Barn Raisers and Old Coots

I love springtime. Early mornings when I walk my two German shepherds – Zeus and Zoë – the air is still crisp and the sun is just starting to creep up, bathing the quiet neighborhood in shades of yellow and blue. The birds are chirping more. Easter – next weekend –is the ultimate annual marker of renewal (specifically resurrection), and of optimistic hope. Our word for Easter carries a connotation of new birth or dawn. Even the more secular aspects of Easter, like bunnies, eggs, and new clothes, signal the hope of spring. I’m ready! 

But I am tired of pessimistic, contrarian people.

Pessimism just seems both un-American and not Christian. Americans of all stripes are known for being hopeful, industrious people. Ronald Reagan famously described his vision of America as a shining “city upon a hill” – “a tall proud city built on rocks stronger than oceans, wind swept, God blessed, and teeming with people of all kinds living in harmony and peace…” Martin Luther King Jr, in a motivational address at Spellman College in 1960, said, “If you can’t fly, run; if you can’t run, walk; if you can’t walk, crawl; but by all means keep moving.” By moving, MLK was talking about moving toward the Promised Land. Hope and optimism are not the same, but they are related.

Neither Reagan nor MLK were calling for blind optimism. In Reagan’s farewell speech, when talking about his dealings with the Soviet Union and Gorbachev, he also said, “It's still trust - but verify. It's still play - but cut the cards. It's still watch closely – and don't be afraid to see what you see.” Sounds pretty rational to me. And MLK’s vision of the Promised Land endured despite his assassination.

Has our optimism evaporated?

Writing an obituary for optimism in the New York Times, Frank Bruni noted that 71 percent of Americans believe the United States is on the wrong track. This “profound pessimism” and “negative mindset” was present during the Obama and Trumpadministrations alike, reflecting a deep well of anxiety and worry. What a downer.

I think our negativity may reflect less a loss of optimism than a pernicious and growing contrarianism. 

Optimists are by nature not contrary people. They find common ground and work toward the collective good rather than basking in selfishness. They are what I would describe as barn raisers.Contrarians, on the other hand, are not team players. They would never show up at a barn raising with its community first, service-above-self spirit.

Now, as a fourth generation Texan, I am well aware that anindependent, pioneer spirit is part of our collective Texas heritage. But going it alone – ignoring the larger community – can lead to unnecessarily tragic decisions (Remember the Alamo!).

Uber-contrarian people are, by definition, difficult people. (We used to say (s)he’s just an old coot, but that person was probably crotchety their entire life.) In my medical practice, I have learned not to argue with old coots. I will never convince them to change their thinking or behavior. (What do I know about medicine anyway!) Old coots are set in their ways. Facts are inconvenient.

Barn raisers understood the need to wear masks for the benefit of the community. Heck, they may not have had complete faith in them, and very well may have objected to broad mandates. But the contrarian’s attitude was, “Hell, no! Your safety, our full hospitals, none of that matters – only my selfish right to do whatever the hell I please!” Same with vaccines.

I was foreman of a jury many years ago. It was – or should have been – an open-and-shut case. The law dictated that the defendant was guilty by association and the prosecution proved their case beyond a shadow of a doubt. One juror – an old coot – would not budge. Any logical argument from the rest of the jury pool was angrily rebuffed with, “You are just trying to trick me!” He was irrational. He did not have facts on his side, only opinion and emotion. He was wrong, and his stubbornness in not following the judge’s instructions and the facts of the case resulted in a hung jury.

Old coots remind me of Evillene, the wicked witch in the musical The Wiz. A quintessential autocrat, she surrounded herself with sycophants who feared her and wouldn’t tell her what was really happening in the outside world. (Sound familiar?) Evillene sings a song titled “No Bad News” that could be acontrarian’s anthem:

“'Cause I wake up already negative /

And I've wired up my fuse /

So don't nobody bring me no bad news”

Writing for The Atlantic, David French warns, “Don’t for a moment mistake contrarianism for critical thinking.”

“The contrarian [is] both excessively cynical and excessively credulous. He’s too quick to disbelieve one side and too quick to believe the opposite… even when the reality and the morality of the moment could not be more clear.”

French’s comment on critical thinking and contrarianism reminds me of one of my favorite verses in the bible, Romans 12:2:

“Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will.”

I read that verse this way: Don’t follow the selfish, contrarian spirit of talking heads on television, but improve yourself by using your brain to dig deeper and learn more. Only then will you be able to tell what is real and what is fake, what is true and what is a lie. God’s will is clear: Love God and love your neighbor.

Newscasts today are all about the latest “crisis” caused by evil opponents on the other side of the aisle, with nary a barn raiser in sight. Old coots, all of them. We need to love God and love our neighbor – together. We have a barn to raise!

Where Does Truth Come From?

 As a physician and Christian, I have been frustrated over the last 2 years with the alarming anti-science response to the pandemic. Two years ago, I shared worst-case predictions of 2.2 million COVID-19-related deaths. I was optimistic that the American people would “flatten the curve” of COVID-19 cases, but the early seeds of doubt and misinformation were already being sown. Ironically, by the time vaccines were available, science had become an enemy. Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases (NIAID) since 1984 and trusted advisor to seven Presidents on HIV/AIDS and many global health issues, including the COVID-19 pandemic, became the hated face of science. The loss of trust in science has profound implications not only for the COVID-19 pandemic, but also for healthcare in general.

Francis Collins, a professing Christian who led the Human Genome Project and recently retired as director of the National Institutes of Health, noted that many white evangelicals have been “victimized by the misinformation and lies and conspiracies that are floating around, particularly on social media and some of it in cable news.” Moreover, he said people are dying as a result. “I am just basically heartbroken in a circumstance where, as an answer to prayer, vaccines have been developed that turned out to be much better than we dared to hope for.” Vaccination rates in the US remain stagnant at 65%. Only 47% of Angelina County are vaccinated, with a mere 17% having received a booster, compared with 28% nationwide.

 Some evangelical pastors, whose political power goals – idols, really – appear to be more important than biblical mandates to love our neighbor and care for the least of these, tolerated and often promoted misinformation as opposed to vaccination, often in sync with a deep mistrust of government (except that of former President Trump). This misplaced “faith” won out over science, with the result that far more of our fellow Americans died of COVID-19 than should have – an astounding one million of us so far.

