Editorial
by David Stevens, M.D., M.A. (Ethics) – CMDA Executive Director
Tribute—to a Pioneer Once when I asked Dr. Paul W. Brand to speak at a future conference, he replied, “Dave, I might not be alive by then.” “If you aren’t,” I responded, “we will get someone else to speak and you will be enjoying heaven and staying busy intervening before the throne of God for each one of us.” Paul’s new joy and task began when he died on Tuesday, July 8, 2003 of complications from a blood clot in the brain. He was 88. We—millions of us, worldwide—will miss him. For such a person as Paul crosses our paths once in a lifetime, if we’re that blessed. Dr. Brand’s Associated Press obituary, which appeared in the New York Times and other newspapers, chronicled his extraordinary medical career as a physician, scientist and researcher. It mentioned his awards as well as his book Clinical Mechanics of the Hand, a standard reference in orthopedics. But the authors left out the most significant things about Paul Brand. He loved unreservedly. He was like Christ to the beggars on the streets of Calcutta and to the leprosy patients he invited into his home. He treated beggars and patients, friends and strangers as if they were the Queen of England—who gave him the Order of the British Empire in 1961. In return for this attitude of genuine charity, this gentle man wasn’t just respected, he was loved and adored by people of all ages, professions and creeds. They flocked to him like the crowds who surrounded the Great Physician, anxious to have their hearts touched and their bodies healed. The Times obituary mentioned that in 1966, Drs. Paul and Margaret Brand were invited by the U.S. Public Health Service to work at the National Leprosarium in Carville, Louisiana. Dr. Paul Brand became chief of rehabilitation at that facility, and for more than 20 years conducted research and taught surgery and orthopedics at the Medical College at Louisiana State University. On the other hand, the Times didn’t mention Dr. Paul’s “religious” books, like Fearfully and Wonderfully Paul W. Brand, M.D. Made, which formed my
thinking about God and His creation. When I read the story of Paul and Margaret’s life, I wanted to grow up and be a doctor just like them. They were my role models, pioneers who showed me the path of faithful service to Christ. Dr. Brand amazed me with his genuine humility. I asked him a few years ago to be a plenary speaker at a national medical mission conference in Louisville. He said, “I’m not as articulate as I used to be, due to a small stroke. Sometimes now I have to write out what I am going to say.” “On your worst day,” I assured him, “you communicate better than the rest of us do on our best one.” His insights and genuineness broke through all barriers during that conference, as was consistently the case wherever he agreed to speak. Dr. Paul Brand, most of all, was a missionary in the true meaning of the word. Born to missionary parents in India, from an early age there was no doubt that he had a “mission” in life. That mission was to introduce, through whatever methods and means might be available, as many people as possible to the Lord Jesus Christ. All his activities, awards and achievements (to which we will return in a special cover story in the winter issue of Today’s Christian Doctor), from the development of innovative surgical techniques to publishing important literary works to lecturing around the world to taking time to mentor a medical student in person, or at a distance, as in my own case . . . all that Paul W. Brand did, indeed the way he lived his life, was but a means to this end. Yes, he was recognized and honored here—and rightly so. But I can only imagine the welcome he received at heaven’s gate, not only from that great cloud of witnesses which he has now joined, but from the Lord, Himself, who must have said: “Well done, good and faithful servant.” Dr. Brand modeled Christ to all of us. He was a living example of what it is to be totally sold out to God and to serve Him through our profession. Yes, along with Margaret and the family, we do and will miss him. Let’s remember to pray for them during these days of adjustment. But isn’t it good to know that the God who molded Paul W. Brand wants to mold us likewise for His own good will and purposes? ✝
Internet Web site:
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CONTENTS
V OLUME X X X I V , N O.3
( O u r 5 3 r d Ye a r )
Fall 2003
The Christian Medical & Dental Associations ––changing hearts in healthcare—since 1931. SM
Today’s Christian Doctor welcomes articles related to the interface of medicine/dentistry and faith. Submit query letter by mail or e-mail, Attn. TCD-Editor, to the addresses below. Not all proposed articles fall within the purview of this magazine, as determined by the editor and publisher, in conjunction with the editorial committee.
