What If We Don’t Flatten the COVID-19 Curve?

On April 5, 2020, US Surgeon General Jerome Adams said, “The next week is going to be our Pearl Harbor moment. It’s going to be our 9/11 moment.” The same day Dr. Anthony Fauci, arguably our most trusted spokesperson during this coronavirus crisis, said, “We’ve got to get through this week that is coming up because it is going to be a bad week.” One oft-cited set of projections showed deaths from COVID-19, the illness caused by the novel coronavirus, and resource use (including ICU beds and ventilators) were expected to peak this weekend. That all of this is happening during Easter and Passover only adds to the sorrow.

For those of us in Texas, the wait to peak is a bit longer. Estimates a week ago were for peak resource use on May 6, 2020, but that prediction has now moved up to April 22, with peak in daily deaths on April 24. Texas appears to be flattening the curve. In Angelina County, we have 16 confirmed cases of COVID-19 as of April 9, but only 283 people have been tested so far. We can only hope that the wise and early decisions by our local elected officials, including the Stay Home – Stay Safe order, will have flattened our curve enough to avoid the healthcare crisis experienced in New York, New Orleans, and other cities.

But what if our hopes are unfounded? What if we get a surge of COVID-19 cases beyond what our healthcare system can handle? In New York City, some COVID-19 victims could be temporarily buried in mass graves in a park, as morgues don’t have the capacity to handle the mounting casualties.

Thankfully, doctors across the nation have been giving much thought to this grim prospect. After the 2003 SARS outbreak, North Texas physicians came together to answer that very question: What would they do if a really big pandemic hits and hospitals are overwhelmed? The result was the formation of the North Texas Mass Critical Care Council. The council established that during a time of crisis, the ethical, moral, and medical approach should be that “access to treatment would be based upon the patient’s ability to benefit from it, using objective physiologic criteria.” In other words, medical evidence – rather than insurance status, social standing, what have you – would guide decision-making about which patients are most likely to benefit from ICU interventions when there are not enough ICU beds or ventilators for every patient. The goal – as it should be in any medical crisis – is to save “as many lives as possible.”

In a similar fashion, CommonSpirit Health, the Catholic health system that is the second-largest nonprofit hospital chain in the US (and the parent of CHI St. Luke’s Health Memorial Lufkin), developed Crisis Response Guidelines for Hospital and ICU Triage Allocation. These guidelines are not based on opinion or guesswork. The many criteria used to prioritize who would benefit from ICU and ventilator support are validated in the medical literature and have been compiled to arrive at a robust sequential organ failure assessment (SOFA) score, based on the degree of dysfunction or failure of the heart, lungs, liver, kidneys, brain, and blood system. This SOFA assessment, well known to emergency and intensive care specialists, is used routinely to predict mortality in any critically ill patient.

Based on SOFA scores and other medical criteria, doctors might determine that an elderly patient with COVID-19 whose organs are functioning well is more likely to recover using a hospital ventilator than a young patient with multiple organs shutting down from the virus, but the decision would be based entirely on whether the treatment is likely to help the patient recover. Doctors are expressly prohibited from considering social status, money or other nonmedical criteria when making these decisions. The last thing doctors want to be accused of is indiscriminately playing God.

A recent Wall Street Journal opinion implied that merely considering apocalyptic scenarios would lead to legalizing euthanasia, and that not having guidelines (and thereby wasting resources on those that would not benefit) was morally superior to sound medical decision making. Texas Health and Safety Code §166.009 acknowledges that sometimes difficult choices have to be made and states that provision of life-sustaining treatment is not required if it “cannot be provided to a patient without denying the same treatment to another patient.” There is a larger problem of futile care in this country that did not start with the coronavirus pandemic and it won’t end once this virus is under control.

Crisis guidelines are not written to decide who lives and who dies; they help direct the most aggressive care to those who are most likely to benefit so that the most lives can be saved. Regardless, all patients are to be treated with dignity and receive appropriate and compassionate care. If I, as a physician and community leader, have little to no chance of survival if placed on a ventilator – based on solid medical criteria – but an illegal immigrant (for example) has a good chance of survival, guess who gets the ventilator? Not me. And that is the way it should be.

We must continue to follow the social distancing recommendations of our city, county, and health district leaders in order to minimize the impact of the coronavirus locally. We can do this – we ARE doing this. As the Lufkin/Angelina County Chamber of Commerce is encouraging us, we are #BetterTogether and #AngelinaStrong.

End-of-Life Implications of the Coronavirus Pandemic

We are early in this coronavirus game of social distancing and hand washing. We haven’t quite become weary of it. We joke about it. And yet, I am starting to see – among my friends – some very real concern about our elder parents and grandparents. But we don’t allow ourselves to linger on those thoughts much. We should.

The United States has been accused of being late to respond to the coronavirus pandemic, late to test our US population compared to other countries (South Korea, for example), and “doomed” in our response. Even so, we are just beginning the initial rise of the now well-known bell curve of the Coronavirus Disease 2019 (COVID-19) pandemic. Known cases are doubling every day, it seems. Deaths are increasing as well.

As a cancer physician with additional hospice and palliative medicine (end-of-life care) certification, I view the coronavirus pandemic with increasingly darkened lenses. Coronavirus is a new and immediate threat to life, and we are not ready for what that means. If we don’t succeed in slowing the spread of coronavirus and suppressing new cases – now widely known as flattening the curve – 2.2 million people in the US could die. We are not talking openly – publicly –about how we are going to handle this massive number of deaths with COVID-19.

If the coronavirus epidemic is as bad as some predict it will be, discussions about end-of-life care with this disease will soon become front and center. There may not be enough ventilators for everyone who “needs” ventilator support. Italy has been forced to triage sick coronavirus patients based on age, given that the death rate among the elderly is so high. Italian doctors have admitted that there were simply too many patients for each one of them to receive adequate care. They describe a “tsunami” of patients and a more than 7% death rate (though researchers have lowered the calculated death rate in Wuhan, where the pandemic started, to 1.4%). Preliminary outcomes of patients with COVID-19 in the US show death is highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years.

The Italian society of anesthesiologists issued fifteen recommendations of ethical and medical criteria to consider if ICU beds are exhausted, saying doctors may have to adopt more wartime triage criteria of gauging who has the best chance of survival versus “first come, first served.” Those who are chronically ill with pre-existing lung disease, even if they survive a serious coronavirus infection, are likely to be left with even further reduced lung function and poorer quality of life.