 Denial of the seriousness of COVID-19, promotion of unproven treatments, and rejection of highly safe and effective vaccines are all more common in evangelical Christian circles. Refusing vaccination became the new creed for many – a mark of membership in a chimera Christian nationalism faith, where wearing a mask in church is considered a political statement and not a safety measure.

For those of us who are Christian and work in science-related fields, the chasm that exists – unnecessarily, I might add – between faith and science is perplexing. In 2015 in an article title Are Evangelicals Anti-Science? Sara Kropp Brown noted that “evangelicals are more than twice as likely as the general public (29 percent vs. 14 percent) to say that science and religion are in conflict and that they are on the side of religion” and that “evangelicals are twice as likely as other groups to look to church leaders for answers to their questions about science.” Pandemic politics are certain to have made those numbers worse.

Historically, there was no inherent conflict between science and religion. Scientists have often been men and women of deep faith, including geneticists, physicists, and mathematicians. Augustine of Hippo (354-420 AD) is often attributed with saying “All truth is God’s truth.” The actual quote from On Christian Doctrine (Book II) is right on target in today’s anti-science, anti-vax, misinformation climate:

Nay, but let every good and true Christian understand that wherever truth may be found, it belongs to his Master; and while he recognizes and acknowledges the truth, even in their religious literature, let him reject the figments of superstition, and let him grieve over and avoid men who, “when they knew God, glorified him not as God, neither were thankful; but became vain in their imaginations, and their foolish heart was darkened. Professing themselves to be wise, they became fools, and changed the glory of the incorruptible God into an image made like to corruptible man, and to birds, and four-footed beasts, and creeping things.” Romans 1:21-23

 But we cannot claim “truth” and twist circumstances (sins of commission and omission) to suit our needs. Commenting in Bez & Co, Daniel R. Jones notes, “If we focus wholly on fragmented “truths” without getting around to glorifying God, we’re only exercising our own pride.”

 Reformation theologian John Calvin, commenting on Titus 1:12, put it pretty bluntly: “All truth is from God; and consequently, if wicked men have said anything that is true and just, we ought not to reject it; for it has come from God.” Christians must recognize truth wherever it is found or we dishonor God, even if that truth comes from people you may think “wicked” from across the political aisle, another denomination, or a different race.

 Truth, along with fellow virtues of justice and love, are side casualties in the unnecessary war between science and faith. People of faith across the political spectrum are being manipulated by politicians only interested in power – not truth, and certainly not the gospel’s command to love our neighbor as ourselves. Let’s take vaccination as a moral truth example applied to Philippians 4:8 (parentheses mine):

 Finally, brothers and sisters, whatever is true (vaccines work), whatever is noble (vaccines save lives), whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy (preventing millions of deaths worldwide)—think about such things.

 This pandemic wave may be dying down, but the truth battle goes on. Science and religion are not incompatible. If the church claims so, she loses credibility. “The culture war is literally killing people,” Collins said. Let’s hope the culture war doesn’t kill the church as well.

Health Literacy, a Pandemic, and the Church

One year ago, a winter wave of COVID-19 cases was starting to surge. The United States had already seen over 250,000 deaths.  The hope of a vaccine was just around the corner. Yet a COVID-19 vaccine misinformation campaign was already well underway.  Now we are approaching a staggering 1 million excess deaths due to COVID-19,  despite having multiple safe and effective vaccines. Why are so many not only not vaccinated against COVID-19,  but angrily opposed only to these particular vaccines against this specific illness?

Also in 2020 – and coincidental to the growing pandemic – UnitedHealth Group issued a report  on health literacy, which is the ability of people to access, understand and use information to promote good health. They noted that health literacy, like other social determinants of health  – social and physical environments, behaviors, access to healthcare, poverty, education, etc. – varies greatly across the country. Maps of health literacy  look similar to maps of county health rankings,  obesity,  heart disease,  poverty,  and education level  – generally worse across the Deep South.

In the paternalistic days of healthcare, health literacy was not even a concept. Patients relied on their physician to make healthcare decisions, trusting that he (almost all doctors were men) had their best interests at heart. Now we “shop” for healthcare as “consumers” in an increasingly transactional relationship. Big Pharma markets directly to the consumer through television, internet, social media, and streaming services. We Google for healthcare information. But are today’s consumer-patients any more educated or more capable of making informed healthcare decisions?

At a very basic level, health literacy must start with actual literacy. Twenty two percent of adults in my county can’t read a newspaper, which is written at around an 11th-grade level.  Add to that the fact that much healthcare information is even more difficult to read and understand, much less process critically. For example, I have otherwise educated patients who cannot tell me the names of the medications they are on and why they were prescribed.

And then along comes a pandemic, a fertile ground for a new, lethal combination of low health literacy and ubiquitous misinformation. A pre-pandemic systematic literature review on the spread of health-related misinformation on social media noted that accurate (often dull) scientific information is easily crowded out by sensationalized news.  The Internet of Everything  promised to help us live an efficient, informed life. Instead, it has produced a far darker reality of unquashable lies and misinformation that, in this perfect storm of pandemic and politics, has resulted in hundreds of thousands of avoidable deaths.  UnitedHealth Group’s report envisioned that increased health literacy might lead to 1 million fewer Medicare hospital visits each year and $25.4 billion in Medicare savings.  No small potatoes. They did not foresee this pandemic, where additional and avoidable COVID-19 hospitalization costs totaled $5.7 billion just from June to August 2021.  

Unfortunately, the evangelical church, of which I am a member, has been on the wrong side of the health literacy discussion, especially as it pertains to the COVID-19 vaccines.  I have written previously about the appalling attempt of many Evangelicals to claim religious exemptions.  Rather than a biblical love your neighbor message, the church – at least the Christian Right version of it – has promoted individual rights and selfishness as the greatest good. Rather than teaching the Beatitudes,  some in the church want to take over the state,  institute a theocracy and claim God’s blessing while doing it. Rather than preaching and being the Good Samaritan  to the pandemic ill, the Christian Right has chosen not only to walk on the other side of the road but to add to the toll of injured.