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Features
10 Count the Cost 15 From Failure to Faith 19 The Fiery Furnace 23 A Thin Red Line 28
Photos for cover and “True Confessions” article are by Mike Andaloro
True Confessions
Issues, answers . . . and some continuing struggles common to women in medicine and dentistry. by Elisa Ghezzi, D.D.S., M.S.
White House appointments immersed this doctor in unexpected controversy. by W. David Hager, M.D.
Sometimes “success” leads to “failure,” and vice versa. by William J. Geiger, M.D.
(Residents’ Corner)
A dying patient showed this intern how to really live. by Pierre Arty, M.D.
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(The View from Here)
If infanticide is repugnant, can abortion be acceptable, since they are morally equivalent? by Alva B. Weir III, M.D., and David B. Biebel, D.Min.
Departments & Series 3 Tribute—To a Pioneer Paul W. Brand, M.D. (1914-2003)
5 Progress Notes (formerly “News and Views”)
31 Advertising Section TODAY’S CHRISTIAN DOCTOR®, registered with the U.S. Patent and Trademark Office. ISSN 0009-546X, Fall 2003, Volume XXXIV, No. 3. Printed in the United States of America. Published four times each year by the Christian Medical & Dental Associations at 2604 Highway 421, Bristol, TN 37620. Copyright © 2003, Christian Medical & Dental Associations . All Rights Reserved. Distributed free to CMDA members. Non-member doctors may receive a complimentary six-month membership upon request or by referral by a patient or other healthcare professional. Non-doctors (U.S.) are welcome to subscribe at a rate of $35 per year ($40 per year, international). Standard presort postage paid at Bristol, Tenn. Postmaster: Send address changes to Christian Medical & Dental Associations, P.O. Box 7500, Bristol, TN 37621-7500. Editor: David B. Biebel, D. Min. Editorial Committee: Gregg Albers, M.D., Ruth Bolton, M.D., Elizabeth Buchinski, M.D., John Crouch, M.D., William C. Forbes, D.D.S., Curtis E. Harris, M.D., J.D., Warren S. Heffron, M.D., Rebecca Klint, M.D., Samuel E. Molind, D.M.D., Robert D. Orr, M.D., Matthew L. Rice, Th.M., D.O., Richard A. Swenson, M.D. Director of Communications: Margie Shealy. Classified Ad Sales: Patti Kowalchuk (423) 844-1000. Display Ad Sales: Patti Kowalchuk (423) 844-1000. Design & Pre-press: B&B Printing. CMDA is a member of the Evangelical Council for Financial Accountability (ECFA). SM
SM
Articles and letters published represent the opinions of the authors and do not necessarily reflect the official policy of the Christian Medical & Dental Associations. Acceptance of paid advertising from any source does not necessarily imply the endorsement of a particular program, product or service by CMDA. Any technical information, advice or instruction provided in this publication is for the benefit of our readers, without any guarantee with respect to results they may experience with regard to the same. Implementation of the same is the decision of the reader and at his or her own risk. CMDA cannot be responsible for any untoward results experienced as a result of following or attempting to follow said information, advice or instruction. Scripture references marked (NASB) are taken from the New American Standard Bible. Copyright © 1960, 1962, 1963, 1968, 1971, 1972, 1973, 1975, 1977 by the Lockman Foundation. Used by permission. Scripture references marked (KJV) are taken from King James Version. Undesignated biblical references are from the Holy Bible, New International Version ®. Copyright © 1973, 1978, 1984 by the International Bible Society. Used by permission. All rights reserved. For membership information, or to request your free six-month membership, contact the Christian Medical & Dental Associations at: P.O. Box 7500, Bristol, TN 37621-7500; telephone: (423) 844-1000 or toll-free, (888) 231-2637; fax: (423) 844-1005; e-mail: main@cmdahome.org; Web site: http://www.cmdahome.org.
New News Format To provide the latest news and information from CMDA, two new resources have been developed which will supplement “Progress Notes” (this section of TCD). The result will be more efficient and timely delivery of news, plus considerable savings annually in printing expense. Each issue of the magazine will include brief notices in relation to which more comprehensive information will be available on our new Web site (sample page at right). In addition, on a bi-monthly basis, a “Progress Notes” e-mail newsletter will be sent to all members with e-
mail accounts. This newsletter will link members to up-to-date information, including “members in the news,” conferences, mission trips, community based ministries, dental news, Washington Bureau, obituaries, memorials and honoraria, Emma’s book reviews, and more. These new resources will be available by going to http://www.cmdahome.org and clicking on “Publications” and “Progress Notes.”