Unlike a localized disaster – most memorably Hurricane Katrina, in New Orleans in 2005, where healthcare decision-making received intense scrutiny and prompted legal action – we are experiencing a global, acute healthcare emergency that may require historic moral and ethical decisions that impact who lives and who dies. We will be rationing healthcare on the fly. Are we ready for that? As family members? As a community? As a nation? Are our hospices ready for the number of patients needing immediate, short-duration, and contagion-related end-of-life care?
Perhaps the most terrifying aspect of the coronavirus epidemic in countries where death has become frighteningly common is the loneliness of the death. Hospitals in the US are already limiting or even forbidding visitors. In Italy, seriously ill coronavirus patients are isolated from family and often die alone. Families are not allowed to have a proper burial, and not just due to restrictions on gathering – morgues have an enormous backlog to work through. That is certainly not what we would call a “good death” and not what those of us in the hospice care field want for any patient.

Trump has labeled himself a wartime president, declaring we are at war with an invisible enemy. "Now it's our time. We must sacrifice together, because we are all in this together, and we will come through together," he said. What is not stated – and what I am afraid will happen – is the wartime sacrifice analogy will extend to real lives lost. In an ironic twist of fate, it very well may be that the remnants of the Greatest Generation are once again on the front lines. Even down to the Baby Boomers, our nation’s elders will bear the brunt of the coronavirus disease, certainly, but likely the financial catastrophe surrounding the pandemic as well. (I wonder if the economic collapse will kill as many or more people than coronavirus does.)

The time is now to have discussions with our older/elderly parents and grandparents about the very real risk of serious illness and death from COVID-19. Wills need to be written and advance directives and durable powers of attorney completed now – before our loved ones hit the hospitals. This is not morbid; it is both pragmatic and necessary. If we emerge from this battle relatively unscathed, we are no worse off for having had the discussions and done the planning. Patients and families should be driving end-of-life care decisions. We owe it to our hospitals and healthcare workers not to overburden the system with trying to care for those who neither want nor would benefit from aggressive measures.

The Graduation Speech I Would Give

Facebook and YouTube are full of graduation speeches that go viral and become memes representing personal life views, political stances, or just feel good, philosophical pablum. Usually, speakers invite you to follow your passion, love what you do, and learn to overcome failure. In other words, graduation speeches motivate you to change the world (like the speaker has) but provide little, if any, real life advice.

That’s not to say the speeches aren’t inspirational.

One address by Naval Adm. William H. McRaven at the University of Texas in 2014 has garnered more than 10 million views on YouTube. McRaven’s speech famously opined, “If you want to change the world, start off by making your bed.” He explained, “If you can’t do the little things right, you’ll never be able to do the big things right.” Coming from a Navy admiral, the importance of discipline is sound.

Denzel Washington’s speech at Dillard University, a private, historically black, liberal arts university in New Orleans, Louisiana, has 21 million YouTube views. Denzel’s advice? “Put God first in everything you do.” Having a spiritual foundation in life is wise counsel.

For even more YouTube views, check out Steve Jobs’ 2005 Commencement Address at Stanford University, which has racked up 33 million views. Steve Jobs, co-founder of Apple, urged graduates to “Follow your heart,” saying, “The only way to do great work is to love what you do.” Passion can certainly keep you going when life throws you curves.

Most graduation speeches I’ve heard or read suggest believing in yourself and having the right attitude will result in success – success meaning significant global impact or financial gain. Is that what graduates want or need to hear? Having finished high school 40 years ago, I got to thinking about what practical advice I wish I had gotten back in 1979.

One of the most important lessons I learned is that making money rarely equates with true success. There is a joke that goes, “How much money does it take to live in New York City?” ”All you have!” Of course, this can apply to living anywhere, if we are always chasing the bigger apartment and the more expensive car. True success is not about accumulation of wealth. Learn early to separate financial gain from successful living.

That being said, you still must save and plan for the future. My parents set the expectation early on that my brothers and I were to get an education and make a living on our own to be able to save and support a family. That was their minimum definition of success. I’d love to hear a graduation speech that focused on saving. Saving should start early. With the first paycheck you bring home (and every one thereafter), set aside some to save.

But don’t just save; give! Yes, you work for you. But it’s not all about you. Give of your time, talent, and treasure to support causes that you believe in (religious, civic, non-profit, etc.). Then live within your means with whatever you have left. Occasional splurges can be planned, but don’t borrow to keep up with the Joneses. That is playing with fire. A major illness (like cancer) at any age can trigger unbelievable expense and a significant risk of bankruptcy. The focus on inequality or “keeping up” breeds jealousy. Equal work does not guarantee equal results, much less equal pay. You can’t live your life comparing yourself to others. Yes, fight for justice. But do your own work without resentment when others happen to have more financial success, fame, or glory. Don’t envy.

Happiness, especially if based on accumulation of things, is fleeting and deceptive. Joy, on the other hand, is a mindset. One of the most joyful people I’ve ever known never had a dime to her name. Reverend Bettie Kennedy was too busy giving whatever she had away, feeding and clothing others. Learn to give.

The Protestant Reformation brought with it the idea of our vocation as our calling, indicating the spiritual nature or our work. Whether Martin Luther actually said it or not, the idea that even a milkmaid can milk cows to the glory of God is encouragement to find meaning in even our most trivial tasks. When we do, we don’t cut corners. We always put forth our best effort. And we treat each person we interact with as the most important person there is at that moment. View your own work as a calling and your interaction with others as your ministry. Love God; love others. Simple to say; hard to do.

Don’t forget to make time for yourself. Burnout is real in any profession. Maintaining your mental and spiritual health is just as important as your physical health, maybe even more so. Learn to retreat.

Finally, expect to regret certain decisions, actions, roads taken. I don’t believe anyone who says they never regretted anything they’ve ever done. In fact, I feel sorry for them. That attitude exposes a selfish view of a life lived with callous disregard for any hurt inflicted on others, much less yourself. A life without regret is a life without grace. Embrace grace.