It is tragically ironic that the self-proclaimed pro-life Christian Right has raged against life-saving vaccination. Ted Cruz, the dominionist darling of the Christian Right,   vilified Big Bird for a “government propaganda” tweet about getting vaccinated.  The church – if it will preach the true pro-life gospel – can’t help but shine a light on this hypocrisy. For so many Evangelicals to fight against protecting and caring for others is not reflective of Christ’s teaching and, at a deeper level, heresy.

When it comes to solving the problem of low literacy and misinformation, avoiding social media and the commentary-based news media is a non-starter. Retracting misinformation is difficult, if not impossible. We have to learn to live with social media and understand that misinformation spreads faster and wider than factual information.  Health care providers must allocate time at every visit to assess what the patient does and does not know and to explain procedures, interventions, and medications in simple, clear language, avoiding jargon, verifying that the patient understands and can repeat back what they were told.  Most importantly, critical thinking should be treated as a core skill in education. We must educate people to be open-minded, to think beyond the noise, to observe and question, to be objective and look for biases, all with humility.

At the end of the day, too many in the Evangelical church allowed fear, misinformation and politics to replace compassion, service, and love. If the COVID-19 pandemic has taught us anything, it should be that loving our neighbors as ourselves is not a hollow commandment;  it saves lives.

Rosie the Riveter and Dolly Parton

The time was the early 1940s. America was at war. The aircraft and munitions industries heavily recruited women to take up important jobs in support of the war effort. In 1942, artist J. Howard Miller created the iconic, yellow background “We Can Do It!” poster of Rosie the Riveter, dressed in blue and wearing a red bandana, flexing her arm and looking straight at you. There is a power of iconic images like Rosie the Riveter to motivate people and to effect change.

We are engaged in battle again today, this time against a deadly virus. The nation needs a modern-day Rosie to recruit for the COVID-19 vaccine war effort. Who better than Dolly Parton, who not only rolled up her sleeve to get vaccinated, she donated $1 million to Vanderbilt early in the pandemic, which helped lead to the Moderna vaccine. To be precise, Ms. Parton did not have to roll up her sleeve when she got vaccinated. Her sparkly “cold-shoulder” top allowed her to get her shot without a wardrobe adjustment. Now it’s a fashion trend. I’d like to nominate her for sainthood.

I’m not sure even a Saint Dolly could increase vaccination rates enough to reach herd immunity. Vaccine hesitancy is astonishingly high. Though political leanings play a role, it is certainly not as simple as Trump supporters versus all others. Jonah Goldberg, writing for The Dispatch, noted that when the COVID-19 pandemic began, very few conservatives and Republicans disagreed that the government had a role to play: “pandemics, like wars, are supposed to be tackled by the government.” Even the staunchest libertarian – focused on “autonomy and political freedom” – can understand that preventing the spread of communicable disease is a necessary and worthy role of government, even as certain means to control disease (government shutdowns, for example) are questioned.

But the libertarian forfeits their principled position when their personal right to act becomes a belligerent and ignorant – not to mention community-harming – stand. So went Custer. Some are even wearing the decision not to be vaccinated as a badge of honor.

When you combine a growing libertarian streak with the individualism and sense of invincibility common among Millennials (aka “Generation Me”), it is easy to see why vaccination rates trail off dramatically the younger you look. A cynical person might suggest that Millennials just want the excess number of Baby Boomers to die from COVID-19 so they don’t have to support them in retirement. Plus, they’ll get their inheritance sooner. After all, those old people were going to die anyway. (Yes, I have heard it said on more than one occasion that COVID-19 didn’t really kill older people; they were going to die anyway.)

Young adults aren’t invincible, despite podcaster Joe Rogan telling them they don’t need to get vaccinated. (He later walked back that comment, stating, "I'm not a doctor. I'm a f---ing moron.") It sells more papers (or internet and social media ads) to play up the rare vaccine side effects than to tell the stories of young people who suffered or died from severe COVID-19. But those stories are out there. Serious cases are on the rise in younger adults, creating a create a "reservoir of disease" that eventually "spills over into the rest of society." Without a doubt, President Biden should order US military personnel to get vaccinated. Our military must be fit at all times.

I have had many thoughtful discussions with people who have not yet gotten vaccinated. Outside of conspiracy theories, I have yet to hear an argument that is not based ultimately on either fear or self-centeredness. The most sensible argument made against the COVID-19 vaccines is that we don’t have enough long-term safety data. (The original argument was that they were developed too quickly, but that was a false argument from the start. Years of advance research laid the groundwork for COVID-19 vaccine development.) But with hundreds of millions of doses given – and only extremely rare serious side effects seen – the safety of the vaccines being given in the United States is unquestioned. Pregnant women can get vaccinated, and there is no evidence any of these vaccines affect fertility.

True anti-vaxxers are a lost cause. They are crazy. You can’t reason with a conspiracy theorist. But there are many honest folk who have heard so much misinformation that they either don’t know what to believe or just can’t get rid of their doubt. These are the people who need to step up and take responsibility for more than just themselves. Otherwise, we are left with pure selfishness. Rosie would not approve.

Though vaccine hesitancy is seen across the nation, rural and conservative areas are the worst. Once again, as with almost every health metric from smoking to obesity, from education level to income, rural America comes in last. One may have different political beliefs and still unite in caring for the poor, the vulnerable, the least of these. Love and justice demand it. The New York Times argues that vaccine hesitancy isn’t a knowledge problem; it is about gut beliefs or “moral intuitions”. Vaccine hesitancy among evangelical Christians is pathetically high. What amazes me is that the folks who claim the moral high ground and purport to be concerned for the eternal welfare of others apparently don’t care enough about others’ lives here on earth to take a simple shot.

So, for the freedom loving, anti- big government individualists out there, hear me: You can mistrust authority and love your neighbor. You can hate Dr. Fauci and still protect your grandmother. You say you love your country? Then protect her and end this pandemic. It boils down to “where your treasure is”. Is your core motivation the “moral preference for liberty and individual rights”, or is it “love your neighbor as yourself”? Maybe one choice honors both. Rosie the Riveter rolled up her sleeve. So did Saint Dolly. You should, too. 