Ruth A. Bolton, M.D. is new President-Elect Ruth A. Bolton, M.D., of Wayzata, Minnesota will take office as President of CMDA in 2005. Dr. Bolton has been involved with the organization since she was a student at Mayo Medical School in Rochester, Minn. She has practiced family medicine for over 20 years. She was an elder in her church for many years, was the president of the board of a Crisis Pregnancy Center, as well as Chief of the Family Practice Section at her hospital. She has been a CMDA Trustee since 1995. Ruth Bolton, M.D.
Did you know? Community Based Ministries received a $50,000 grant for the purpose of exposing every freshman medical and dental student to the gospel. Go to www.cmdahome.org, click the link to the student section. Global Health Services is our newest ministry promoting AIDS outreach through member hospitals and their associated churches in Ethiopia, Kenya & Tanzania. Professionally qualified volunteers needed. Go to www.cmdahome.org, click “Missions.” CMDA announced Phase II of the Capital Campaign at the National Convention. For info, visit: www.cmdahome.org, “Giving.” CMDA received $150,000 matching grant to strengthen the voice of Christian doctors. For information on both of the above visit: www.cmdahome.org, “Giving.” A new consult service for missionaries is available. Find out how you can participate as a missionary or as a consultant at www.cmdahome.org, click on “Missions.” Free Chinese evangelism materials are available. Call Alicia: 888-231-2637. Quantities limited.
Internet Web site:
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CMDA Honors Key Members During the national conference each year, CMDA honors select members (and spouses, as appropriate) for their special contributions in a variety of fields. This year’s recipients, shown at right, in most cases with outgoing president Dr. Alva B. Weir III (and at the bottom with Dr. Warren Heffron, current president) were: Missionary of the Year—Rebekah Naylor, M.D.; Servants of Christ—Dr. Harold and Bonnie Jo Adolph; President’s Heritage Award, W. David Hager, M.D.; Educators of the Year—Richard Swenson, M.D., and Linda Swenson. Texts of the citations read in each case may be accessed at: http://www.cmdahome.org.
News from Medical Education International Upcoming Team Opportunities* December 26-January 9, 2004: A team will be traveling to Christian Medical College in Vellore, India to participate in a teaching program. There are specific requests for those working in Ophthalmology, Cardiothoracic Surgery, Family Medicine, Emergency Medicine, and Liver Transplantation. February 2004: A team will be traveling to Kenya for the purpose of putting on courses in ACLS, ATLS and BLS for the Kenyan physicians. We are interested in physicians who are certified to teach within any of these areas. We will also be presenting the “Saline Solution” to members of the Christian Medical Fellowship of Kenya. February 2004: A team will be traveling to Nigeria to put on a conference covering the diagnosis and treatment of congenital heart disease as well as demonstrations of basic pediatric cardiovascular procedures to the Nigerian surgeons. There is a need for all pediatric cardiovascular specialists including those within pediatric cardiovascular surgery. April 10-24, 2004: A team will be traveling to Mongolia for the purpose of teaching at the various specialty hospitals in Ulaanbaatar. There is a need for all specialists, especially those working within the field of trauma.
Missionary of the Year Award Rebekah Naylor, M.D.
Servant of Christ Award Dr. Harold and Bonnie Jo Adolph
Contact: Jeffrey J. Barrows, D.O.; Administrative Director, MEI; 7334 C.R. #10; Zanesfield, OH 43360—(937) 599-3050; e-mail: jeffreybarrows@yahoo.com. *See the Web site: http://www.cmdahome.org for an expanded calendar and more information.
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President's Heritage Award David Hager, M.D.
