, which is an inspiring memoir by Corrie Ten Boom who was part of a Dutch family who resisted the Nazis and provided safe haven for Jews during World War II before they were captured and imprisoned. It was an amazing story of love, loss, and forgiveness. I am humbled when I read such stories. How much of a hero have I been? How much risk have I taken to save lives? To those who suffered at the hands of the Nazis, it must have seemed like hell on earth. How could one forgive such enemies and even pray for them, as Corrie's sister Betsie did?

I have very little to complain about in this life. I am so grateful for health, warmth, shelter, food, and faith. I am also thankful, in advance, for a new anterior cruciate ligament. It is good to slow down long enough to appreciate what really matters.

Goodness

2010-01-29T22:13:00.000-05:00

I remember listening to NPR one morning over the holidays. The topic was on giving and the featured speaker made an argument that good giving meant that the giver of the gift would receive no added benefit or recognition as a result. My first reaction was thinking that if we all had to give out of perfectly pure motives, there would be much less generosity in the world. Psalm 112 says, "Good will come to him who is generous and lends freely." I'm sure that anyone who has lent freely has at least gotten some positive press out of it, in addition to a lot of appeal letters in the mailbox at the end of the year. And why at the end of the year? It seems that tax breaks are a great way to motivate charity, or is it just that we are thinking more about giving at Christmas time?

The global outpouring on behalf of Haiti has been something to behold. The goverment of Senegal has offered land to Haitians who wish to emigrate, according to the BBC. A poor country, the Democratic Republic of Congo has pledged $2.5 million to relief efforts. Contributions are also coming from other countries such as Zambia and Sierra Leone. One African woman interviewed on NPR talked about this story.

Jesus sat down opposite the place where the offerings were put and watched the crowd putting their money into the temple treasury. Many rich people threw in large amounts. But a poor widow came and put in two very small coins worth only a fraction of a penny. Calling his disciples to him, Jesus said, "I tell you the truth, this poor widow has put more into the treasury than all the others. They all gave out of their wealth, but she, out of her poverty, put in everything - all she had to live on." Mark 12: 41-44

That's what I would call giving until it hurts.

As of three days ago, the total U.S. contribution was said to be $379.7 million and growing. This number unlikely accounts for other forms of aid in personnel, expertise and supplies. The UN is pledging a similar amount in emergency aid. Of course, there has been a long and somewhat controversial legacy of UN peacekeeping forces in Haiti. The presence of the U.S. military stands to be misperceived as well.

Haiti is the poorest country in the Western Hemisphere and has been for decades despite being the greatest recipient of foreign aid. History hints at why Haiti has been hampered in development. The Sunday Times (UK) published an article on how the French, for hundreds of years imposed deadly oppressive slavery, importing tens of thousands of slaves to Haiti because so many died in their travail. Haiti's deforestation began and agriculture was oriented toward production of export crops of sugar cane and coffee. After a 12 year slave revolt ending in 1804, the French were defeated; however, in order to stave off reinvasion, the new republic agreed to reparations to the French amounting to 150 million francs. This debt was still being paid off in 1900 and amounted to 80% of the national budgetary expenditures! Reparations were only finally paid off in 1947.

The U.S. has not been entirely innocent in its policies toward Haiti. Millions of dollars were paid in aid during the Duvalier regimes, in an era where Communism was greatly feared. Under their rule, 30,000 Haitians disappeared and economic prosperity was for the few. Natural disasters mixed in with political disasters, with a number of misguided efforts at development. Haiti became a country dependent upon imports for its food supply. Though well-intentioned I'm sure, rice imports under the Clinton administration put rural farmers out of business. The recent global economic crisis led to food riots in Haiti. All this before January 12, 2010.

Truly there is goodness in the global outpouring toward Haiti. Money alone won't solve the problems Haiti has faced for so long. Hopefully this time relief will progress to meaningful partnership with Haitians in rebuilding the country. Hopefully, Haitian-led development will emerge from the rubble. After visiting Haiti in college, I was impressed by the faith and hope of Haitian people in the face of abject poverty. All of the outsiders trying to help should be sure to learn from them. This time, may all of this global outpouring lead to the good for Haiti.

Holding Pattern

2010-01-16T14:38:00.001-05:00

A week after my return to Baltimore, I consulted Dr. Andrew Cosgarea in orthopaedics. It was good to finally meet him after referring patients to him for a number of years. He is an expert in sports medicine. I was all gung ho to consider reconstructing my ACL as soon as time would allow. By February 1st was the thought, since I have met my out-of-pocket maximum expense and my insurance is changing over. From Dr. Cosgarea's perspective, it seemed the best plan was to rein back and even consider whether or not surgery was necessary. That was a surprise to me.

A key aspect of success with ACL reconstruction is rehabilitation after surgery. This will amount to at least 7-10 days out of the office and two subsequent weeks of a half schedule, followed by months of physical therapy. For years, I have been in denial about the need to have knee surgery much because of the recovery time. These past two bouts of popping, however, have been an experience I dare not repeat. The pain and swelling, instability and change in my lifestyle are enough to convince me that it's time to get the problem fixed. Besides, I am now forbidden from three of my favorite sports: swing dancing, soccer and skiing. At least I may be able to get back to hiking soon. I'm not a major enthusiast of the stationary bike; though, it works for exercise in winter.

One silver lining of 2009's medical saga is that I have learned that it is possible to cut back my practice and still survive financially. It's not as though I have been putting money in the bank, yet neither did I collapse last year. It is ironic that breast cancer would teach me that it's alright to take time off for my health. Hopefully that will also translate to feeling alright about taking a couple of weeks to travel outside the country in the future. I am still working on the arrival of reinforcements to make that one possible.

As I thought about when to have surgery, it became clear that waiting a little while might be best after all. Since I just came home from vacation, I'm not in need of another "vacation" quite yet. In addition, it will be easier for my Colorado family to come and help once the ski season ends at Easter. Tentatively, I'm planning on the week before Passover so that I will be able to recover when it is a little quieter in the office. Everything seems to be falling into place as far as timing.

A couple of my gentleman patients took the time to express their worry over me this week. Their fatherly concern means so much to me. I sometimes feel that the deck of cards has been stacked so high against me this past year. I was really feeling sorry for myself at the end of November. By late December, though, the car breaking down just before vacation and then the last minute knee injury just struck me as funny. I've even called it "hilarious" and have truly laughed from my gut. How ridiculous 2009 turned out to be with one challenge after another! 2010 is looking better so far, believe me.

A New Song

2010-01-01T12:23:00.001-05:00

I waited patiently for the LORD,
He inclined and heard my cry,
He lifted me up out of the pit,
Out of the miry clay,
He set my feet upon a rock
And made my footsteps firm
I will sing a new song...

Psalm 40

"40" was the first song I learned to play on guitar. It was the summer of 1988. I had just graduated from Aspen High School and was off at Frontier Ranch in Buena Vista, Colorado. My Young Life leader, Brendan McNamee, had talked me into volunteering for a month at the camp in the woods. I believe that my mother may have conspired with him to ensure that I was placed on the housekeeping staff. We were called the "Tawashees", and I sure did brush up on my cleaning skills which, up until then, had completely atrophied in the chaos of adolescence. It was there, at Frontier, that I came to appreciate the joys of a tidy environment and even the sense of accomplishment in restoring cleanliness and order.