Vaccine Website Up and Running

As of Monday, March 8, 2021, the new online COVID vaccine registration portal is up and running at www.etxcovidvaccine.com. A result of the efforts of a volunteer group known as the Deep East Texas Partnership working with the Angelina County & Cities Health District, the website contains a simple to use bright red link to sign up for the vaccine as well as links to CDC and vaccine information and a link for those interested in volunteering to help with the vaccination effort.

 

The website details who is eligible to be vaccinated – currently Phase 1a (front line healthcare workers and residents at long-term care facilities), and Phase 1b (people 65 yrs. and older and those 18 yrs. and older who have chronic illness; education and child care personnel; employees, teachers and staff in pre-primary, primary and secondary schools; Head Start and Early Head Start programs; and licensed childcare providers). In the first couple of days that the website was live, more than 2,500 people signed up to get vaccinated. For those who cannot register online, they can still call the health district’s Coronavirus Call Center at (936) 630-8500, Monday - Friday from 8AM - 4PM.

 

This website and registration process is the result of many volunteers and organizations in the community coming together to implement what arguably should have been set up earlier. This paper justifiably was concerned about the missteps in preplanning for and coordination and implementation of a hub vaccination effort for Deep East Texas. Recently, however, they were unduly critical of what has essentially been a community volunteer effort to make up for lost ground and get a vaccine registration website up and running. I am grateful for the volunteer partnership that quickly raised a quarter million dollars and organized an army of volunteers to increase our vaccination rates. Sincere thanks are due to the TLL Temple Foundation, Angelina College, the Civic Center staff, and the many volunteers who have gone above and beyond to work with the health district, demonstrating what a community can do when it comes together.

 

So how are we doing with the vaccination effort locally?

 

As of March 9, 2021, 18.4% of the total US population has received at least one shot (23.9% of those age 18 and older). Texas is several percentage points behind the national rate at around 15.2% of the total population. In Angelina County, 12,484 people 16 years and older have received at least one dose (14.4% of total county population, or 18.6% of the eligible adult population). Yes, we are a little behind. The convention center hub is vaccinating 1,200-1,500 people a week. They have capacity to increase that number. With local, regional, and state leadership pressing our case, the hope is that a greater number of vaccine doses will be allocated to our Deep East Texas hub soon. After all, Hardin and Orange counties apparently are allocated so many doses that they have opened their COVID-19 vaccine appointments to anyone.

I have been heartened to read that more and more Americans are willing to get vaccinated. A recent Pew Research survey shows that 69% of the public intends to get the COVID-19 vaccine, or already has, up from 60% in November. This is incredibly encouraging news. About three-quarters agree that a large majority of Americans getting a vaccine for COVID-19 (i.e., achieving herd immunity) would help the US economy. We must keep heading that direction! Just this week, the CDC issued new guidance for those who have been fully vaccinated, including relaxed restrictions on indoor gatherings. There is a light at the end of the COVID-19 tunnel!

 

Regrettably, as David French points out in The Dispatch, “vaccine hesitancy breaks down sharply along partisan and religious lines, and that hesitancy is so profound in white Evangelical communities that it could disrupt the quest for herd immunity.” He notes that Evangelical vaccine hesitancy is both an information problem and a spiritual problem, with White evangelicals being the least likely to say they should consider the health effects on their community when making a decision to be vaccinated. As I have urged many times before, loving our neighbor is the heart of the gospel. For true believers, that love requires – no, demands – action. Two obvious and public actions to love others are mask wearing and getting vaccinated. I have been encouraged by those I know in the faith community who, with few exceptions, are planning to get (or have already gotten) vaccinated. In my estimation, Lufkin has long demonstrated that it is a living, loving community, far more willing to help others than most communities. Let’s hope our final vaccination numbers prove me right!

 

The www.etxcovidvaccine.com website will be an ongoing source of regularly updated information about available vaccines, vaccination locations, and the overall eligibility and registration process. Use the website; it is the easiest, most efficient way to get registered. But if you or your loved one do not have internet access, call (936) 630-8500. Either way, get vaccinated as soon as you are able. Together, we will we protect our community.

Trump, Faith, and the Church

Our mettle as Americans is being tested. Weary from months of anxiety and self-isolation due to the COVID-19 pandemic, we have emerged into crowd-filled streets to protests against racial injustice while our self-aggrandizing President – ever the expert on any issue – fans the literal flames of violence. The events of June 1, 2020, where the President of the United States tear gassed peaceful protesters so he could have a photo-op – Bible in hand – in front of the historic St. John’s Episcopal Church in Washington, DC, proved once and for all that Christianity is nothing more than a prop to Trump. Frankly, if that is all Christianity is, I want none of it.

But if the tenets of Christianity are true – which I do believe – then Christians must condemn the hypocrisy of a President who continues to attack anyone he doesn’t agree with on one hand – viciously, hatefully – while holding a Bible in the other. The Beatitudes did not include, “Blessed are the politicians who hate.” Loving God and loving our neighbor (white churches: not just our white neighbor), caring for widows and orphans, feeding the poor – these are the acts of the true, living Church.

Granted, Trump is not alone when it comes to caustic rhetoric. Hateful speech can be heard on all sides. But the President of the United States bears the highest responsibility to set the tone, to lead by example, to rise above the fray, especially in times of crisis. But let’s not kid ourselves – a pig loves the mud. The Church has a hard enough time being authentic without the President dragging her into the mud with him.

Four years ago – an eternity? – I wrote a column for the Lufkin News titled, “Let’s Not Get Trumped.” It was April 2016 and Trump had not yet received the Republican nomination. I wrote then, “Trump's campaign speeches are bullying and belittling, full of empty rhetoric and supportive of (indeed, encouraging) violence.” I was appalled at how blindly many evangelical Christian lemmings followed this reality show Pied Piper – one who played “an enticing but fundamentally deadly tune.” It has turned out even worse than I expected. Evangelical Christian pastors who believe they can sidle up to the President to achieve their pseudo-religious, American theocracy, Republican-Party-or-die goals, and not even  look the other way or hold their noses when he tweets, have much to answer for. Apparently, their sycophant-filled congregations aren’t holding them accountable, but a day of ultimate accountability will come (and a terrible day for them it may be).