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2003 Educator of the Year Award—Richard Swenson, M.D., and Linda Swenson
Washington Bureau Update The Christian Medical Association has been providing the White House and the Department of Health and Human Services (HHS) with CV's of qualified CMA members interested in servShari Falkenheimer, M.D. ing on federal commissions or in fulltime positions. Listed at right is a summary of recent appointments: President Bush has nominated CMA member Shari Falkenheimer, M.D., M.P.H. for the Board of Regents of Uniformed Services University of the Health Sciences, the governing board of the military medical school in Bethesda, Maryland. This position requires Senate confirmation this fall. HHS Secretary Tommy Thompson also recently named Dr. Falkenheimer to the HHS Advisory Committee to the Director, National Center for Environmental Health, Centers for Disease Control and Prevention. CMA member David Hager, M.D. has been appointed to the Centers for SM
Disease Control (CDC) Substance Abuse and Mental Health Services Administration Commission and the Health and Human Services Women's Advisory Committee (see his story, pages 15-18, this issue of TCD).
Contact information: CMA—Washington Bureau Phone: (703) 503-1158 Fax: (703) 503-7121 P. O. Box 1016 * Springfield, VA 22151 http://www.cmawashington.org
Kristin Crosby, M.D.
HHS Advisory Committee on Regulatory Reform
Shari Falkenheimer, M.D.
Board of Regents, Uniformed Services, Univ. Health Sciences
W. David Hager, M.D.
FDA Advisory Committee on Reproductive Health Drugs in Women; CDC Substance Abuse and Mental Health Services Administration
Warren S. Heffron, M.D. HHS Advisory Committee for Primary Care Education Chris Hook, M.D.
HHS Secretary's Advisory Committee on Genetics, Health, and Society
Nancy Jones, Ph.D.
HHS Secretary's Advisory Committee on Human Research Protection
Joe McIlhaney, M.D.
Presidential Advisory Council on HIV/AIDS
Craig Whiting, D.O.
Advisory Committee on Training in Primary Care Medicine and Dentistry
Jean Wright, M.D.
National Advisory Panel on the Child and Terrorism
PayMaxx Supports CMDA PowerPayroll is a secure, Internet-based payroll and tax filing solution. Ideal for businesses with 100 or less employees, PowerPayroll is convenient and simple to use. If you entrust your payroll to PayMaxx, not only will you alleviate the stress of payroll management, you’ll also be contributing to the CMDA ministry fund, as PayMaxx will provide CMDA with a percentage of revenue generated from payroll services supplied to CMDA members. Proceeds from this program will go first to benefit missions to underdeveloped countries and then toward the annual budget, which supports Community Based Ministries, the Washington Bureau, policy and media to be the voice of Christian doctors, as well as other ministries. For more information, call 1-877-7296299, and say you are a CMDA member.
Internet Web site:
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President’s Letter Several years ago, I was president of the American Board of Family Practice. One of our CMDA members was taking the recertification exam and was frustrated by a question to which he knew the answer, but he could not make a choice from the options. He had studied this particular aspect of medicine just the night before and was upset with himself for not being able to remember the specific answer. He thought that a walk for a few moments might clear his mind, so he went to the restroom. On his way back from the restroom, just on an impulse, he walked around the corner to his nearby room, quickly looked up the answer, then returned to the exam and wrote the appropriate response in the answer book. Over the ensuing few weeks, this doctor realized that what he had done was wrong. As a Christian and a member of CMDA, he felt that by cheating on that one question he had broken his Christian commitment. After wrestling with the issue, he wrote to the Board, confessed what he had done and told the Board that as a Christian he simply could not live with what he had done and asked them to judge him and make a determination if this was an important aspect of his passage of the exam. The Board reviewed his examination, which he had passed easily, and to them it was clear that this one
question made no impact upon his eligibility for certification as a family physician. Yet as a Christian physician he felt this ethical violation was perhaps more important than the many questions he had answered correctly, which lifted him above the passing bar. He asked that his ethics be included in determining the pass/fail outcome of his exam. After a lengthy discussion, the Board felt that based on his ethical values and moral standards that what he had done was inappropriate and that he should be required to take the exam again the next year. He took the exam the next year. Once again, he passed. I was very impressed with the attitude of this physician who said, “I am a Christian. I am a member of CMDA. I wish to be held to a different standard than those who might cheat merely to pass an exam.” He was willing to submit himself to the additional study, costs and time of taking the exam two years in a row. That man had a tremendous Christian witness to me, and I am sure to several other members of the Board. In effect, he said: “I, as a Christian, behave differently. I, as a Christian, must make restitution when I make a mistake or when I commit an error. When I commit a sin, let me seek forgiveness, start over and then I can be board certified in a real meaningful fashion according to my Christian beliefs.” This is the quality of physician that makes up our membership—Christians who happen to be doctors.