The main goal I had set for myself, though, was to play guitar every single day that month. I had numerous false starts at learning guitar in high school, mostly because it was painful. Until callouses form on the fingertips, each practice session hurts. It was too bad, because my stepfather is a professional guitarist. I could have had all the free lessons in the world. Somehow, I was not destined to become a specialist, however, and other interests distracted me. Even so, I decided to commit to daily practice while at Frontier. One of the fellow volunteers showed me how to play "40" with just 3 chords - E - A - B. Pretty great to be able to play a song that I could also sing. Pretty soon, "40" became a heart song to me, as many other U2 songs would as well.

Contemplating 2010, I have been thinking about singing a new song. One of my friends recently wrote to me, "May 2010 be a year that ends with a long list of joyful events to rival 2009's challenges!" Can I hear a resounding "Amen!" ?

2009 was not letting go so easily. I was in the midst of a beautiful ski vacation, at home in the Rockies and near the top of my game. True, I was still falling asleep at 9 pm, needing a bit more rest than usual. It was still possible for me to cross country ski a couple of times. I was on my fourth and final day of telemark skiing, just about on the last run. December 30, 2009. Due to the clouds, the light was flat. The run was steep and bumpy. Out of the blue, my knee popped as I hit an edge. Then, I flipped forward, felt a burning pop in midair, and landed in the snow in agony. My left knee was killing me, the same knee that I injured playing soccer last fall and eight years ago playing ultimate frisbee. My stepdad, who had been skiing with me, was beyond earshot. I sat on the mountain and unzipped my ski pants to above the knee. It wasn't visibly swollen or deformed. A moment of queasiness then passed, but I knew I was hurt.

Thankfully, along came Chuck Brown, hiking up the mountain on his tele skis. He called ski patrol and stuck with me till Arnold from Switzerland arrived with his toboggan. Both guys knew my family, because that is how it is in small town Colorado. My knee was splinted and I was strapped into the toboggan, wrapped up like an eskimo, for the jolty ride down.

Inside my mind, I toyed with denial. This could simply be the kneecap tracking problem that my Baltimore orthopaedist diagnosed last fall. Perhaps a little more time at the gym, more weight lifting, would suffice. By the time my stepdad came to pick me up at the bottom of the hill, my knee was the size of a grapefruit. "Perhaps we should take you to the hospital to have this checked out." The ordeal of taking off my ski boot was enough to convince me, along with the consideration that I have just about met every possible insurance deductible this year.

It was time for an MRI. The PA and the ER doctor both agreed, even though they detected no instability on exam. Only a few injuries could cause such swelling, they told me: fracture, meniscus tear, ruptured ACL or patellar (kneecap) dislocation. The latter was not thought likely due to the absence of physical signs. Thus, even before the MRI, I had a sense that it was unlikely to simply be the matter of unstable tracking of my kneecap.

Into the MRI I went. The plain ceiling lights had been replaced by a mountain lake scene from Switzerland. It took some intense meditation and prayer to overcome the menacing grinding chants, beeps and knocks of the machine. Fifteen to twenty minutes later it was over.

The PA slipped around the corner to my curtained "room" to bear the news: ACL rupture, medial collateral ligament strain and tibial plateau contusion. He explained the mechanism of the injury which helped me understand the location of the pain. As I think about it now, I am pretty sure my ACL (anterior cruciate ligament) was well on its way when I injured my knee last fall. The location of the pain and the swelling were much the same as they are now, though to lesser degree.

I will sing a new song in 2010! This latest development sure did feel like much of the same old tune to me. One of my friends commented on my Facebook status, "Oh no. What did you do to tick off God?" Thankfully, my theology interprets otherwise. Since Jesus died on the cross to pay the penalty for our sins, those who believe in Him need not fear God's punishment. In the Book of Isaiah, quoted in Handel's Messiah, it is said, "The LORD hath laid upon Him the iniquity of us all." Even though God is not punishing me, I do believe He has some lessons for me to learn through this. Just riding through the airport in a wheelchair is a lesson in humility. Having to rely upon others is also an opportunity to build community. Perhaps most of all, this seems to be an extension of my season of slowing down and taking care of my own health. At least it isn't cancer! I am even looking at upcoming knee surgery in a positive light. It will be good to restore stability. It may also be time to get out that old guitar.

Nog Blog

2009-12-23T19:59:00.003-05:00

Click on the title link. Merry Christmas, all!

Little House

2009-12-18T10:52:00.001-05:00

I have always admired Laura Ingalls Wilder. When I was a child, I aspired to being her. Now I know better than to ask for the challenge of the kind of life she lived. It was the era of manual labor, and no advil. Awhile back, an acquaintance encouraged me to read her books. I admit that I only knew her life through "Little House on the Prairie" which we watched every single Monday night of my entire early childhood.

So, I found my way to the Adolescent section of Daedalus Bookstore this weekend and bought a copy of Laura's first book _Little House in the Big Woods_. I find myself slightly secretive about reading a book from the teen section while exercising at the Hopkins gym, rather than reading a book about, let's say, applied physics. I have to say, though, that I am captivated again by her spirit of discovery. Whether it be the making of bullets (not that guns were ever approved of in the household of my childhood) or learning that a late spring snow increases the yield of maple syrup, Laura richly describes the lessons of her growing up years.

I find myself wishing I could read this book aloud to a couple of young children. There are nice, short stories within stories. I am sure that children would have a lot of questions to ask of Laura. I would have asked her what it was like to have horses and to live in a log cabin. The questions I would ask of her now are somewhat different. "Do you think your father carried a gun into the woods only because he might encounter a bear or a panther? Or was he also arming himself to encounter Native Americans who had been forced to live as fugitives in their own territory after the settlers came to push them out?" The innocence of "Little House" seems undisrupted by such queries.

Still, I like to think that I still have some of Laura Ingalls Wilder's adventurous spirit. I don't exactly live in a little house and am neither in the big woods or on the prairie. As I think of probable snow this weekend, though, I have to say that I am much more pleased with the thought of tromping to the store after it snows rather than fighting the crowds of anxious Marylanders buying a year's supply of toilet paper and canned goods in case of the worst. Mind you, I live less than 6 blocks rather than 6 miles from the nearest store!

Flicker

2009-12-13T21:28:00.002-05:00

A flickering flame can either spark and light a fire or be snuffed out by the slightest draft of air. Our lives are so fragile. I feel that my inner flame has been fanned back to vitality this week, much with the help of a re-read of C.S. Lewis' _Screwtape Letters_. I felt like it explained a lot of what has gone on in my life the past couple of months. The book served to remind me of the perfect freedom we have in serving God and loving others, rather than living our lives for our own glory and gain. It is so hard to be counter-cultural, though.