To summarize, the best graduation advice I can give is to save often, give freely, live within your means, treat your work as a calling (but take a break every once in a while), treat others with dignity, and accept and extend grace. Success is not found at the journey’s end; it is embodied in the life well-lived. Sounds like good New Year’s advice as well.

The Financial Burden of Cancer Care

As a board-certified radiation oncologist, I’m trained to know all about cancer and its physical effects on people. Similarly, as a board-certified hospice and palliative care physician, I am well-versed about the psychosocial and spiritual trials patients go through, especially at the end of life. But a recent study I read stopped me in my tracks with a disturbing finding: Cancer is bankrupting an astounding number of patients.

Adrienne Gilligan, PhD, publishing her research in the American Journal of Medicine, found that 42% of cancer patients deplete their life savings within 2 years of diagnosis. This “financial toxicity” –  arguably every bit as serious as the emotional and physical toxicity associated with cancer treatment – risks forcing far too many cancer patients to make an agonizing choice between almost certain death and overwhelming debt.

The Advisory Board Company, a Washington, DC-based organization that researches best practices in healthcare and other industries, highlighted from Gilligan’s article that “the direct medical costs from cancer exceed $80 billion in the United States. [The authors] cited previous research finding that up to 85% of cancer patients leave the workforce during their initial treatment, and more than 50% of cancer patients at some point experience bankruptcy, house repossession, loss of independence, and breakdowns in their relationships.”

One observation from this research that should be even more concerning for those of us in deep East Texas is that in more vulnerable populations with lower socioeconomic status and clinical factors such as smoking and poorer health – this describes Angelina County and surrounding counties – the risk of asset depletion is even greater. Even for those with health insurance, the researchers wrote, deductibles and copayments for treatment, supportive care, and nonmedical or indirect costs (for example, travel, caregiver time, and lost productivity) may be financially devastating.

I see this financial burden all the time. Monthly, I get a report from my billing office on the bills that patients are not paying despite multiple contacts. Most of the time, these are deductibles and copays that patients – who live paycheck to paycheck and who have no savings to start with – never are going to be able to pay. Sometimes it is the entire bill, in the case of uninsured and indigent patients. As a physician, I really only have two options: send them to a collection agency to harass them and try to get whatever proverbial blood out of the turnip they can, or write them off. That my patients should suffer not only with a cancer diagnosis and treatment side effects but also possible bankruptcy is absurd. I am rightfully appalled and angered that our federal healthcare reimbursement system and the private insurance complex have achieved “cost savings” by placing more and more of the financial burden onto patients, who simply are unable to pay. The bankruptcy monster is always at the door.

Doctors are familiar with the Latin phrase primum non nocere – first, do no harm. The idea is really that we should balance the risks of treatment with the benefits. I imagine when that phrase was coined the author did not have financial harm in mind. Today, it has become one of the most important “risks” when weighed against the hoped for gains of treatment. Unfortunately, the provision of healthcare has become a commodity and providers are reduced to revenue-producing cogs on the wheel in a system that has replaced the patients’ needs with productivity metrics. The profession of medicine is less and less in charge of the provision of medicine.

In spite of this new reality, healthcare providers – doctors, hospitals, etc. – must recognize that the mission of any healthcare organization is first and foremost health, not profit. When profit alone drives healthcare decisions, the cart is before the horse. And forcing patients into bankruptcy with draconian billing and collection policies profits no one (except maybe collection agencies). Accounts that have little chance of being paid need to be written off quickly and completely.

In hospital systems, some critical services – for example, social work, patient navigation, discharge planning – may have no direct link to the bottom line in terms of a reimbursable, codable procedure or office visit, but nonetheless have a profound impact on preventing financial losses by impacting readmission rates and avoidable costs associated with inability to comply with prescribed courses of treatment. In addition, finding sources of payment for patients can bring dollars in that otherwise would not be seen. These services must not only continue, but be expanded.

Ultimately, legislators need to change the way healthcare services are valued and reimbursed so that the increasingly unmanageable financial burden that falls on everyone – even the insured, hardworking folk – doesn’t bankrupt us all. This isn’t about patient responsibility; it is about preventing personal financial catastrophe. And now it’s January with high deductibles and never-ending copays to meet. I’m afraid we are in for a bumpy ride. Happy New Year!

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.

What I Would Like to See in Healthcare Reform (Part 2)

Last month, I wrote about the bloated, incredibly inefficient federal bureaucracy that eats up hundreds of billions of dollars annually in administrative costs. I mentioned that Obamacare was not, in my opinion, true healthcare reform and did not address these inefficiencies; rather, it simply added people to the rolls of a broken system.

In this column, I am not intending to argue for or against Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”, whatever that might be. I am simply pointing out areas where I see daily a burden for both patients and providers. My dream would be for simplification of much of the process of valuing, coding, and billing for healthcare services. Whether any of these thoughts are achievable or affordable, I don’t know.

Let’s start with that dreaded hospital bill. Medical billing is indecipherable. Even patients with advanced degrees can spend hours trying to interpret the bill they receive for a hospital stay. And that bill is obscenely higher than what either the hospital or the providers are going to get paid. What’s ironic is that bill often has no correlation with the actual cost of the care received or the value that the federal government (or the insurance company) places on that care. We must simplify how we charge for medical care and how hospitals and providers get paid. Unfortunately, the only patients who get stuck with the full, inflated bill are those without insurance – the ones who can least afford to pay it. That is unethical.

The overall cost of care (and your bill) is determined by coding every aspect of care, from the Kleenex and bedpan to the heart valve. For every cancer patient I treat, there are dozens of separate codes submitted for reimbursement covering all different aspects of planning, designing, QA’ing, and delivering treatment. I have no doubt that much of that could be combined into, say, a fixed reimbursement for treating prostate cancer. The problem is, when the government wants to bundle procedures together, they do it to cut overall reimbursement immensely. We still do the work; we deserve to get paid. Why can’t we work out a way to simplify, cut administrative costs, and make it a win-win both for the providers and the payors?

Along the same lines, consider a simple office visit to the doctor. The complexity required to determine whether I get paid a level 2 or level 3 office visit – which reimburse only $25 and $50 – is outrageous. These so-called Evaluation and Management (E&M) codes – and there are many of them – are based on four different possible levels of complexity of three aspects of the patient encounter: history, examination, and medical decision-making. Take history, for example. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Do you see where I am going with this? Documentation of these encounters (consultations, follow up office visits) often takes longer than the encounter itself! And, any "error" in billing is considered fraud and abuse. It is common to hear patients complain that their doctor never looked at them, but was always looking at the computer screen. We need to simplify coding and put physicians back face-to-face with their patients.