—Warren S. Heffron, M.D.
Global Health Outreach Calendar* November 15 – 30 December 6 – 14 January 10 – 17, 2004 January 10 – 24 February 5 – 21 February 13 – 22 February 14 – 28 March 12 – 21 April 24 – May 2
Aparri, Philippines Taulabe, Honduras Valladolid, Mexico Addis, Ethiopia Ghana Suriname El Sembrador, Honduras Hanoi, Vietnam Cartagena, Colombia (PFI)
GS, PM&D, Ph, N PM&D, Ph, N Orthopedic Surgeons and OR Nurses PM&D, Ph, N PM&D, Ph, N PM&D, Ph, N PM&D, Ph, N Dental Specialists Needed PM&D, Ph, N
Codes: GS-Gen. Surg.; PM&D-Primary Medical & Dentistry; Ph-Pharmacy; N-Nurses *See the GHO section of the Web site: http://www.cmdahome.org for an expanded calendar and more information.
NOTE: The CMDA General Calendar, which includes regional and National Conferences, Seasonal Conferences, Conferences for Singles and Students, Specialty Conferences (Domestic Missions, Evangelism, Student Leadership, Women in Medicine & Dentistry, etc.), Dental Activities and marriage Enrichment Weekends can be accessed via the CMDA Web site at: http://www.cmdahome.org.
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Speaking from the heart, this doctor identifies key issues she has faced (and some that continue), offering insights, biblically-based wisdom and practical advice for colleagues on similar career and life paths. Trust, she says, that the Lord who called you into healthcare both understands and cares for you and yours is the key to a life of peace in the midst of what may, at some times, seem chaotic and overwhelming.
Elisa Ghezzi, D.D.S., M.S.
I
have a confession to make. Actually, I have several to make. I’m a wife, mother, dentist, professor, student and, of course, a daughter of God. I love and enjoy each one of those roles. But I’m having a hard time fulfilling them all at once. Let me be more specific.
Confession #1 Sometimes I feel as if I have a personality disorder: Who am I supposed to be at any particular moment? With so many roles, I can get confused. If you tell me it hurts, should I “kiss it and make it better” or give you more local anesthetic? 10
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As I begin to write this, I have a wonderful husband, Steve, also a dentist; a two-year-old daughter, Elena; and, a second child on the way. As a member of the faculty at the University of North Carolina (UNC) School of Dentistry, I do research, teach and treat patients. I’m enrolled in a Ph.D. program in Epidemiology at the UNC School of Public Health. But most importantly, who am I? I’m a daughter of God, seeking to follow His will for my life. Needless to say, life is hectic. You might say I’m like the celebrated “Proverbs 31” woman who “rises while it is yet night” to take care of her family, works hard at her career “with willing hands,” has no clue what “the bread of idleness” would taste like—but, unlike that wealthy matron of long ago, has no “maidservants” to help out (see Proverbs 31:10-31). My husband and I both work full-time. Although we attended dental school at the University of Michigan, where we had immediate and extended family, we now live 600 miles from our nearest relatives. We came to the University of North Carolina so my husband could complete a two-year general practice residency in dentistry. Before we can begin to feel settled, we’ll be picking up and moving again. Recognizing the need to be closer to family and friends, we’ll be returning to Michigan at the end of the residency. But in the meantime, there are no grandparents, aunts, uncles or even second cousins nearby to rely on when we need support. At times my responsibilities seem overwhelming.