I was troubled last night by the news that my friend's brother committed suicide. This is the second news of a suicide from within my circle of friends in the past month. It came on the tails of watching the worst movie I have ever seen, ironically titled "World's Greatest Dad", which was also about suicide ...kind of. I have no idea why I rented it this week. There is something frightening about Hollywood and even some literature normalizing or anesthetizing suicide. In reality, there is inestimable pain for those left behind by a suicide, especially when it is committed without warning. Evidently, 2/3 of those who commit suicide do not leave a note. It must be the darkest "night of the soul" for the desire to die to outweigh the desire to live, and then to leave without telling loved ones why.

In all honesty, since last night's news I have wanted to call all of my loved ones and wrap them in secure love, to fan the flame and encourage them to live their lives with burning purpose. This has been a depressing, financially stressing year for so many. Many people are under duress. Some find it hard to admit. Yet, the Christmas season is all about God reaching down in love, taking on poverty and all of the rest of human frailty, to be with us and walk with us and show us the way to new life. Emmanuel means "God with us." None of us is alone. "Light and life to all He brings, ris'n with healing in His wings. Hark, the herald angels sing. Glory to the newborn King!"

Crash and Rebirth

2009-12-05T15:42:00.006-05:00

It is so strange to report that I still don't really feel up to any major celebration as yet. I still feel tired, emotionally tired. Though I never preferred to think of my breast cancer story as a battle, I have felt embattled still, like a college student who has come through final exams. I used to go home for the holidays and simply crash for a few days after finals. After that, I would eventually re-emerge. I haven't quite recovered from this year of craziness, still feeling a bit "crashy".

I experienced a crash of another type this past week when my home PC was taken over by an evil virus. It mimics anti-virus software with Windows warnings and Microsoft messages that state that there is impending doom, then the virus itself takes over internet and operating system functions. After calling Comcast, I was referred to McAfee. After calling McAfee, I was informed that "the infection went deep" into the system, the high level experts had to be called in. My computer darn near died in the process, and I was afraid of losing most of my data. I am so thankful to my network engineer, Daryl Sirota, for stepping in and finding a way to preserve the data. Thankfully, after reinstalling the operating system, my computer is almost fully recovered, though it was clocking 3:03 for an hour yesterday. Documents and photos are preserved in its memory.

As I sat in church today, I started really thinking about this virus. The metaphor grew in my mind. I was thinking that, as human beings, our sinful natures have fully corrupted our operating systems. Outward acts of sin are only a manifestation of the inward sinful nature that is fully at work. Fixing our behavior alone will not result in a solution, even as I was unable to fix the individual programs on my computer. In order to be made clean, my computer's operating system, the very heart of it, had to be removed and re-installed in order to function according to its original design. Much in the same way, those who put our faith in Jesus have to die to our sinful nature and be reborn with a new operating system. We need a heart transplant, a cleansing of the core of our beings.

When I was a young Christian, I thought of this rebirth as a one-time only affair. I had a notion of the Christian life as a pathway of progressive holiness. This set me up for high expectations of myself and others. How my bubble was burst in my early 20's, when I came to recognize that the Christian walk entailed an ongoing struggle with sin. I saw how thoroughly sin affected every aspect of my life and how much I stood in need of ongoing transformation. Then, I also intersected with other Christians and their sinful patterns. I came across Bible verses like the ones from James, "You do not have because you do not ask," followed by, "You do not have what you want because you ask with the wrong motives." In final analysis, each and every motive of my heart could be brought to question. The end result could easily have been despair, and sometimes I have greatly despaired that I am not more pure in heart.

Cancer treatment brought me as close as I have ever been to dying. There is little comfort in that place, only the bare bones need to breathe in reliance upon the Almighty. Thankfully, the King of the Universe was not too busy to reach down His healing hands and restore me to physical health. Chemotherapy ended in August, and radiation ended nearly a month ago. With exercise, my muscles are growing strong again.

My computer crash, on the tails of emotionally crashing over the past few weeks, finally brought to the fore my need for heart transformation. In the midst of all of the hits of this past year, I fell away from exercising certain "means of grace" such as reading Scripture, praying and meditating. I also grew discouraged in the midst of the trials of the past couple of months and started to question God's goodness and love. In addition, idols had grown up in my heart. What we worship other than God is often so subtle. Most of the objects of my worship are good things, at face value: the desire for success, the hope for a husband, the longing for family, the desire for acceptance. Worshipping anything other than God is a sure formula for great unhappiness, though, and so I found myself unhappy at a time when I should be celebrating. It is time, again, to die to myself and allow God to re-instill and re-install the right operating system. The memories still remain, like my photos and documents, yet everything is redeemed.

We are here for such a short time. May none of this life be wasted.

Grace

2009-11-27T10:54:00.003-05:00

I was reminded, listening to NPR, that the root of the word "grace" is from the Latin and relates to "thanks", hence "gracias" in Spanish. The writer being interviewed also cited a reference to the word as "a touch of the divine." What could be a more appropriate meditation for Thanksgiving? Apparently, Abraham Lincoln was thinking of the Divine when he proclaimed Thanksgiving as a national holiday to be set on the last Thursday of 1863. In the throes of the Civil War, evidently at its worst, it must have seemed like a very dark time in history. Even so, Lincoln took that moment to call the nation to pause and give thanks to Sovereign God.

I have not been through anything like a civil war; though this year has certainly had its battles. Too often have I forgotten to pause and say "grace" or thank God before a meal. At this Thanksgiving time, I feel compelled to contemplate the countless things for which I am grateful.

First and foremost, I am reminded of the privilege of having a relationship with God, through Jesus' great sacrifice on the cross. So great is God's love and forgiveness for me that I am constrained to love and forgive others and myself, for that matter. That is the ultimate grace.

I am grateful for my health, that my breast cancer was caught early and has been fully treated and did not stop me from practicing medicine this year. I am so thankful for the doctors, nurses, techs and medical assistants who were on the detail. In addition, I am amazed at all of the cards and Facebook encouragements, the meals, phone calls, timely gifts, and the presence of friends and family. Apart from God's direct love poured into my life, these sustained me through this year.

I am also so thankful to have grown up in a family where I was shown overflowing love. I love my big family, cousins, aunts, uncles and all. As I reflect, I think about the way that my grandmother Phoebe modelled welcoming others into her home at Thanksgiving in Aspen, sharing the abundant joy of kinship. My Aunt Mary carried on the tradition yesterday by welcoming 35 people to her house. I was told that three scrumptious turkeys were served!

How great it was to grow up in a household where our parents read to us and encouraged us to read. I am sure I have said this before. I am thankful for the English language that is so rich and diverse in its roots, so expressive and wonderful both to read and to write. After a long season of reading only medical literature, I'm now looking forward to feasting on novels again in the comfort of this God-given old house of mine. What a blessing this house has been, a blessing to have a home at all, and not to be among those "living outside." At times, my house seems too big for just me. Yet, I am reminded of how I found it after a whole year of looking and how it matched every item on my list. It has been good to have room to welcome guests, especially this year with Mom coming to stay for five months.

I know this sounds random, but it is also a great blessing not to be incarcerated, especially not for reasons of conscience. As I think of those imprisoned, both rightly and wrongly, I think of what favor I have in my freedom to plan my day, to drown out noise, to move about, and to live unassaulted.