Then there is the ever-increasing burden of deductibles and co-pays. We have such a mishmash of healthcare plans, each with their own deductibles and co-pays, that it is virtually impossible to keep it all straight. At the beginning of every year, doctors’ offices and hospitals cringe. Did a patient change insurance plans, or did their insurance lapse? What about the deductible for the new year? What about co-pays? More than half of Americans have less than $1,000 in savings. Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017. Can the majority of Americans afford that? Certainly not! This is an unfair burden both on patients and on providers, who end up providing that care for free. Why? Most of it gets written off, but only after we spend a lot of personnel time and effort proving we try to bill for what we can’t collect in order to avoid the appearance of fraud and abuse. Those patients who are forced to pay may rack up credit card debt, get sent to a collection agency, and/or go bankrupt. Some go without the care they need rather than add to their debt. I truly believe co-pays and deductibles are a vestige of a bygone era. I would like to see the dollars saved by decreasing the administrative burden of healthcare go to actually paying hospitals and providers what they deserve and earn, and do away with co-pays and deductibles. There should be one price for a procedure or encounter, and that cost should be paid 100% by insurance.

What about insurance companies? In the best of circumstances, they pay fairly and quickly. But too often they can and do delay patient care and prevent patients from getting the care they need in a timely manner, if at all. They do this through a process called precertification or prior authorization (read: denial). And sometimes when they do give prior authorization, they still deny payment. This ought to be illegal. But it happens without recourse because the state insurance regulations are written in favor of the insurance companies. We need to loosen the precertification grip on the practice of medicine, and we need to be able to hold insurance companies accountable to their agreements. A preauthorization is a contract to pay.

The two hospitals in Lufkin (Woodland Heights Medical Center and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on electronic health records, not to mention what individual and group physician practices have spent, all mandated by the federal government. To what end? This was supposed to be about “quality”, but that emperor had no clothes. There is precious little improvement in communication between providers and hospitals than before electronic health records. The various doctor’s offices use a number of different vendors, and each hospital uses their own separate vendor. None of them share information with each other. I dream of a truly universal electronic health record language with seamless interconnectivity between offices and hospitals, but I sure don’t want to live through the incredible expense, time and effort it would take to get there. But I do dream.

Finally, let’s talk about rights. I have never felt that free or universal healthcare was a “right”. Hear me out. No one has a "right" to healthcare without some responsibility. That responsibility may be in purchasing insurance, but that is not the only way to contribute. The most glaring, but not the only, example is smoking. Half of long-term smokers will die of a smoking-related illness. If you smoke, the rest of us are burdened with some (or all) of your healthcare costs. On average, a pack of cigarettes in the US costs a smoker $5.51, while the combined medical costs and productivity losses attributable to each pack are approximately $18.05, according to researchers. This is where consumption taxes are attractive, but only if the tax truly goes to help offset the cost of healthcare. How we balance rights and responsibilities in healthcare is a good subject for a doctoral dissertation.

As well all hear about and read about proposed healthcare changes over the next year or two, look for what they are really trying to change, and ask yourself, are they really improving the system, or are they just trying to squeeze more people under a broken umbrella? Can they do both? Let’s hope they try.

History and Medicine in Angelina County

I recently came into possession of Angelina County Medical Society meeting minutes dating back 80 years, from 1936 to 1954. These archives were kept by Dr. W. D. Thames. A walk down medical memory lane with these records is remarkable. Some facts are simply mundane. For example, dues in 1936 were $10.50 per member - $488 in today’s dollar. That makes our current County Medical Society dues of $100 seem like a bargain.

More fascinating to me is that even though the practice of medicine has changed profoundly over the last 80 years, little of the economics and politics of being a physician has changed. For example, charity care issues were documented back in 1937. We struggle with that today. The physician-patient relationship – what today would be assessed by patient satisfaction scores – was the topic of lectures in 1938.

The broad legislative issues on the table today are hardly different than those in 1938 when a Legislative Committee was appointed. Scope of practice issues with optometrists and chiropractors were discussed way back in 1941. In 1953, Dr. Arnett “encouraged members of our society to join the American Association of Physicians and surgeons, which is a political organization of doctors. Its purpose is to stop socialized medicine.” (What would they say now?)

Some issues from the past seem frankly quaint today. In 1952, Dr. Arnett was to appoint a committee to investigate a physician who took out an ad in the Lufkin Daily News, apparently quite the no-no at the time. The next month’s minutes document how that physician “apologized and said it wouldn’t happen again”. The Society even had a secret ballot to vote whether he was guilty or not guilty of advertising. He was acquitted on a 9 to 2 vote.

Admirably, the Angelina County Medical Society minutes also contain notable evidence of community involvement and civic leadership. In January, 1940, the Society was holding joint meetings with city and county officials and the Chamber of Commerce directors to discuss a federal aid program for the building of a county hospital. It was these very discussions that spurred local industry leaders to join together to build a new hospital. The legend we pass down is that in 1941, Arthur Temple, Sr., President of Southern Pine Lumber Company, W.C. Trout, President of Lufkin Foundry & Machine Company, E.L. Kurth, President of Southland Paper Mills, and Col. Cal C. Chambers, President of Texas Foundries, along with ten other businesses and industries, joined resources, refused federal funds, and raised one million dollars to build the non-profit Memorial Hospital (now CHI St. Luke’s Health Memorial). But we have forgotten the groundwork was laid the previous year by the healthcare community, the city and county leaders, and the Chamber of Commerce, all working together. Such cooperation and leadership can still take place today.

Another more poignant event occurred in February, 1954. Then President Dr. Gail Medford “read a letter from the Negro Chamber of Commerce wanting help from the Angelina County Medical Society in their plan to improve sanitary conditions in the colored community. Drs. Taylor and Spivey, City and County health officers, were appointed to work with the colored organization.” We cringe now, thinking about Jim Crow segregation and disparities in neighborhood services and conditions. But do we recognize similar disparities in healthcare today? Are we addressing the needs of the indigent, uninsured and underserved populations among us? Is the medical community as approachable today as it apparently was in the segregated 1950s?