I fervently pray that my grown daughters and their generation will understand that the faith they were raised with – the faith I cling to – is strong enough to handle these dark and difficult times, the complex issues, the hypocrisy, the hatred, the racism, the injustice in this world, and that they will keep that faith as their own. Of course, faith without works is dead; we have much work to do, many mouths to feed, many wounds to heal.

Christianity – much less democracy – is not validated by tear gassing people protesting injustice so you can get your picture taken holding a Bible in front of a church. True faith would have been displayed by opening the doors of the church and walking inside, arm in arm with protesters in peace and love.

There's Something About a Sabbatical

As this column is printed, I will be three weeks into a four week sabbatical. Since I am writing ahead of time, I obviously can’t have predicted how it is going. I can say what I hope it will be, at least to some extent.

I am a Type A personality and part of me – as I write this – wanted to plan out every moment of this break from my daily routine. I even made a list ahead of time of what the sabbatical is and isn’t (for me, mind you). High on that list is that I should not feel guilty if I don’t accomplish certain things that my Type A personality thinks I should. That I should just let it be what it will be. That’s hard for me.

People often ask me – when they find out I am a cancer and hospice physician – how I can do what I do without staying depressed. “Isn’t it hard?” they ask. My pat answer is that I love what I do, so how could it be hard? When I am doing what I believe God has gifted me to do, it is the easiest job in the world!

But that simple answer obscures that fact that burnout is a real possibility, even for me. Even though I love my job, frustrations arise. Not every patient is pleasant or easy to work with. Stress happens. We all need a break sometimes.

There are different ways to get away, and how we go about it may depend on where we are in life. During the routine work year, breaks can come in all shapes and sizes, from the afternoon off to a three day weekend or a more substantial week or more off for a vacation. These standard breaks rejuvenate us and help us stay focused when we are back at work.

A sabbatical is something altogether different.

The word sabbatical has at its root what we recognize as Sabbath – rest – which has a deeply spiritual meaning of both rest and worship in Judeo-Christian theology. The idea of an extended rest from work has a long history in the academic setting, where professors are given time off from teaching to travel, write a book, or study. But I never hear of doctors taking a sabbatical.

Doctors need it. Physician burnout is, according to some, is at epidemic levels. Others call it a crisis. Whatever. Let’s just say, burnout among physicians is far too common. The specialty of emergency medicine reportedly has rates of burnout at nearly 60% with many other specialties at 50% or higher. Burnout is basically severe, chronic stress characterized by emotional exhaustion and lack of empathy for patients along with a cynical or negative attitude and a sense that you are spinning your wheels in your career and not getting anywhere. Does that describe any physician(s) you know? I guarantee it does. I don’t want it to describe me.

Why physician burnout exists (and is increasing) is not the subject of this essay. But if you talk to doctors, government bureaucracy, electronic health records, insurance companies, and declining reimbursement despite longer work hours are almost always going to come up.
Doctors need a break. More than just a scheduled afternoon off or periodic vacation. I would argue that at some point in a physician’s career – if they want to stay the course for the long haul – they need to take a sabbatical.

What does a sabbatical look like? It depends on the person. My advice for those considering a sabbatical is to keep in mind three key components: time, distance, and purpose.

Time is important in order to distinguish a sabbatical from a vacation. Two weeks, for example, is not long enough to truly get away from work. You spend the first week just beginning to unwind and the second week worrying about the hell you are going to pay when you get back to the office. Four weeks is a minimum for a true sabbatical.

Distance is important as well – certainly physical distance, in that you want to avoid the temptation to check in on work. Get out of town. Out of the country, even. In this digital age, electronic distance is also important. Are you still going to be tied to Facebook? Instagram? Twitter? Or worse, to your electronic health record? Emotional distance is key as well. Let go of the thought that only you can do what you do.

Finally, consider if there are things you’ve always wanted to do – books to read (or write), goals to accomplish – but you’ve never had the time to do them. Be creative; think outside the box.

Avoid the temptation simply to travel, where you feel obligated to visit every cathedral and museum from A to Z. That’s a vacation. A sabbatical is about you. Be careful, though, that you don’t set unrealistic goals for your sabbatical, and that you don’t come back feeling guilty that you didn’t accomplish all that you set out to do. Remember, the definition of sabbatical is rest. Be still. Listen. Be open. Don’t just “do”! Find out more about who you are apart from medicine.

Personally, I’m taking my cue from two Biblical imperatives that guide my thinking about life in general. The first, Romans 12:2 (NIV), states, “Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will.” And the second is from Philippians 4:8 (NIV): “Finally, brothers and sisters, 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 such things.” I will be reading German theologian Dietrich Bonhoeffer’s profound book, The Cost of Discipleship. But I am not going to feel guilty if I don’t finish it. I’m resting, after all.

The Importance of Spirituality in Healing

Spirituality has gotten a bad rap. This is understandable, given the watering down of and movement away from organized religion in the late 20th century through today. The use of the term spirituality to describe any inclination beyond the purely physical – often based solely on “it feels right” – makes it difficult to assign any validity to the term. Add to that the oft-accompanying rejection of organized religion (most especially Christianity), and the term spirituality becomes as ethereal as the east wind.

I don’t believe this type of spirituality – this vague notion of otherworldliness or mysticism – has any particular benefit. I doubt it does much harm, either. It is just there. However, a spirituality that equates to magical thinking is not benign; it can be quite harmful. Spirituality is not a golden ticket to physical healing. 

Those who “claim” physical healing based on the strength of a person’s faith or the perceived closeness of a person’s relationship with God are gnostic charlatans peddling a vile snake oil that insinuates that those who are not healed are spiritually inferior and somehow less worthy than those who are. I have had the honor of participating in the cure of thousands of cancer patients over my career. Some of those cases have been so remarkable or unusual as to be “a miracle”, but I have never actually observed a truly miraculous healing. Any such healings that might occur must be ascribed to God and God alone, and God is not a lifeless puppet manipulated by human prayers.

I wish everyone would be cured, but that is not the world we live in. I have also had the privilege of caring for thousands of dying patients in my career, and providing comfort through the dying process is every bit as important – and rewarding – as the curative treatment I provide.