On a lighter note, I am thankful not to be fighting the crowds at the stores today. I will eventually "contribute to the U.S. economy" this holiday season, I'm sure.

Air

2009-11-24T20:30:00.006-05:00

The word "air" actually has 10 definitions according to Merriam-Webster's online dictionary, ranging from "nothingness" to an Elizabethan term for "an accompanied song or melody." When I walked out of day 2 of the ABIM Recertification Exam, all I can say is that I looked up at the air and the sky above me and was able to take in a pure breath. As my lungs filled with oxygen, I felt for a moment like Maria in the opening scene of "The Sound of Music". I resisted the impulse to go twirling around the parking lot, but that was the feeling inside of my heart. It was just a great feeling to walk out into the world, unencumbered and finally free. Though I may not know of a passing score until weeks to come, I feel that I have done my part. It is too much for me to quote my Lord and Saviour in His final words, "It is finished." I know that my worldly suffering isn't over, but it seems to be over for the moment... and that is enough. I have envisioned hiking to many mountaintops in the coming year, just to recapture the open air, just to raise my hands to the heavens.

I have to say that I feel almost too tired to really celebrate yet. I let a few items back up as if behind a dam, waiting for this exam to be over. Now I have to catch up a bit. This past weekend entailed a variety of social events in different circles. I saw my first movie in awhile, a great true story called "Blind Side." Then soccer came to the end with a wonderful celebration and a slide show. As I look over the photos from the soccer season, I know that it was worth all of the effort. Soccer is a reminder of so many answered prayers this year.

On Saturday night, my friend's brother played a set of folk songs that he has written while a group of us sat and listened in my living room. It was a sweet reminder of past events. Sunday involved singing on the music team at church, a baby shower for beloved friends, and afternoon tea with my swing dancing set, topped off by a small gathering for Bible study at my house. By the end of the weekend, I knew that I had overdone it a bit.

I'm not totally back to normal life yet. For one, my hair has barely grown back. I did take the opportunity to throw off my final wig on Friday. Now I'm sporting a short, short do and think that I look somewhat like Batman's sidekick, Robin. Chic? Sassy? Stylish? These are adjectives I've heard this week. Is it Holly? I'm trying it on. I feel it is a mark of this next phase, the phase of survivorship, and the phase of moving on. My oncologist and voice-of-conscience, Dr. Fetting, reminded me to find rest. I hope to do that with the four day weekend coming up.

Insecurity

2009-11-17T08:05:00.003-05:00

I will never feel prepared for the ABIM Recertification Exam. The field of internal medicine is vast, so it was hard to know where to begin. Even if I had the luxury of studying for a whole year, I am unsure whether I would be able to walk into an exam room and feel adequate to the task. As I took the time to pick out music for our soccer celebration slide show this coming weekend, I came across the most beautiful song by Kirk Franklin entitled, "Imagine Me." It was one of those songs whose lyrics melted my heart. "Imagine me in a place of no insecurities, and I'm finally happy 'cause I imagine me."

Of course, all of the imagination in the world will not infuse more medical knowledge into my brain at this point. I think that letting go of the worries that tend to consume me at exam time would be a key part of the strategy, though. I feel so emotionally raw and easily criticized at times like this, even though I know that I have put forth much of my best energy toward my career over the past 10 years. How could it be that I should have had to have received a phone call from a colleague last night who took the time to point out my inadequacies? It is said that if an internist ordered every test, counselled every patient on every issue, examined every necessary part, and lived up to every written standard of care, that we would all be working 16 hours a day. I am perpetually behind on my "to do" list. We are held to a high standard.

In the end, I find myself on my knees before the Maker and Creator of the human body, asking Him to expand my understanding of all that He has gloriously put together. I have been asking The Great Physician to help me to know and learn what I need to know to save lives and relieve suffering. He knows what I need between now and the end of the test on Friday. I have asked Him, again, to carry me through this brief spell of suffering to a more secure and restful place.

Escape

2009-11-15T18:02:00.002-05:00

I'm still very much in the midst of the stress of preparing for my exam. So much drama has mixed into the past two months, that I find it hard to focus on my studies. I would like to just go to sleep and wake up on the morning after it is all over. I surely wouldn't mind an escape, but not the type that took place this afternoon.

Deciding to take advantage of the sunny, 70 degree fall afternoon, my cat Wilberforce managed to escape! He snuck through the porch door which I had inadvertently left ajar while preparing to hook up my leaf blower. I saw him jump past me and under the great big pine trees next to my house. I called him, but naturally there was no response. It is said, "Call a dog and it will come to you. Call a cat and it will get back to you." Not only did he not respond, he failed to appear and could not be found.

Not being an outdoor cat, I had supposed (erroneously) that he would stick close to the familiar. Cats have escaped before and have always easily, if unhappily, been caught. This little munchie was nowhere in sight. I shook cat treats and the other cat came running, but no Wilby. I started to think of what I had read about ragdoll cats, about how they are so trusting that they are easily eaten by wildlife! It had been awhile since the last fox sighting, but still. Then there was Walker Avenue, a road busier than I would like to admit. Hopefully Wilby would have enough commonsense to avoid turning into roadkill. After calling and calling, he was still inapparent.

I carried on and raked for awhile, hoping he would appear. As the sun began to set, I dropped the last deposit of leaves on my compost pile and went around the nearby houses, calling and shaking cat treats. It became darker and darker, with the final light cast behind the trees. I prayed that God would speak to Wil's kitty heart and draw him home. I came into the house and got ready to think of the next phase of the search. Finally, a faint meow issued. I called out. Meows again. There he was, underneath the pine trees. Had he been there all along? Only Wilby knows. I opened the door wide, and in he scooted, reconnecting with Aliceanna, possibly recounting tales of adventure and hopefully not convincing her to conceive of similar future escapades. For my part, I took a deep sigh of relief. Having a missing cat would have been just one more thing. Now I can rest more easily, hopefully, "princess and the pea" that I am.

Cabin Fever

2009-11-08T21:05:00.005-05:00

I have a case of cabin fever, even without a snowstorm. I've tried to lock myself up at home in order to study for this exam; however, I am afraid that I have grown unaccustomed to long periods of concentration. It is hard to sit with my books without thinking about other things or going to grab a snack. As happened during medical school, my compulsive housecleaning gene kicks in and I suddenly have to empty the dishwasher, organize the closet, or sweep the floor. There is the additional distraction of leaves that need raking. Even after hours of clearing away the leaves on my yard and driveway this past weekend, it appears as though nothing was actually accomplished. The leaves are still accumulating on the front yard by the hour. I'm going to have to get back to raking again this coming weekend. At least, they say that exercise improves concentration, so this study-break chore should serve to improve my exam score.