Confession #2 I have no women friends nearby. Actually, the truth is that I don’t have any close female friends nearby. While my life is full of people—husband, daughter, patients, students, research subjects, classmates, professors—the busyness, traveling and relocating leave me little time to develop close friendships with other women. Fortunately, e-mail allows me to keep in touch with many friends throughout the world and to maintain a social network. But there’s a void nonetheless. Other female doctors tell me this is common. Those who best understand and empathize are also too busy to develop close friendships. Sometimes I feel, then, not so much like the Proverbs woman, but like the psalmist who called out to God, “I’m like a lonely bird on the housetop” (see Psalm 102:7). I long for close fellowship with other women. Internet Web site:
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Confession #3 At times I compare myself to the Christian friends of my childhood who today are not full-time professionals but rather full-time stay-at-home moms, and I wonder whether I made a mistake. Aren’t all Christian mothers supposed to stay at home full-time with their children—and maybe even homeschool them? I remember what I once thought my life would look like when I grew up and had kids: I would live in a neighborhood full of children whose ages matched mine and I would visit with their mothers at the playground and at school outings. God may yet have this scenario planned for my future, but it certainly doesn’t describe my life at the
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moment. And while I covet the luxury of having more time to spend with my family and would be willing (by His grace) to forego my research career if He were to call me to that, I know I am currently where God wants me to be. Sometimes I feel guilty that I send my daughter to daycare. When I was four years old (and my siblings were three and five) my father traveled regularly on business, my mom attended law school and we children were placed in daycare for a year. I hated it. I missed my mother and I didn’t like not knowing where she was. Fortunately for me, at the end of that year my mom decided to postpone her professional studies until we were grown. As a child I was determined that when I grew up, I would never subject my children to that experience. But our daughter arrived as my husband was finishing dental school and we were moving to North Carolina. With no family around to help with childcare, we’ve had no choice but to send her to daycare. Probably the biggest challenge of a professionally working mother with young children is answering the “Am I doing the right thing?” question. I’ve learned that we may not always be confident about the answer to that question. But what’s important is to keep it on the radar screen and reevaluate periodically. So I find myself praying regularly: “Show me the path I should walk, for to You I entrust my life” (Psalm 143:8, 10). “Do what is right for you and your family” may sound like a cliché, but it’s appropriate here. God and I have regular conversations about this. Some days I’m frustrated with work and ready to throw in the towel. But days like that aren’t the right time to discern the answer to this or any other question. Unfounded guilt, regret or anxiety over this decision can hinder my ability to discern God’s will accurately. Like Elijah, I have a hard time hearing the Lord in the whirlwind, but if I quiet myself and listen, He can speak in a “still, small voice” (see 1 Kings 19:9-18). It’s also important to realize that “for everything there is a season” (Ecclesiastes 3:1) and that life is changeable. Our two years in North Carolina have been a time of focusing on survival. By working full-time, we made it, paid the bills and the large school loan payments. But survival isn’t the same as living. The experience of our first year there convinced us that we needed more family support. That’s why we’re moving back to Michigan as soon as possible, where my husband will start private practice, and I will continue my research part-time. Our daughter (and second child) will have a new schedule that significantly reduces their time in daycare each week: one day with me, one day with my mother, and half a day with my husband. In the meantime, I’ve learned that my daughter is not like me in important ways. Just because I didn’t enjoy daycare doesn’t mean that my people-person daughter doesn’t relish the opportunity to relate with other kids. In addition, she’s learned valuable skills from the interactions with other children and the structured exercises. In the future we may be able to discontinue daycare completely, but if not, I know I’m not permanently damaging her by sending her there. Then, too, I’m not sure I’m ready to quit work completely. I not only enjoy the intellectual stimulation; I thrive on it. And while I don’t want to work forty-plus hours a week, quitting cold turkey wouldn’t be easy.
Confession #4 Sometimes I need to take care of myself. Most of my energy is typically spent getting my family through each day. I’m fortunate in that my husband is incredibly helpful and does more than his share of washing dishes, doing laundry and caring for our daughter. Even so, I must be careful not to neglect my own needs. Allowing myself to burn out makes me less effective in serving my family. Sometimes I need time by myself. Last summer, I was able to take a few days away to attend the CMDA national convention by myself. I left the wife, mother, dentist, professor and student roles at home and focused solely on being a daughter of God. This is a critical relationship, of course, and it must be cultivated daily. But an extended period of time away can help me refocus and remind me who I truly am in God’s eyes. Just as I need a weekend getaway with my husband, and Elena gets her special hang out time with Mom (usually when Steve is on call), I need time to let God hold me and tell me how much He loves me. So I take Jesus up on His offer: “Come to me, all you who labor and are burdened, and I will give you rest” (Matthew 11:28).