Technology has revolutionized healthcare over the last eighty years. But technology cannot replace the heart. Let us not forget our calling, our oath, and our love for the patient. The practice of medicine should never be just a job. It is a profession.

I invite everyone to the Salute to Healthcare banquet on Thursday, November 10, 2016. Help us recognize and honor those in our community who set the standard in healthcare and who are true to the calling – the profession – of medicine. Call the Chamber at 634-6644 for ticket information.

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.

Doctors Must Reinstill Sense of Duty

This article was originally published at Houston Chronicle http://www.houstonchronicle.com/opinion/outlook/article/Doctors-must-reinstill-sense-of-duty-6733668.php?t=d4a64f80cb&cmpid=email-premium and is reprinted here with permission from the author (me).

I am a physician. Being a doctor defines me. Whether I am seeing patients in my Cancer Center or dining at a restaurant, I am Dr. Roberts. I have expectations of myself in my role of physician, certainly. But the broader community has expectations of me, as well - expectations of competence, compassion and especially availability. Surveys and patient satisfaction scores, however, show that physicians are not meeting those expectations.

I see two broad reasons for this disconnect. One is related to how we practice medicine in the 21st century (in front of a computer rather than in front of our patients). The other has to do with what we see our role to be as physicians.

As a member of my hospital's Performance Improvement Committee, patient safety is our primary concern. Too often, though, we get bogged down in an ever-increasing slough of statistics. Some data we need to track (mortality rates, infection rates, etc.) but other data (such as whether patients think the bathroom is clean enough) are, to put it mildly, distracting.

Chasing data has become the focus of American medicine, and the individual patient has been lost in the process. On top of this is the stress and frustration of working with a bloated and perversely incentivized health-care bureaucracy that views every failure to dot an "i" or cross a "t" as fraud and abuse. Not surprisingly, not only has patient satisfaction declined, but physician satisfaction with the practice of medicine has tanked as well.

It isn't simply about computers and bureaucracy. Since I started practice in 1991, the percentage of physicians in private practice has dropped dramatically. "The New England Journal of Medicine's" CareerCenter website posted that physicians coming out of residency are increasingly gravitating toward contracted rather than private practice positions. Anecdotal reports put the desire to be employed as high as 80 percent. Various reasons are given, including the uncertain direction of health-care reform, declining reimbursement and rising overhead costs. Increasingly, physicians just want to show up at work, practice medicine (without having to deal with administrative and insurance issues), and then go home. They believe that employed positions offer a more predictable work schedule than private practice.

This growing employment model, not just among millennials, coincides with a major shift in attitude among physicians about their role - dare I say duty? - when it comes to patient care. "Becker's Hospital Review," an industry magazine, noted that physicians increasingly expect their affiliated hospitals to provide compensation for on-call coverage, which used to be an expectation of all physicians who had hospital privileges. By 2001, nearly two-thirds of health care organizations provided call pay to at least some physicians.

In our hospital committee meetings, we - the self-selected 10-percenters who are involved in medical staff leadership - bemoan the loss of a sense of citizenship among physicians. We opine on the privilege of being on a medical staff, and that there are responsibilities that come with those staff privileges. Ultimately, we just want our fellow physicians to "do what is right." That simple ethical imperative is the heart and soul of the practice of medicine. Not just doing what is expedient. Certainly not just doing what you hope (or demand) to get paid for.

I fear this is where we are in medicine today. Being a physician is no longer a profession - a calling, a responsibility - it is simply a job. The art and practice of medicine has been reduced to a series of individual transactions, each separately identified in an ever-complex system of billing codes, rather than an ongoing relationship not just between doctor and patient, but between doctor and community.

How can we recover the profession? How do we reinstill a sense of duty? Of moral obligation?

Medical schools have the initial obligation to provide a strong ethical foundation for the practice of medicine. But organizations that provide ongoing training and continuing medical education are responsible as well. The Texas Medical Board requires two ethics and/or professional responsibility CME credits every 24 months as part of a total of 48 credits required.

The Texas Medical Association, which has more than 48,000 physician and medical student members, offers 62 ethics-related CME courses ranging from communication skills and dealing with difficult patients to stress and burnout and HIPAA compliance. However, there is not a single course on basic ethical principles, which have guided the practice of medicine in Western civilization for centuries. Maybe that is because an ethical imperative to "do what is right" presupposes we know (and are willing to agree on) what "right" is.

The United States Conference of Catholic Bishops produced a document - Ethical and Religious Directives for Catholic Health Care Services - which guides all Catholic healthcare institutions, including CHI St. Luke's Health hospitals. Physicians of all faiths would be well served to read and abide by these directives, which first and foremost stem from a sacred view of human dignity. If nothing else, physicians should re-read the Hippocratic Oath, which for centuries has united physicians in a common, patient-centered cause.

Finally, we should look to physician role models around us. The Lufkin/Angelina County Chamber of Commerce hosts an annual Salute to Healthcare banquet where they honor a Healthcare Professional of the Year, Nurse of the Year, Individual of Merit, and a Lifetime Achievement Award winner. In November, I had the honor again of emceeing the event. As I announced the Lifetime Achievement award recipient, I emphasized the award is not just about showing up at work for 40 years and then retiring. That's just doing your job. What we honor each year is the extra - the above and beyond - that exemplifies a career marked by service not just to patients but to society. I hope that by honoring those who set a great example of leadership, compassion, and generosity over and above medical skill, younger physicians will be inspired to follow these examples of care beyond the dollar.

I challenge my physician colleagues, young and old alike, to "do what is right" by all patients. This is your profession, if you will still claim it.

Doctors Are From Another Planet

Jupiter and Venus aligned recently in what was called a Bethlehem Star event. The next time the two planets appear this close together will be in 2023. The rarity of planetary conversions reminded me of the 1993 bestseller from PhD counselor Dr. John Gray, titled Men Are from Mars, Women Are from Venus. If you haven’t read it, apparently there are more than 50 million copies floating around.

The basic premise of the book is that men and women are naturally different in the way they think and communicate. We all know that an underlying lack of communication in a relationship keeps that relationship from maturing or even kills it. The success of the book is rooted in the knowledge it imparts (in very humorous ways) about how our spouses think and, therefore, how we need to relate to one another.