Meanwhile, reviewing test questions has proven far more stimulating that reading over course notes from last summer. These have also shown me where my weaknesses lie. I have pulled up "Clinical Practice Guidelines" from online and have started to take notes (my best form of learning). In a geeky kind of way, it is fun to study; of course, there are topics that I love and others that remind me of dental work. Then, there's the medical trivia that boards exams seem to gravitate toward. Of course, this trend ignores the fact that most practicing providers tend to search after the trivial online rather than sending our own mental librarians through our personal, dust-laden archives. I am certain that it is the specialists and not the generalists who write most of the exam questions. So be it. I'm working myself up to the challenge of updating 10 years of internal medicine in less than 10 days. Hopefully no one will bump into me along the way and knock the knowledge out of my head.

Gone are the days of staying up all night to cram in the details. Short-term memorization will probably be pretty low yield at this point. Besides, my sleep requirement is about 9 hours these days, as I recover from the end of radiation treatment and minor surgery. I have had to set my health as the main priority. Tami, who recertified as a PA last year reassured me with this thought. "I am unsure of what the pass rate for this exam is; however, I thought about it this way. I was pretty sure I wasn't in the top 10% of all of the people taking the exam, but I was pretty sure I wasn't in the bottom 10% either." So be it. Back to the books!

The End

2009-11-04T20:31:00.003-05:00

Believe it or not, the end has come. 9 months ago came the discovery of a lump in my breast, and now I have finally reached the end of breast cancer treatment. It brings tears to my eyes to think about it. My last round of radiation therapy was this morning. After treatment, I was given a little bell to ring. It was a nice celebratory touch to an admittedly anti-climactic moment.

Of course, deep down in my heart there is joy. It is hard to cut loose, though, with the exam on the near horizon. I am reminded of having medical school exams right after the Christmas holiday. The holiday, usually intended for rest never really lent to it. I would strive to have the better attitude that it is fitting to read up on medicine, to pursue excellence in doctoring, and to focus.

I have started to dream of a long vacation, maybe three weeks or more, somewhere overseas - maybe St. Petersberg then Scandinavia with some kind of venture to see polar bears farther north. I would love to have a short spell devoid of any major responsibilities, just to kick back and take in the beauty and wildness of the world, just to rest and meditate on the goodness of being alive and to slow the clock now that I'm finished being a patient for awhile.

Foreign Body

2009-11-01T13:07:00.003-05:00

I had grown accustomed to my port, a port being the semi-permanent IV access point for chemotherapy. In truth, it had been with me ever since February. Most people have this placed beneath the collarbone; however, I had mine placed under my left arm so that I wouldn't have to look at it in the mirror every day. After all, who needs to be reminded of cancer treatment? Even though it was in an unusual location, I didn't regret having it placed there. I would feel it if I laid on that side to sleep, but rarely did I ever see it. Certainly having a port reduced the overall suffering of chemotherapy. It was a sure spot from which to draw blood and also served to safely deposit that toxic medication into larger veins in my body which were better able to withstand it than the peripheral veins. Though they had to get used to it, most oncology nurses told me that they would prefer my unique location if they ever had to have a port placed.

With only three rounds of radiation remaining, I had no more need for it. It was a moment of great joy this Friday, having the surgeon remove it. I felt very little discomfort, as I had numbed my skin with EMLA (lidocaine) cream covered in saran wrap for several hours beforehand. It was such a fine feeling, having this foreign body taken out of me. Having the port removed symbolizes the end of breast cancer treatment. It feels like the chemotherapy has mostly washed out as well. My fingertips feel less numb, I feel less tired, and my hair keeps growing bit by bit.

Radiation has caused me very little trouble. I believe the only fatigue I experienced over the past six weeks was related to life circumstances. My skin did not peel or become irritated, only just now a bit tender and red in the right armpit since the final eight treatments have focused an electron beam into what was the tumor bed. Regular exercise has kept me from any of the forewarned stiffness.

I must remember to be thankful. It hasn't been as bad as it could have been, by any stretch of the imagination. This is not to say that it has been easy! Answered prayers include: early stage disease, no "sick days", healing from three surgeries, protection from permanent cardiac or neurologic side effects of chemotherapy, renewing of my spirit by Sundays most weeks, being able to coach soccer, and finishing my board recertification projects. Now, I'm praying that I will be able to pass the exam in a few weeks. God just provided a study buddy for next weekend. It's time to buckle down. I want to honor God with excellence in my profession and am thus reminded of the privilege of being able to study my discipline and be tested.

Disaster

2009-10-29T18:35:00.002-04:00

What to do when you've had one of those years?

This year is starting to remind me of 2002 when, in 6 short months, I broke up with a boyfriend I truly loved and then got in a minor car accident. Then, the basement of my newly purchased home flooded due to maple tree roots invading 60 year old terra cotta pipes leading out of the house. Then, my biggest oak tree was felled by lightning during a five minute thunderstorm on a sunny day (thankfully not killing my housemate who witnessed the event from her car parked on my driveway). I happened to be studying the minor prophets of the Old Testament at the time and began to feel as though God were judging me; though, I had really given up on sin more than gravitated toward it during that season.

The very week of the oak tree disaster, my mom became manic for the first time in years. She remained ill for the next three months, only finally snapping out of mania the week after my father died. Meanwhile, I could only ask, "What more?"

As I sat by my pond in August, befuddled, I started to read from 1 Peter in the New Testament. It was as though each word came up off of the page and sank deeply into my heart. 1 Peter talked about how, when we suffer despite doing good, we come into closer touch with Jesus. We become more like him. It shed a whole new light on the difficult year I had been having. I recall feeling quite alone during that time, singled out in such intense suffering. My spiritual roots in evangelicalism did little to prepare me for the reality that suffering is part of the Christian faith. I was not owning my Job-like circumstance.

Now, years later, I am still not sure that I am ready to step up and volunteer to be God's suffering servant. There is so much a part of me that desires a settled average American life. One of my friends commented on how much my life has been like Job's this year. I don't really want to step in those shoes. There is a part of me that knows that I will continue to honor God, no matter what comes my way, but there is a certain agnosticism generated by one crisis added to another.

I am still working on ridding myself of the bronchitis of the past three weeks. My white blood cell count is down to 2500 from 2700 a few weeks ago (normal 4000-10,500), thus my immune system isn't quite back up to speed.

Then, yesterday morning, I noticed that my cats didn't make it upstairs to greet me in the morning. When I went downstairs to feed them, I discovered a half an inch of water flooding the utility side of my basement. Since it had rained heavily, I realized that my maple root problem had recurred. The plumbers met me at 6:30 am this morning to try to root out the pipes, but this time it looks as though they will have to be dug up from the yard and replaced with new pipes. What a mess! One to two of my beautiful old maple trees will have to go, as a result. This has been a looming threat for years, now culminating with classic timing.

My faith is stretched through all of this. I am really supposed to be studying for my recertification exam which is in three short weeks. I have hardly cracked a book, even though I truly want to take the time to learn and update internal medicine. I am not stretching myself past reasonable balance, however, because my health demands that I rest when needed. It has been 5 straight weeks of crises. One of the songs from last Sunday's sermon referenced trusting in God rather than human endeavor. Now more than ever, amen.