Ultimately, healing is more than just a physical event, as much as we strive for that. Dame Cicely Saunders, founder of the modern hospice movement, famously coined the phrase “total pain” to include not just physical pain, but also the emotional, social, and spiritual components of pain. That holistic concept translates to the overall healing process as well. I might cure a patient’s cancer, but their persistent financial distress, guilt, broken family relationships, and spiritual angst can result in no actual relief of suffering.

Anecdotally, I get a strong sense that patients who have a more than superficial faith cope better with the suffering associated with illness and death than those who do not. There is data showing that faith and religious practices do help patients not only cope with their illnesses but have a better quality of life.

Patients who continue to suffer spiritually despite good medical care often seem to fit in one of two categories: those who have no belief in a hereafter (and worry they have not accomplished enough in this life), or more commonly, those who fear death and eternal punishment for not having lived a good enough life. Either way, they worry they haven’t been “good enough” and it’s kind of late in the ballgame to turn things around. 

On the other hand, orthodox Christian faith starts with that very acknowledgement that none of us are “good enough”. Comfort – the healing of our spiritual pain and suffering, if you will – comes from accepting that God loves us anyway. Further, our suffering ironically can have meaning. That is not to say, as many well-meaning people too often do, “God meant it for good,” or worse yet, “What sin in your life have you not confessed that caused this to happen?”

The Christian faith – more so than any other – speaks volumes about the significance of suffering. Others may teach suffering is something to be overcome by quashing our desires, or that suffering is just a test from God (or worse, always a punishment). Biblical Christianity teaches not only the universality of suffering but the provision of comfort in and through suffering, whatever the cause.

Having a major illness is expensive, stressful, and often all-consuming. Without a comprehensive approach to care for the total person, we will never truly heal. That means more than doctors and nurses need to be involved in the healing process. We must include social workers, chaplains, and frankly, the entire community.

We need to recognize the spiritual struggles that attend our illnesses and the importance of spirituality in promoting comfort and healing. We can do this by sharing our stories with one another, listening without judging, and by mending and strengthening relationships within families, our houses of worship, and the broader community. And, yes, we need to pray for healing and comfort, not as a magical spell compelling some god to act on our command, but as a partner with the one true God who knows what it is to suffer. Let the healing begin.

Palliative Care: Something We All Want

As a hospice physician – in addition to my role as a doctor who treats cancer – much of my focus is on comfort care. Part of my motivation to study medicine stems from my childhood concept of who a physician was and should be: a healer and comforter. The physician of yesteryear came to the bedside to care for and comfort the sick (and yes, the dying). I love that the Latin root for comforter is confortare, meaning, “to strengthen much.” In Christianity, the Holy Spirit is also called the Comforter.

Frankly, all physicians should practice comfort care. We know we aren’t to harm our patients. That obligation not to inflict harm intentionally is the ethical principle of nonmaleficence. It is summed up in the Latin phrase Primum non nocere – First, do no harm. The Hippocratic Oath states, in part, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.” That oath – to help the sick – expresses our obligation to do good (the ethical principle of beneficence). Though the actual oath used in various medical schools has changed over time, the overarching mandate to help the sick – and, at a minimum, not to harm them – is universal.

What does it mean to help the sick? That seems, on the surface, like an obvious question. “To cure, of course!” we would say in the 21st century. But curing disease is a quite modern concept. For most of medical history, comfort care was the primary goal. Modern technology and the emphasis on cure got us advanced cardiac care, open heart surgery, amazing innovations in cancer treatment, and so much more. But by 1980, most people died in the hospital. This was rare just a generation or two prior to that, when nearly everyone died at home (or on the battlefield). 

Since 1980, the number of people dying in the hospital has declined somewhat, thanks in part to better end of life care (including hospice care). However, 7 out of 10 Americans still die in a hospital, nursing home or long-term care facility when 7 out of 10 of us say we want to die at home (only 25% of Americans actually do die at home). Utilization of hospice care at the end of life is still woefully low.

But, what about those in the hospital who aren’t expected to die, who want a better, more “comfortable” hospital care experience overall? “Cure sometimes, treat often, comfort always,” is a wonderful mantra attributed to the 19th century tuberculosis physician Dr. Edward Trudeau. This phrase sums up a newer movement in medicine called palliative care. 

Palliative care focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing any serious illness. To palliate means to relieve – literally, to cloak – with the focus being on symptoms. Symptom management obviously should not be limited to end of life care.

As an example, for an ICU patient suffering from an acute exacerbation of lung disease, probably on a ventilator for a short period of time (but expected to recover), the physician historically has been paying attention to oxygen and carbon dioxide measurements, volumes of air going in and out, the acidity of the blood, and other “numbers” that paint a picture of how the patient is doing. But not how the patient or family is feeling. Shortness of breath? Anxiety? Nausea? Pain? Dealing with prognosis and potential end-of-life decision-making? Social and spiritual support? These are issues that might benefit from a palliative care consult.

Every hospitalization (whether ICU or not) has the potential for needing some degree of palliative, or comfort, care in addition to and alongside the acute medical needs that precipitated the admission in the first place. Often, the treating physician can and should address these needs. Quality metrics such as patient satisfaction, length of stay, and even cost of hospitalization are improved with good symptom management.

And, believe it or not, sometimes patients live longer with good comfort care! In my field of oncology, randomized trials have shown improved quality of life and even improved survival with early use of palliative care. The American Society of Clinical Oncology (ASCO) recommends the integration of palliative care with conventional oncology treatment, and the American Society for Radiation Oncology (ASTRO) has urged early palliative care referral when cure is not expected, even if death is not imminent and treatment still is ongoing.

CHI St. Luke’s Health Memorial in Lufkin will be starting a new palliative care consult service later this fall. A team consisting of a physician, nurse, and social worker all certified in palliative care will be available to consult with and advise physicians on any patient with difficult to manage symptoms, regardless of whether or not the patient has a terminal prognosis.

As we learn more about palliative care, we remember the Golden Rule: “So in everything, do to others what you would have them do to you, for this sums up the Law and the Prophets (Matthew 7:12, NIV).” 

Comfort always.