Communication among doctors is equally important, but what may die in this physician-physician communication desert is you, the patient.

Everyone knows the phrase from the 1967 Paul Newman movie, Cool Hand Luke, “What we have here is a failure to communicate.” A scholarly article in the Journal of the American Medical Association in 2007 noted that direct communication between inpatient physicians and primary care physicians happened in less than 1 in 5 hospitalizations. It is just as bad inside our hospitals.

Physicians are notorious for expecting others to communicate for them. Part of that is time crunch, but mostly it is laziness. It is easier to write an order for a nurse to contact another physician to see a patient rather than to make the call yourself. Although, with cumbersome electronic medical records and CPOE – computerized physician order entry – it is getting easier again just to pick up the phone and call.

Consulting physicians are busy, too, and getting one on the phone can be a challenge. But if I am asking another physician see my patient, I’m the one who knows best why I am making that request and what I want from that consultant. I shouldn’t delegate critical communication to others. That gets back to one of my golden rules: take the time and do what’s right.

What’s more, patients are demanding better communication among their healthcare team, and rating hospitals and physicians on whether or not they measure up. A 2011 National Academy of Medicine discussion paper noted, “Consistent and effective communication between patient and clinician has been associated in studies not only with improved patient satisfaction and safety, but also ultimately with better health outcomes, and often with lower costs.” In addition, “Breakdowns of communication, or disregard for patient understanding, context, and preferences, have been cited as contributors to health care disparities and other counterproductive variations in health care utilization rates.” In other words, when we don’t communicate, extra tests may get done and patients can get hurt.

However, communication is a two way street. You, the patient, need to know at a minimum your own medical and surgical history, what medications you are taking (and what doses), and what you are allergic to. Medical records are not perfect, and as with any electronic media, if garbage goes in, garbage comes out. If you don’t give your physician or the hospital accurate and complete information, that’s just garbage in. Can’t remember everything? Write it all down and bring in a copy.

Communication is a skill, and skill development requires practice. Yes, some physicians (and patients) need more practice than others. Let’s work together to align our communication stars and usher in a new era of patient safety, better outcomes, lower costs, and greater satisfaction.

Doing the Right Thing, One Day at a Time

As I write this column, it is Saturday morning of Memorial Day weekend. I have been at my office several hours working on patient charts and mapping out cancer treatment plans. This type of work cannot be done in the midst of a busy clinic day. Once I am done today, my radiation physicist will compute these patient plans. Then I will come back out later today or tomorrow to review and approve them so treatment can start next week.

Such is a typical Saturday morning for me. This is the tedious, mental work that requires me to be alert, focused, and very careful. Modern radiation treatment is highly precise, and the treatment is only as good as the planning process. If I don’t accurately target the cancer, it doesn’t get treated. And if I don’t carefully protect surrounding normal tissues, side effects can be worse. All of this takes dedicated, uninterrupted time. So, I am here at my office this lovely Saturday morning because, well, it is the right thing to do.

What does it mean to “do the right thing”?

A number of guiding principles come to mind. For me, the most important one is to take my time. Doing the tedious work on a Saturday morning or weekday evening. Spending adequate time with my patients. When I rush or get careless, I make mistakes. And by the way, we should acknowledge our mistakes and learn from them.

A second principle is: don’t do either more or less than required. Medically speaking. What I mean is physicians shouldn’t do procedures that are unnecessary just to pad their pocketbook. The flip side is also true: physicians should provide needed care even if they do not expect to be paid for it. Yes, there are times when this is not possible, but the concept and practice of providing charity care is part of who we are and what we profess to be as physicians.

Third, don’t be afraid to ask for help. I can provide most radiation-related cancer treatment in Lufkin, Texas, thanks to the fantastic equipment and personnel at CHI St. Luke’s Health Memorial. But there are rare or unusual cases where I don’t mind asking colleagues for assistance. It’s OK to pick up the phone and call my Houston colleagues if needed. In a similar vein, I tell my patients that I am not offended if they decide to seek treatment elsewhere. Patients need to be comfortable getting their care from me, and almost all are. Some physicians get all bent out of shape and act offended when someone wants to go elsewhere for care. They need to get over it and realize it is not about them. We are to serve our patients, not the other way around.

Fourth, treat everyone the same. What I mean by that is, each person has value, and that value is not based on their insurance plan. We shouldn’t let money dominate our decision-making.

Reimbursement for one’s work is important, but physician compensation comes with an obligation that an ever growing, younger crop of physicians seems unwilling to meet. We “old school” physicians often lament that younger doctors don’t view medicine as a profession. New medical school graduates view medicine as a job, with an employee, get-in-and-get-out, do-the-minimum mentality. Yet, they expect high salaries off the bat. What a shame! Sometimes the best payment is the heartfelt gratitude of a needy patient.

Each of us should strive to do the right thing, one day at a time, no matter what our profession or job.

Recognizing Stages of Grief

My father recently passed away from pancreatic cancer at age 81. What a devastating disease! He lasted a mere two months. Thanks to attentive physicians and great hospice care, he was comfortable and at peace when he died.

For my mom, who was married to my father for nearly 60 years, grieving will be a process. In the medical field, we are taught to think about grief in five stages first described by Elisabeth Kübler-Ross in 1969: denial, anger, bargaining, depression, and acceptance. Watching my mom walk through my father’s diagnosis and death, I caught glimpses of many of these stages in her emotions and responses. It is important to note that these stages were never meant to be all-inclusive or rigidly ordered. Depending on circumstances, certain stages may be more prominent than others, or not experienced at all.

Denial is indeed often the initial response to hearing that you have (or a loved one has) a terminal disease. We just can’t believe it is happening, especially when the one with the diagnosis looks so well on the outside or doesn’t feel that bad. Unfortunately, denial can result in poor judgment. Luckily for my parents, any flashes of denial were tempered by solid medical advice and faith in their doctors.

Anger is one of those ugly emotions that can pop up at any time. But, it is one that is not difficult to understand. I typically see anger as a reaction because of dreams that will go unfulfilled. My mom was humorously a little miffed that my father didn’t make it to their 60^th anniversary in April. But anyone familiar with my mother knows she is too strong a Christian to be truly angry. Significant, unresolved anger can signal deeper emotional or spiritual needs that can affect everything from pain management to dying a peaceful death.