Distribution

2009-10-23T21:12:00.003-04:00

Last week, I read an interesting editorial in the New England Journal of Medicine. It was talking about the worldwide distribution of the H1N1 vaccine, especially if the pandemic were to take a turn for the worse. The article made the ethical argument that the vaccine should be purchased on a sliding scale, according to each country's ability to pay. This would help guarantee access to the vaccine worldwide. The article was amazingly idealistic, and that's a lot for me to say.

We haven't gotten it right with influenza vaccine distribution here, so it is hard to imagine that it will work right elsewhere in the world. In years past, during seasons of vaccine shortage, the big chain stores and supermarkets were the first to get the vaccine. Doctors' offices were hard- pressed to obtain it. This year's push for H1N1 vaccine production and distribution has put a wrench in the production and distribution of the seasonal flu vaccine. Again, the Walmarts and Walgreens are stocked. Again, doctors' offices are unable to obtain it. Why should this be, when doctors possess the clinical judgment as to who needs the vaccine the most? Sad, but true, I believe that it all comes down to money. Stores are willing to pay above cost for vaccines in order to bring customers through the doors. Doctors are unable to do the same, because insurance company contracts restrict profit margin on vaccines to the point that, in some cases, it costs more to give the vaccine than what insurance companies pay. Primary care doctors are particularly unable to eat excess costs.

In the spirit of expanding access to healthcare, increasing the number of vaccinations, and creating "herd immunity", it is probably a good thing to offer flu vaccines at a variety of locations. It takes little skill to administer them. Convenience is important. I do not think it is wrong, in principle. It is just frustrating to be unable to offer the vaccine at my office. The lack of vaccine leads to many missed opportunities. Many frail, elderly patients are unable to wait in long lines at public locations and would greatly prefer my quiet, "grandmother's living room"-like waiting room. The elderly, frail, and chronically ill are most prone to death from seasonal flu. Giving the flu vaccine to those over age 65 reduces mortality by as much as 15%.

Interestingly enough, we were able to obtain ten times as much H1N1 vaccine. This amounts to 200, as opposed to 20, doses. H1N1 is more critical for the younger population. The H1N1 vaccine was distributed by the State of Maryland, rather than by our private medical supply distributor. It turns out that we neither have to pay for it, nor are we allowed to charge for the vaccine. We are only charging for its administration. We were also made to sign a contract that we would only distribute it according to Department of Health guidelines. In many ways, this unburdens us from difficult decisions. Perhaps similar guidelines could hold superstores and pharmacies accountable for the timely and appropriate distribution of the seasonal flu vaccine. In an ideal world...

God, Not Dog

2009-10-20T08:28:00.002-04:00

My mom gave me a set of New Yorker cat cartoons, and one of them depicts a cat perched on the back of a chair, looking down upon a dog. The caption reads, "I was a dog in a previous life, but came back as a god." Even though we all know that to be a bit of an exaggeration, it is funny. Cats do seem to prefer to be in charge of the house, even of their owners. It is said, "Dogs have owners, cats have staff."

I'll tell you, I adore my cats; though, they are not good at guarding the house. I really seriously considered getting a dog after the recent break-in. In final analysis, however, I simply do not have the time or the energy or the desire to take care of a dog. I am going to have to rely upon God Himself to protect my property. God and ADT and steel patio doors soon-to-be-installed and prudence with keeping the house lit and trimming trees around my windows and maybe having housemates again. At times like this, I wish I had a husband... kind of like those times when buying a car or getting auto repairs. Even just for show. I'm half-kidding, of course.

Not having a dog will preserve future flexibility. There is still a latent world traveler inside of me. This has been hope deferred for some time now, as I have applied energy and resources of the past five years toward starting the practice. Being in solo practice was never my intention, even as being single was never either. Yet, that's where I find myself for now. My life is pretty simple without dog, husband, or business partner. "A committee of one gets things done," they say. Even so, we are stretched and grow through relationships. The dog is the relationship most within my control, and I've decided against it for now. As for the latter two, it's a matter of waiting and prayer and good judgment, not settling for less than the best.

Rainy Days

2009-10-17T20:08:00.002-04:00

It might as well have been rainy this weekend. I have been fighting off bronchitis all week, finally taking yesterday as a "sick day"; for a Friday, this meant not actually surfacing at the office to check messages. I still handled some calls from home but struggled with a touch of laryngitis. Imagine calling the doctor, and she's sicker than you are! At least it's not H1N1. After spending a good part of yesterday in bed and sleeping in this morning, I am significantly improved.

Soccer was obviously cancelled due to the dreary, Londony weather. Hopefully, by next week I will have recovered enough to be able to run around with the kids. I am also in need of getting back to exercise, especially those knee-strengthening exercises my physical therapist prescribed. Reality is, I haven't really felt like doing anything until today.

I took advantage of this rainy day to catch up on medical journals and to attempt to finish my second ABIM recertification project. The latter effort was thwarted by a bug in their software that resulted in repeated loss of data. Grrrr. I'll have to tackle it again on Monday when I can call a live human being. I need to catch up on bookkeeping as well, after finding out that the corporate account dipped to about $145 a couple of days ago. I find myself in a funny energy state at times, knowing that various responsibilities loom, but feeling too tired to really address them. Thankfully, none of those involve patient care. Later this evening, I hope to start studying for the recertification exam. Have to start, at least!

Halfway There

2009-10-13T08:12:00.004-04:00

Today marks the halfway point, or a little over halfway. I just had the 17th radiation treatment out of 33. All is well, with no skin changes and no discomfort. The little 5 minutes every morning is a peaceful meditation. For whatever reason, I have meditated on colors this year. I will look up at the ceiling and see blue and then think of the beauty of that color, bringing to mind various places in my life that have been splashed with blue - the Colorado sky in summertime, intricate Mexican blue tiles, the ocean in Cancun...

Going to treatment 5 days per week has accelerated the calendar; though, I must say that 7:30 am is very early. I felt quite tired last week. I sat back and considered whether I was just worn out because my house was broken into, whether it was a side effect of treatment, or whether it was the change in the weather and the length of daylight. Thankfully, I feel a bit less tired now.

My thoughts have been occupied by the recent break-in. I figured out that the thieves probably went through the attic window, which was the only open point of access. There was no other way to explain how the patio doors which were bolted together (and one of which is bolted above and below) came open. Those doors were opened from the inside. Thankfully, it still appears that nothing of value was taken. The alarm going off when the doors were opened must have startled the perpetrators.

Having retold the story again and again this week, which is my form of processing, the local opinion is that I should get a dog. The challenge would be to find a dog who would defend the house without eating my cats. I would also have to be sure to steer clear of eleven and twelve hour workdays of the past. Would this mean raising a puppy? A puppy would have a chance of understanding the fact that the cats rule the house. A puppy would also take a great deal of effort. Then the question arises, "What type?" Some suggestions have included mixed breeds (always my inclination since I, myself, am such), a Rhodesian ridgeback, or a German shorthair. I've even thought about a German shepherd. All said, since I enjoy hosting so much, I would not want to own a truly ferocious beast.

Then, too, if I get a dog then I will probably have to trade in the old Honda for a station wagon. It doesn't fit much with my sensibilities to trade in my Honda, since it may have another five or ten years of life. Even so, it may be reasonable to finally have a 4 wheel drive car, in case I am also on call during the next blizzard (as I was a few years ago).