The Demise of Polite Conversation

When did the art of pleasant conversation and open dialogue end? Every national new item – it seems – sparks vitriol that demands an alignment in one political camp or the other, one race or the other, or one sexual orientation or the other. I am afraid we have lost the ability to exchange ideas, to communicate freely, to learn from one another. To celebrate our differences rather than condemn them. Passionate speech and polite speech are not incompatible.

But I am afraid to speak, for fear my words are misinterpreted. I am afraid to write, lest my writing not encourage the thoughtful conversation I intended, but provoke a hateful backlash. Is it no longer possible to have civil discourse?

I am afraid to laugh, for fear my laughter is misconstrued. Can’t I both laugh at Tina Fay’s Saturday Night Live sheet-caking stunt, for example, as well as at Chad Prather’s “Unapologetically Southern” YouTube videos? At political cartoons of both the Wall Street Journal and the New York Times? Or is humor no longer funny, only hateful? Can’t we laugh at ourselves anymore, at our own hypocrisies? We all have them. I’m afraid we no longer recognize that; we are blinded by our self-interest.

I am afraid of social media. Facebook has unfortunately turned into a forum where, other than the annual birthday wish or mundane vacation photo, posts are filled with inflammatory opinions and commentary-as-fact with the self-righteous, ignorant replies that follow. Mob mentality sets in and people post things they would never say to your face. Hurtful – hateful – things.

Free speech is not the same thing as kind speech, uplifting speech, or frankly, intelligent speech. Nor should honest disagreement be labeled hate speech. Unfortunately, much speech today is designed to shut down the conversation by labeling one’s opponent –are they really an opponent? – a bigot, or by declaring they have no moral standing even to join the conversation. That is coercion, intimidation, and bullying no matter which side is doing it. That makes me very afraid.

I am afraid when I see fellow Christians deciding that following politics is more important than following the Ten Commandments. When they opt for strict party affiliation over and above "Thou shalt love thy neighbour as thyself" (Mark 12:31, KJV). And when they decide it is expedient to legislate hate, discrimination, and economic disparity while ignoring inconvenient moral issues like poverty and healthcare. What happened to being Jesus to those around us?

Rod Dreher, in his timely book The Benedict Option, notes that political victory does not vitiate the vice of hypocrisy. The socially liberal churches are just as guilty of blindly aligning with the Democratic Party as the fundamentalists are with the Republican Party. Could it be that Jesus understood this when he said, “Render therefore unto Caesar the things which are Caesar’s; and unto God the things that are God’s” (Matthew 22:21, KJV)?

I am afraid our clumsy, partisan involvement has resulted in a political environment increasingly hostile to the very real – and very Christian – charitable work of the Church. We must redirect our gaze outside our church walls and into our increasingly diverse and desperate communities. Putting our faith to work on the ground speaks volumes and accomplishes so much more than legislating selective moral conformity.
It often takes a crisis – a disaster? – to bring the country together to work for the common good. Perhaps Hurricane Harvey will accomplish that. It appears to be doing so; I just hope it lasts.

Dreher wrote, "The state will not be able to care for all human needs in the future, especially if the current projections of growing economic inequality prove accurate.” Christians need to rediscover an ethic that marries personal responsibility with intentional charity and corporate love and respect. I fear we may have drifted too far to do so.

But I am afraid not to try.

The Significance of an Ethical Foundation

Last month, I wrote about the role of the hospital Ethics Committee and commented that open and honest communication between healthcare professionals, patients and family solves most ethical dilemmas. That assumes we are speaking the same ethical language and have a common ethical foundation, both in medicine and in society at large. In our increasingly pluralistic society, that is no longer a safe assumption. The recent Orlando attack on a gay nightclub showed us that people can do terrible things when ostensibly motivated by a perverse ethic or belief system.

Ethics, at its core, is simply a set of moral principles or values which guide an individual’s – or a religion’s or a government’s – actions. In the United States, that governing set of principles has been rooted, sometimes more and, regretfully, sometimes less, in a Judeo-Christian ethic based on the inherent (and, according to the Declaration of Independence, Creator-endowed) equal value of every individual. In medical ethics, the two related guiding principles date much further back, to Hippocrates around 400 BC: the sanctity of human life and the concept of “first do no harm”.

Modern medical ethics rests on four major pillars: Autonomy (the patient decides), Beneficence (does it help), Non-maleficence (don’t harm), and Justice (is it fair or impartial). In other words, do our medical recommendations and interventions respect the rights of the individual patient, are they helpful, do they not do harm, and are they fairly and equally available. It is a tall order to keep these broad principles in mind, especially when trying to balance competing interests with limited resources.

American history in general – and medicine in particular – has tended to elevate Autonomy over and above her sister principles. We are a pioneering, individualistic “I did it my way” society. The winds appear to be changing, both in healthcare (with the move toward universal healthcare) and in political discourse. The traditional emphasis on the individual’s responsibility in his or her own pursuit of happiness is taking a back seat to the notion that it is the government’s role somehow to guarantee equal outcomes, seemingly regardless of effort, for all. For example, we just completed a groundbreaking primary season where an avowed socialist garnered significant support on a platform of income redistribution.

Amidst this sea change of process, of roles and responsibilities, can we agree on a common ethic to guide us?

I firmly believe that regardless of who we elect and within whatever system of healthcare delivery we end up with, a Judeo-Christian emphasis on the inherent, God-given value of each and every individual (whether black or white, gay or straight, handicapped or not, born or unborn) is uniquely protective of both the individual and society as a whole. Mass shootings and terrorist acts demonstrate that our moral ethic (or lack thereof) determines our behavior. To paraphrase a Dostoevsky character in The Brothers Karamazov: If God does not exist, all things are permissible. A disturbing corollary appears to be: If my moral ethic condones and encourages killing lots of people, why not do it?

Motivational speaker Zig Ziglar once said, “Since belief determines behavior, doesn't it make sense that we should be teaching ethical, moral values in every home and in every school in America?” Whose values? All belief systems are not equal. Governments and terrorist organizations which do not value the individual, inherent worth and equality of “all Men” – to again reference the Declaration of Independence – are not going to treat their (or our!) citizens equally. In fact, they may kill them (and us).