Bargaining is the most interesting stage to me. There is a deep desire in us to bargain as Faust did with the devil for something unattainable… in this case, a cure. Sometimes we bargain with God: “If only you would spare him, I promise I would do anything!” In the terminal cancer arena, this bargaining often takes the guise of a search for alternative, unproven “snake oil” treatments. (Mexico, anyone?) To my parents’ credit, they did not pursue futile, expensive elixirs or elusive cures.

Depression and acceptance tend to wrestle with one another, with melancholy eventually fading and acceptance gaining the upper hand. At least that is what we expect with typical grief.

My mother is a strong, confident woman. She held her head high at my father’s funeral and presided over the reception and luncheon with poise and grace. She so appreciated having her sons and relatives with her! I feared she might not do well by herself after everyone left, but she firmly informed me that she needed some time alone to grieve. For her, that was the right decision. She will cry; she will remember. But she will go on, I have no doubt.

Grief shouldn’t be buried. Tears are OK, even desired. However, debilitating, ongoing depression is not healthy. A minority of people experience a complicated grief that requires significant emotional, psychosocial, even medical support. Hospices are obligated to offer bereavement services for families of patients. What most don’t know is that you don’t have to have lost someone on hospice to join a hospice bereavement group! If you are grieving a recent loss and want to talk to someone or participate in a support group, contact your local hospice for help. You don’t have to grieve alone.

Tips for Success in Any Office Environment

My wife, Catherine, starting working for St. Cyprian's Episcopal Church as Parish Administrator about four and a half years ago. We were close to empty nesting at the time, and she felt she wanted to get back in the workforce in a meaningful, purposeful way. St. Cyprian's has been a blessing for her, and she for them.

Catherine was recently asked to provide her job description for other churches in the diocese. She wisely commented that the key to being a successful admin is understanding that your calling is to make someone else successful. A well-written job description is a great starting place, but a smart admin thinks beyond the dry description. What follows are her guiding principles, in her own words:

Smile. Every parishioner deserves to be welcomed into the office with a cheerful attitude. Not because they pay your wage, or you might need them to do something for you, or simply because you regard them as a friend beyond the walls of the church, but because this is God’s house and we are a very small reflection of Him and the joy He has in His people.

Menial Work. Every job has tasks that seem menial. When I’m feeling a little weighted down by such chores, I remember that Martin Luther once said that a dairy maid could milk cows to the glory of God. So I milk the cows and am surprised by how the more enjoyable aspects of my job pop up unexpectedly in the middle of the humdrum.

Don’t bring troubles to work. Don’t come to work thinking that you are coming to therapy or your own counseling session. Yes, be open and honest with your co-workers, but remember how much emotional baggage they are expected to carry for others already.

Wear multiple hats. Learn how to compartmentalize within your work relationships. That sounds bad, but think about the different roles that are necessary to function smoothly in an office. With my former rector, I would put on my Employee/Employer hat to discuss things like salary or vacation or working conditions. The Friendship hat I wore outside the office when I would invite him and his wife to events or would socialize with them away from the office. The Big Sister hat was worn when I needed to try and teach him something about parenting or life (I am 15 years older).

Listen closely. As you gain trust and credibility, people will begin to solicit your opinion. Note that sometimes they are simply practicing or working out their own thoughts and ideas by talking them through. You can be a valuable asset by listening closely, reflecting back what they have said, and helping them think through the implications of what they are discussing. Sometimes you will be able to contribute an original idea, but what the ministerial staff really need is a safe ear to listen. The freedom to think out loud in confidence is a gift you can give them. Most of them are very verbal people who talk things out and sometimes don’t want to just talk to themselves.

Finally, try to say yes more than you say no. This job is full of the humdrum, the interesting, and the surprising. Be flexible and enthusiastic. It is a valuable ministry. Every day I am blessed to further God’s kingdom in some small manner by helping his shepherds and their sheep to follow him better.

What Catherine has written is great advice for all of us, regardless of our position or job or ministry. Thanks, Catherine!

Being There for Those Who Suffer

Two articles appeared recently in major newspapers discussing how we can be more helpful to those who are suffering. The New York Times article by David Brooks (The Art of Presence) looks at helping those who are experiencing tragedy, while The Wall Street Journal column by Elizabeth Bernstein (To Be a Friend In a Time of Need, Talk Less, Listen More) specifically addresses helping those with depression. The lessons of each apply equally well to anyone who is grieving or suffering. To me, Brooks sums up our mission with one word: presence.

What does presence look like? Better yet, what does presence sound like?

First and foremost, silence. That means shut up. When I am sick or grieving, I don't want or need your advice unless I ask for it. Don't tell me I should go see XYZ doctor just because you or your Aunt Melba did. I can make my own decisions, thank you very much. But do let me vent sometimes, without thinking you have to fix it for me. Just be there for me; that is comfort. The Latin root of comfort means to come along side with strength. The Holy Spirit is also called the Comforter. Isn't that a beautiful image?

As friends, we don't feel very strong, though, so we try to overcompensate. Why do we always feel we have to solve someone's problems, rather than quietly comforting? Bernstein notes how we can comfort others with our notes and cards. Brooks agrees it is often simple non-verbal expressions like bringing soup that mean so much. Both emphasize: listen.

When I was in college, one of my best friends was very ill in the hospital from juvenile rheumatoid arthritis. She nearly died. She was a baby Christian, and I tried to "be there" for her. Unfortunately, there were others who told her that her faith was not strong enough or she wouldn't be sick. Not only is that terrible theology - Job, anyone? - it is devastating psychology.

Often, what presence boils down to is time. I remember conversation I had recently where I delivered some devastating news to a patient and her caregiver. It was near the end of a long day, and it would have been so easy to say some platitudes and "give hope" when what was really needed was simple truth delivered with compassion and grace. When the visit was over, the caregiver followed me out into the hall and said, "I know you are busy..." That's when I stopped in my tracks, paused, and replied, "You are the most important thing right now."

She asked some particular questions that made me realize we needed to have a much deeper conversation, and that the "truth" I delivered needed a little more "presence". So, we went back into the room and had the unrushed conversation we should have had all along. We talked much more about prognosis, treatment options, and whether or not to continue with plans to see another specialist and get more tests done.