All of these thoughts are somewhat distracting as I enter into that season of studying for the recertification exam. I haven't even cracked a book thus far. I am wondering how much I will remember from the August course. If anything, I should study simply to relearn my discipline. There is a constant stream of updated information. One day, I will feel caught up.

Break In!

2009-10-06T08:10:00.004-04:00

Yesterday morning while at work, around 10 am, I received a call from ADT Security Services to notify me that my back patio alarm was sounding. Did they want me to notify the police, or would I be responding? I happened to have had a cancellation on the schedule, so I let my staff know and dashed home to find police at the scene. They were still searching the house to ensure that the thief was no longer on the premises.

It was kind of overwhelming. I was already feeling pretty stressed about the various responsibilities that have lined up, including leading a women's Bible study on Wednesday. Though I had started work on it, I didn't even have the final theme in place. Now, I had a broken window, insecure back patio doors, and missing cats. Thankfully, Wilberforce managed to appear before I had to run back to work. I was able to assume, then, that Aliceanna was hiding which is what she always does in the face of unexpected change. A cursory glance revealed that nothing of value was missing, even though my purse, a friend's expensive camera, and my guitar were all within striking distance. There was no vandalism either. Thank God! I am also grateful that I was not home when it happened.

The crime lab had still not arrived on the scene when I had to leave again for work. Thankfully, Larry Stappler came to my rescue. After I called him, he drove to my house right away in order to officiate. By the early afternoon, my broken window pane had been replaced with a laminated one that will be harder to break. Tears came to my eyes at Larry's act of kindness. He has been like a father to me, and that is a big deal since I have no family living here in Baltimore.

As I thought about the event, in the midst of all of the craziness of this year, I realized that perhaps I should talk about "Finding Faith in the Midst of Hardship" tomorrow night. This Christian journey is certainly not guaranteed to be trouble free. In fact, one of my Christian patients from India remarked, "Why are Christians so surpised when we suffer? For Christians, suffering is almost guaranteed." Where the hope lies is in knowing that our suffering is redeemed. God takes the bad things in our lives and somehow turns them for the good. One of the greatest values in hardship is that it makes us more like Christ. I think the Christian walk would be more comprehensible with this understanding. So often, when we seek the LORD's blessing, it is for material things, for comfort, or for personal security. His blessings, though, are often in disguise. They are the kind of blessings that are recognized with the "retrospectoscope." I don't know why my house was broken into, other than the fact that there is evil in the world. Some day, though, redemption will come.

"Do not store up for yourselves treasures on earth where thieves and rust break in to steal and destroy... rather store up treasures in heaven. For where your treasure is, there will be your heart also." from Matthew 6

Published!

2009-10-04T13:07:00.003-04:00

Click on the title to be linked to an article I wrote that was just published in the Baltimore Sun today. After last week's luncheon, I became convinced that I should turn my bullet points into a letter to the Editor. I am still not convinced that the Public Option is dead, even though reports and commentaries on NPR have been somewhat discouraging. Somehow, in the midst of my crazy life, this is what came about.

Meanwhile, orthopaedist Dr. Barry Waldman, consulted on Friday and pronounced that my knee problem is non-surgical. Hallelujah! I just need to get back to the gym and do some quadriceps strengthening exercises so that my kneecap tracks properly. I also have a pretty little knee brace to wear when coaching and playing soccer. My knee feels so much better, and I feel tremendously relieved. The talk went well yesterday, but I was so tired after coaching that I went to bed before 9 pm last night! I'm still thinking about the topic of losing victoriously.

As far as radiation therapy, it's 10 down and 23 to go. All is well. I have had no perceivable side effects except (maybe) fatigue or maybe that's due to plowing full steam ahead with life as usual. I have to be careful to give myself a break once in awhile. It is hard to believe that breast cancer treatment will be over in 4 1/2 weeks. It will be strange after November 21st, because then radiation will be through... and soccer will be over... and I will have hopefully passed the board recertification exam. What will I do with all the free time?

Defeat, Victory

2009-10-02T09:26:00.002-04:00

Every week, one of the soccer coaches gives a talk to the kids during what we call "the huddle". Generally, the talk has to do with sports and with building character. I'm up this week.

After being the "losingest" team last year, I started thinking about how I would talk to our kids about losing. It may not seem like the most uplifting topic; however, I think it is important for every kid who plays a sport to be able to lose well. Of course, we would all much rather win. The usual outcome, however, is that at least one team will lose every time we play a game. I didn't want to bring in the topic of my breast cancer, because I don't want 6 to 14 year olds to worry about my health. They may worry anyway, because I'm still limping a bit after my knee popped during the coaches' game last week. I'm seeing the orthopaedist (orthopod) today, hoping for a reasonable prognosis.

The following is what I'm planning to bring to the huddle tomorrow.

Last week, we talked about the importance of having Jesus inside of you. Remember?

Today, I’m going to talk to you about “The thrill of victory, (and) the agony of defeat”. This expression was coined by a reporter named Jim McKay who lived in Maryland and was a sportscaster for ABC News. He just died last year. When I was a kid, we used to hear it the phrase all the time while watching sports on TV. “The thrill of victory, the agony of defeat.”

Can any of you tell me what “defeat” means?

Does anyone here like losing? Losing isn’t much fun, is it?

When Jesus came to earth, the Jewish people were waiting for a Messiah (or someone who would save them). They had been ruled by the Roman empire and were unfairly taxed. Some of them had even been killed by the Romans. The Romans occupied their land with soldiers. Many Jewish people had the idea that when the Messiah came, he would be a military conqueror and help them defeat the Romans. Other people expected the Messiah to perform great miracles. Jesus performed many miracles throughout his ministry.

Can any of you tell me a miracle that Jesus performed?

Jesus had 12 guys who hung out with him regularly. Who were these guys?

The 12 disciples had high expectations of Jesus, too. Jesus had already told them that he was the Messiah.

So, imagine that your superhero is suddenly captured, taken away from you, given an unfair trial, and killed! Jesus was taken away from his friends and crucified.

How do you think the disciples felt?

The disciples must have seen this as a great loss!

Yet, who can tell me what happened three days later?

Jesus rose from the dead! Because Jesus rose from the dead, those of us who believe in him also have the hope that when we die, we will rise from the dead and live forever with Jesus in heaven. The greatest “agony of defeat” on the cross had turned into the most thrilling victory in all of history!

Remember John 3: 16, that coach Dan shared with us last week? “For God so loved the world that he sent his only begotten Son that whoever believes in Him shall not perish but have everlasting life.”

God loves taking something that seems bad and changing it for the good.

I was born with birth defects. When I was a young child, the doctors told my parents that I might be mentally retarded. I was very shy about my appearance after starting school. I was teased a lot by other kids. I had many surgeries to fix the way I looked. Finally, one day, my sister introduced me to Jesus. She told me that Jesus was not nearly as interested in my outward appearance as He was in what was inside of me. I decided to that day to give my heart to Jesus.