One of my favorite family events used to be the annual 5K run with my husband, dad and brother-in-law. Today, the thought of even walking 5K sounds exhausting. Because regular exercise is important, we’ve made it a priority to take evening walks together as a family (weather permitting). But I haven’t found time to train for the 5K this spring. So how does a woman become a model Christian doctor, wife and mother in the 21st Century? I think the superwoman model of the late 20th Century is outdated. No one can live up to that standard. And that leads me to my final confession.
Confession #5 Work-related travel can provide some of those treasured moments of time by myself, but how I envy my colleagues who have a secretary to book the flight and hotel room, and who need only to make sure their bags are packed. I mean, of course, the ones with wives. Sometimes I think I need a wife . . . or maybe one of those handmaidens the Proverbs woman employed. When I recently had a four-day trip to San Diego for research meetings, my husband was on a rotation that allowed him to return home only on weekends. We arranged for my father to fly in from Michigan to stay with our daughter, but I was left to make my flight and hotel reservations, set my daughter’s schedule, pick up my dad from the airport, and, oh yes, pack my bags. What an emotional drain!
Confession #6 Sometimes it bothers me that, even after two years, I don’t fit into all my pre-pregnancy clothes. With pregnancy comes weight gain. Some women actually find that the pounds melt off soon after delivery. But for the majority of women, this isn’t the case. I belong to the majority. And now that I’m pregnant again, I get depressed knowing that this cycle will repeat itself before some of those clothes come out of my closet. I know the scriptural reminder that “beauty is fleeting” (Proverbs 31:30), and I honestly don’t think I’m given to vanity. My primary concern, rather, is to take good care of my body and to keep this “temple of the Holy Spirit” in good shape (see 1 Corinthians 6:19). Yet I’m not in as good a shape now as I was prior to having Elena.
Internet Web site:
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Elisa M. Ghezzi, D.D.S., M.S.
Confession #7 I am not superwoman. I am not perfect. These confessions reveal a few of my very real concerns. Some are petty and embarrassing to admit. I don’t yet have the solutions to them. But I’m learning that I don’t have to. Not everyone will understand my life. And I certainly won’t fit into everyone’s image of the ideal wife, mother, dentist, professor, student or even daughter of God. However, I do need to live up to God’s expectations of me. I find out what those expectations are by daily seeking His direction for my life and being flexible as He directs me to paths I never thought I would follow. Of one thing I’m certain. The One who has called me into a healthcare profession understands my concerns and frustrations. His promise is sure: If I cast my cares on Him, He will care for me—and for those I love (1 Peter 5:7). ✝
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lives in Ann Arbor, Michigan with husband, Steve, and children, Elena and Joseph. The Ghezzis are expecting a third child in November. She is an Assistant Research Scientist in the Department of Cariology, Restorative Sciences, and Endodontics at the University of Michigan (UM) School of Dentistry and holds a position as an Adjunct Clinical Assistant Professor at UM Hospital. In addition, she is enrolled in the Epidemiology Ph.D. program at the UM School of Public Health. Dr. Ghezzi has been a member of CMDA since 1991, and served as the Resident Trustee (1997-1998). She is currently a member of the Women in Medicine and Dentistry Commission and the Christian Dental Association Advisory Council.
DENTAL NEWS:*
Dental Director Dr. Jack Shuler visited 14 dental schools in the Midwest and West during his first 10 months. Primary need expressed by students: mentors. CDA will have a large booth at the ADA meeting in San Francisco in October, and at the Greater New York Dental Meeting in November. In 2004, CDA exhibits at the Southwest Dental Meeting in Dallas. A dental interview CD and a dental brochure have been produced. Contact information: Jack Shuler, D.D.S., F.A.G.D.; Director, Christian Dental Assocation; P.O. Box 7500; Bristol, TN 37621. Phone: (603) 437-8922; Fax (603) 425-2007; E-mail: jackcda@earthlink.net. *See the Dental section of http://www.cmdahome.org for more information.
IF YOU AREN’T BEING YOU AREN’T IN THE ARENA
PERSECUTED,
by W. David Hager, M.D.