If I had to choose one word to describe the ethical principle I pursue in life and in healthcare, it is love. Not hate, not selfishness. Not religious dogmatism. And not a “love” of government, cult or fanaticism that discriminates or (God forbid!) kills others in the name of some god or political whim. It is the pure Christian commandment to “Love your neighbor as yourself.”

Is this idealistic? Absolutely. Is it achievable? No, to be honest. But that doesn’t mean I stop working tirelessly, incessantly toward that goal. Our country should do the same.

The Role of the Hospital Ethics Committee

For most of my 25 years in medical practice, I have been involved in hospital ethics committees. You may not know that ethics committees exist, or that there are ethics consults in hospitals.

An ethics committee is a group of people ranging from physicians to chaplains, nurses, social workers, and sometimes community representatives who may meet to develop policies on topics like end-of-life care or medical decision making. It is easy to understand that conflict may arise, for example, when a patient is unable to voice their desires and family members don’t agree; it is much harder to devise or articulate a process toward a solution. Sometimes state or federal law dictates a path; more often, a Solomon is needed to split the proverbial baby. Hence, the Ethics Committee can be consulted to advise on a course of action.

In each institution I have been associated with, the Ethics Committee does not decide which course of action to take. They merely facilitate discussion between parties, advising on known statutes or regulations, and – more than anything – making sure each party is hearing what the other is saying. Most ethics consults end up being non-issues; once communication is clear between parties, agreement on a course of action is often reached.

On rare occasions, family members insist on care being provided or continued when, from a medical standpoint, that care is considered futile (or, in PC-speak, non-beneficial). This is a perfect example of #firstworldproblems. It was only in the 1960s that coronary care units came into existence. Prior to that, death in the home was the norm, with family at the bedside. With the advent of intensive care, we have come to expect immortality in the Temple of Medicine.

As reported in 2010 by PBS’s Frontline program Facing Death, nearly half of all Americans die in a hospital (nearly 70% in a hospital, nursing home or long-term-care facility), while 7 out of 10 Americans say they would prefer to die at home. More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying. Yet only 25% actually die at home. The difference between desire and actual care is striking.

Why, if we want a certain type of care, do we not get it? For one, we don’t effectively make our wishes known. In that same Frontline series, only 20 to 30 percent of Americans report having an advance directive such as a living will. And, even when patients have an advance directive, physicians are often unaware of their patients' preferences.

The default action in hospitals is to provide any and all care possible. Blame our perverse incentive to do procedures, our desire to avoid litigation, and our misguided belief that we can save everyone, and you get patients dying in the hospital not even knowing they are at the end of life. It is this window where a hospital Ethics Committee is most consulted.

In my personal experience, the ethical conflicts that arise within a religious context are the most frustrating. Some patients or families hold on to the miracle cure lottery ticket, demanding care that is both ineffective and injurious, afraid to let go of “faith”, as if death itself is under their control.

That type of faith – sincere as it may be – is nothing more than magical thinking that binds God to the believer, making God not even a god, but a puppet. As Billy Graham reportedly said, “Prayer is the rope that pulls God and man together. But, it doesn't pull God down to us. It pulls us up to Him.”

In healthcare, there is no “right” to expect or demand care that is not appropriate. Physicians have an obligation to “first, do no harm”. This is nowhere more important than at the end of life, where comfort care and quality of life are paramount. To bridge this unnecessary divide, open and honest communication between healthcare professionals, patients and family is key. When communication breaks down, the Ethics Committee can help.

Let's Not Get Trumped

I am ashamed. I wrote that phrase recently on a Facebook post of two Finnish friends who are looking across the ocean with a combination of disgust and disbelief at the Trump phenomenon. Consider my vow to avoid public political commentary this year broken.

The first president I ever voted for was Ronald Reagan in 1980. I have voted Republican ever since. But I will not vote for Trump if he is the Republican nominee. Don’t worry… I’m not voting Bernie Sanders, either. The socialist movement in the Democratic Party is just as disaffected and radical as the Trump wing of the Republican Party… and just as dangerous to our American way of life. We are not Finland. But with Sanders, you know what you get. With Trump, all bets are off.

Trump's campaign speeches are bullying and belittling, full of empty rhetoric and supportive of (indeed, encouraging) violence. I don't care how angry you are at the “establishment”; there is no place in American politics for Trump’s inflammatory, derogatory speech. Yes, he has a right to say those things. But shame on each and every American who jumps into the pig sty with him, eggs him on, and actually votes for him! Regrettably, all of us on the sidelines have been stained by Trump’s mud.

To my fellow Christians in particular, Trump – in his campaign rhetoric, at least – displays no evidence of being a Christian, which he claims to be. There, I said it. Forgive me if you think I am being judgmental, but I simply don’t see the fruit. This is not about waffling on various social issues on which well-meaning Christians can and do disagree. Consistently, his public demeanor is far from “Love God”, much less “Love thy neighbor as thyself.” If Trump loved anything as much as himself, we’d all be better off.

I don’t get how so many people – Christians in particular – are following like lemmings in the wake of a reality show Pied Piper – one who plays an enticing (but fundamentally deadly) tune. It is ironic that Jerry Springer, who long ago helped set the nasty reality TV tone that is emblematic of Trump’s campaign, can’t believe we would elect Trump as president.

I get that Trump is tapping into popular themes like immigration and "making America great again" – whatever that means – but the reality TV emperor has no policy clothes. In effect, Trump supporters are saying they want an angry president who doesn't know what he is doing. That is both startling and dangerous. Anger does not lead to sound foreign policy.

Trump's narcissism, lack of a verbal editor and foul speech suggest a personality disorder at a minimum. More worrisome, they expose a disturbing lack of compassion and respect for the innate value of other human beings. Add in a questionable moral compass and I truly fear the international fallout with his impulsive finger on the nuclear trigger. He’s just plain scary.

Ultimately, this column is not really about Trump. It is about me. By what ethic do I live my life and cast my vote? Do I believe that might makes right? Does the end justify the means? God forbid!

What about you?

If the Republican Party implodes (or if the Democrat Party nominates a Socialist), I do not blame the "establishment". I blame voters on both sides of the aisle who can't tell the difference between a slot machine and a voting booth. They just blindly pull the red or blue lever hoping for a jackpot. If only they could see, with that approach we are all going to lose.