Jesus then helped me not to worry as much about my looks. He was much more concerned about what was inside of me. It was more important to Him that I love other people. I was able to start helping other people and eventually became a doctor. Jesus took what seemed very bad in my life and turned it into something good.

I can pretty much guarantee that each and every one of us will experience “the agony of defeat”, at some point in life. Sometimes it will seem like we are losing over and over again. Yet, we experience “the thrill of victory” even in when we lose, as long as we allow God to take that situation and transform it into something good. If we put our lives in the hands of Jesus, we will win in the end.

Bullet Points - Health Reform

2009-09-28T21:21:00.004-04:00

Wish it didn't all come down to money, but here's my 2 cents, points recently raised over lunch with one of my favorite politicians.

Bolstering Primary Care

“Primary care, the backbone of the nation’s healthcare system, is at grave risk of collapse,” according to The American College of Physicians 2006 (1)

Why? -

Increased demand for primary care physicians:

- aging population

- growing number of chronic illness survivors

- need for coordination of increasingly complex medical problems

- need for a human connection in the midst of technological advances

Decreased supply of primary care doctors

- poor compensation, deterrent to young graduates with loans to pay off

- rising overhead not met with rise in compensation

- rise in productivity not met with rise in compensation

- serious, acute problems now being handled in-office under time-pressure

- time demand of coordination of care of older patients with multiple chronic conditions

In 2009, only 42.2% of family practice residency slots were filled (5)

Value of primary care:

- care provision

- care coordination/centralizing information

- cost reduction – prevention, reducing unnecessary procedures

- improved clinical outcomes

Example and point:

Primary care cost of treating hypertension for one year = approx $400-700 (HD)

Cost of hemodialysis (often caused by untreated high blood pressure) = $173,507 (2)

Cost of kidney transplant in 1^st year $106,000, then $17,000/year in medication costs thereafter .

Countries with higher “primary care scores” have drastically lower per capita health expenditures than the U.S. (3)

Per capita health expenditures were associated with the same life expectancy as seen in the U.S. where expenditures were twice to thrice as high (4)

Salary comparison, private practice in 2008 (4):

General Internal Medicine: $177,059 (by the way, this is way more than I make)

Gastroenterology: $406,345

Geriatrics: $161,888

Orthopaedic surgery: $425,000

A Real Public Option

“The United States is the only wealthy, industrialized nation that does not ensure that all citizens have coverage.” The Institute of Medicine

America has lately grown too familiar with failures of prevention. Katrina and The Wall Street Crisis are fresh on our minds. The healthcare system stands to be an even greater failure, with healthcare expenditures projected to outpace the growth in GDP for the next 10 years

2009 projected health care spending = $2.5 trillion!

Health insurance companies haven’t lived up to expectations to lower cost of health care through competition nor to expand healthcare access to the uninsured

In fact, employer-based health insurance premiums have risen 119% over 10 years

62% of bankruptcies in 2007 were found related to medical expenses, and 80% of people filing for bankruptcy had health insurance

1.5 million families per year lose their homes due to unaffordable medical costs

The uninsured population poses significant threat to the U.S. economy and to public health. It will cost more, if we leave them uninsured.

Lack of health care leads to chronic disease which leads to unemployment and government dependence. Sick, impoverished populations are prone to spread of disease.

The uninsured seek care in emergency settings $$$, rather than from primary care $

The public option pays for itself by way of premiums, pooling low- and high-risk individuals, and sustaining low overhead. The best way to guarantee a large low risk pool would be to mandate insurance coverage for all

Waste and fraud can be minimized by promoting use of electronic medical record systems which are easier to audit.

The public option must be able to negotiate with drug companies and hospitals to lower costs

Sources:

1. The American College of Physicians. The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Healthcare: a Report from the American College of Physicians. January 2006.

2. The American Journal of Managed Care 15: 509-518. August 2009, #8, Published online 8-7-2009

3. Starfield B and Shi L. Policy relevant determinants of health from an international perspective. Health Policy 2002; June 60 (3): 201-218

4. http://apps.who.int (extrapolated data)

5. Queale and Keller. The Primary Need. Editorial. The Baltimore Sun. September 27, 2009

Zapped!

2009-09-23T22:08:00.003-04:00

Radiation therapy began this week. It had been over a month since the end of chemotherapy, and the break was much needed. Monday morning, at 7:10 am, I greeted Jerry and other staffmembers in the radiation oncology suite. Four more tattooes were required, in addition to films to ensure my proper positioning. Then it was time for the first treatment. A couple of beeps and rattles, a repositioning of the machine, then more beeps and rattles, and it was all over. There was no sensation of receiving treatment; however, a geiger counter was used the next day to ensure that the right dose was delivered. No glowing involved.

Now, 3 treatments down and 30 to go. Radiation therapy is 5 days per week, before work.

I finally took a good look at the machine today. Pretty high tech. The part that beams the radiation reminds me of Marvin the Martian, of Bugs Bunny vintage. There is no funny voice-over, however, only a variety of 60's, 70's, and 80's music playing in the background. Evidently, one of the patients did not care for the music they played in the past and created a mix. Yesterday, they played "In Your Eyes" by Peter Gabriel which is one of my very favorite songs. It was good for a brief meditation. The overhead light fixture is decorated as if one is lying on the grass near the Jefferson Memorial, looking up at the sky through cherry blossom branches. Nice touch. The cherry blossoms will always be a romantic memory for me.

Energy Wave

2009-09-18T22:29:00.003-04:00

Most of the time, when people ask me how I've been feeling lately, I tell them that I am feeling much better. My energy is almost back to normal, at least 75% of normal, or so, maybe...; though, admittedly, I have had some pretty profound waves of fatigue. Being a go-getter, I may have suddenly found myself a bit over-committed. All noble causes.

It is a bit hard to predict when I will be hit with tiredness. I haven't even started radiation yet, so I am hoping that I get a handle on the present condition before new side effects pile on. Some feeling tired is to be expected. I do believe that my blood and immune systems are still in the process of reconstituting. Then, there is all that energy my body is spending upon growing new hair. Maybe it is taking extra energy to grow the baby hair, lanugo, that is now growing on my head. Bringing back the eyebrows may take extra oomph. Hopefully, I'm not spending hidden energy fighting off H1N1 flu; though, I did see my first confirmed case this week.

One of my debates is whether to exercise or not to exercise. Instinctively, I know that exercise generally improves energy; though, I know that I still have to work more to build up my stamina. I do try to get 8 hours of sleep every night; however, I don't always sleep well. Should I drink caffeine or avoid it? That is a question. Then what about dietary composition? Lately it's been more fruits and vegetables and less meat, more water and fewer other beverages.

On a certain level, it would simply be justifiable to be tired. This has been a big year. A lot has happened and is still happening. More needs to happen to reach treatment goals, recertification goals, and life goals. The goal of coaching soccer this season will soon be realized. Kids from Pen Lucy will arrive tomorrow morning for our first day, ready to play and to train in soccer drills and hopefully gain in life skills. It is an answer to prayer to be able to do this. Not only that, it is a joy. Putting the "exercise more" theory to the test...