Ultimately, I recommended hospice care - end of life care focused on comfort rather than prolongation of life. I wasn't sure if the patient would agree. But this lovely woman – who couldn't speak from a prior stroke, but who could understand fully the intricacies of the conversation – looked at me and gave me the most peaceful smile I have ever seen, along with her faltering, "Yes."

At the end of a busy day, that smile meant the world to me. The gift of presence, returned with a smile.

Memorial and Catholic Health Initiatives

In my January column, I wrote that we have an ongoing obligation to provide non-profit care locally so that Memorial’s mission of compassion, established in 1949 by our community forefathers, can continue. I am thrilled that Memorial has strengthened its ability to deliver on that mission by becoming part of Catholic Health Initiatives (CHI), effective June 1. CHI operates 89 hospitals in 18 states, with more on the way.

Much has been written about the transfer of ownership already, so I thought I’d comment on what this transaction is not:

It is not a takeover of physician practice. CHI has committed to preserve existing physician relationships in the community and build new ones. CHI’s relationship model with physicians is very much dependent on the region of the country they are in. Ultimately, improved coordination of care and better patient outcomes have to happen. Quality, efficient care is the focus, not whether or not physicians are independent or employed.

It is not a transfer of care to Houston. In fact, CHI wants to see Memorial become an even stronger hub for healthcare in the region. Of course, we will have increased access to highly sophisticated care through closer ties to CHI St. Luke’s Health in Houston and its affiliations with Baylor College of Medicine and Texas Heart® Institute. That will only strengthen our position in the region and improve the quality of care we deliver locally so that even more health care can remain local. Over the next two to three years, it is CHI’s intent that Memorial will become a part of CHI St. Luke’s Health. In my own area of cancer care, this can only enhance my options for my patients, including improved access to clinical trials.

It is not a drain of money from the local economy. The fact is, Memorial’s board recognized that the landscape of healthcare had so fundamentally changed that maintaining mission in a fiscally responsible way was becoming increasingly challenging without the resources and expertise of a well-capitalized, national partner. Over the next 5 years, CHI will invest more than $1 billion to expand and enhance the southeast Texas region’s health care infrastructure. Memorial, for its part, is guaranteed to see significant capital improvements over the next 6 years.

It is not a change of mission. Having read the Ethical and Religious Directives for Catholic Health Care Services – the guiding document for ethical behavior in health care for Catholic institutions – I can tell you that CHI’s mission and Memorial’s mission mesh beautifully. Both Memorial and CHI share a commitment to putting the health of the people and communities we serve at the center of everything we do. CHI intends to maintain the core health care services and charity care currently provided by Memorial in the East Texas community, which will continue to be overseen by a local board of community and physician leaders. I have the privilege of serving on that board, and I can state with confidence that Memorial’s strong commitment to charity care will continue.

It is not an end of an era. In 1949, our community forefathers got together to establish Memorial Hospital to take care of the people here in deep East Texas. They were compassionate, innovative, and forward-thinking. Their descendants – some in name and all in spirit – have led this health system to maintain that mission for sixty five years. Today, with no less compassion and thought for the future, we have taken a bold step to preserve and advance non-profit care for our region. Here’s to the next 65 years!

The Profession of Medicine

Physicians today rarely encourage students to consider becoming a doctor. There are quicker ways to start earning a good living. (Petroleum Engineering and Investment Banking come to mind.) But beyond the financial aspect, being a doctor just isn’t the same as it once was. Increasingly, patients don’t trust doctors, much less respect them or care whether or not they are happy.

A recent online Daily Beast article suggests the public should have more empathy for doctors. The author notes that 300 physicians will commit suicide this year, making it #2 on the list of the 19 jobs where you are most likely to kill yourself, according to Business Insider.

Why? She believes well-intentioned people working to solve the healthcare crisis have come up with answers that are “driving up costs and driving out doctors.” A simple example: “Just processing the insurance forms costs $58 for every patient encounter.” She also quotes noted writer Malcolm Gladwell, “You don’t train someone for all of those years in [medicine]… and then have them run a claims processing operation for insurance companies.”

Insurance claims, bureaucratic red tape, “quality” metrics (that are often more about trying to successfully report than actual quality) – all of these take away from face time with patients and chip away at the joy of what is increasingly becoming an unrewarding profession, not only monetarily, but emotionally.

In other words, practicing medicine has become a demeaning, demoralizing, punitive, bureaucratic nightmare for many physicians.

Don’t get me wrong. Most physicians make a good (or even great) living. I do, and I am not ashamed of it. As an honor graduate from Rice University with a medical degree from Baylor College of Medicine, followed by an additional four year residency, I am proud of my training and feel I have worked hard to get where I am. But with position comes responsibility.

Unfortunately, physicians have, for decades now, not paid attention to the cost of prescribing the latest and greatest drug when an older, cheaper generic is just as effective. Likewise, we put expensive imaging and treatment equipment in our offices and refused to acknowledge that there may be a conflict of interest, when studies show we order more tests and do more procedures as a result.

On top of that, I fear there is a growing contingency of younger physicians who see the practice of medicine as a job only, with a corresponding (and alarming) callousness toward the poor and uninsured.

There is hope. We have many physicians in Lufkin who have earned our respect, and I am honored to call them colleagues. Since 2008, Drs. Ravinder Bachireddy, George Fidone, and Kay Carter (and Mrs. Demetress Harrell) have each been recognized as Healthcare Professional of the Year at the Lufkin/Angelina County Chamber of Commerce Salute to Healthcare banquet. The Chamber has also honored Drs. WD Thames, Anna Beth Connell, George Thannisch, Dan Spivey, and Jacob Thomas with Lifetime Achievement Awards. Young physicians, who may not have gone into medicine for the “right’ reasons – indeed, all of us – would do well to follow their example.

Emily Shelton, the wife of my long-time partner, Dr. Bill Shelton, gave me sage, simple advice when I first moved to Lufkin in 1992: “Just do what’s right.” A sense of duty, compassion for the poor, cooperation with the healthcare team, communication with patients and families, collegiality with fellow physicians, and, of course, excellence of care are hallmarks of a great physician. That’s what being a doctor is all about. It can still be a rewarding, respected profession if we “just do what’s right.”