Consideration for White House appointments led to unwarranted vilification and undeserved persecution of this Christian doctor, who rejoices that the net result was that 200 million persons were exposed to newspaper, magazine and broadcast articles about him, in every single one of which the name of Jesus Christ was mentioned. n mid-2001, I was carrying out my duties as director of the University of Kentucky-affiliated Residency Training Program in obstetrics and gynecology at Central Baptist Hospital, Lexington, Kentucky. I was also engaged in the clinical practice of obstetrics and gynecology, serving as principal investigator for two clinical research studies and speaking and writing as usual. One day as I was seeing patients, I received a call from the White House Personnel office asking if I would consent to an interview about a possible appointment in the Department of Health and Human Services (HHS). I had not pursued such an appointment and was honored to even be considered. I was honestly amazed that the Administration would be interested in me for any role of service since there are so many qualified physicians with extraordinary expertise who could serve. As I do with any issue such as this, I prayed about it and felt led to be interviewed. The interview occurred in Washington and was atraumatic. I returned home and resumed my duties with no response from HHS for several months. This was good for me because my life was unsettled for much of that year. In early 2001, when I was serving as chair-
I
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person for the Greater Lexington Franklin Graham Festival to be held in October 2001, I had prayed during my quiet time, “Father, I love You and no matter what You do to me or what happens to me, I will always serve You and never deny You.” My responsibilities with the Festival were numerous and took me into every major church in the area to speak. The support was phenomenal, but attacks upon our organizational committee began to occur. The person who originated the idea for the Festival was diagnosed with colon cancer and would subsequently die right after the Festival. Another member was diagnosed with cancer, and another put to bed with back problems. We pressed on with God’s direction and had a wonderful crusade in Rupp Arena. Having never been sued in over 20 years of practicing obstetrics and gynecology, I was served with my first law suit; a case from 1984. The papers arrived late in 2001. On February 2, 2002, my wife of 32 years decided to leave our marriage and subsequently married another man. In June my second son
was married. In August, I was called by the White House Personnel Office and asked if I would serve on the FDA Advisory Committee for Reproductive Health Drugs. I was told that this was confidential information and was not able to tell anyone about the possibility of serving. I agreed to serve and was excited about the possibilities for contributing to the health and well-being of the women of this country by evaluating data on medications and helping to make suggestions for use or disuse. Shortly thereafter an article appeared in Time magazine written by Karen Tumulty, entitled “Jesus and the FDA.” Now Ms. Tumulty had never interviewed me and I was shocked that she even knew about the proposed appointment. She said that I was scantily credentialed, had a voluntary appointment at the University of Kentucky Medical Center, refused to prescribe contraceptives to unmarried women and recommended specific Scripture readings and prayers for such ailments as headaches and premenstrual syndrome. Although she indicated that I had not returned her calls, she failed to note that when she called, I was out of town and was never informed of her inquiries. My credentials stand on their own. I have a paid faculty appointment with the University. I do prescribe contraceptives to unmarried women if they are going to be sexually active (I advise all of my sexually active single patients that abstinence is the only way to absolutely avoid non-marital pregnancy and STDs). Although I have suggested prayer and meditation as integral parts of managing stressrelated disorders in women, I recommend medications, appropriate diet and exercise as well. Many other articles began to appear—all citing Tumulty’s information as fact and basing their writing upon it. Maureen Dowd wrote an op/ed subtitled, “WWJD at the FDA.” The Philadelphia Daily News published a cartoon with the bookshelves in the office stocked with only one book, the Bible. At the same time, the FDA asked that I not respond to any requests for interviews and remain quiet. All the while the attacks on my personal character and my qualifications continued unabated. It is difficult to remain silent while others are attacking you with incorrect information, but after praying about the situation, I
“Oh,” they say, “it is fine to have your views and your faith. Just don’t express them.”
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felt that this was what I should do. I struggled to understand why there was so much controversy surrounding my nomination. After all, I am just a grain of sand on the beach of life. I am one of 12 members on the Advisory Committee. This is not a Senateconfirmed appointment, so why the big deal? Not only were national magazines and newspapers publishing articles, but there were over a thousand e-mails sent to me castigating my character, besmirching my qualifications, denouncing my faith, insisting that I never agree to accept a position in government service and insisting that I am a danger to women’s health. It became evident to me that this uproar centered primarily on my convictions about abortion and abstinence. Since I had been asked to be the front person for the Christian Medical AssociationSM (CMA) with the Citizens Petition filed with the FDA on RU-486, many CMA members were made aware of my situation by Drs. David Stevens and Gene Rudd. The members wrote me letters and e-mails in large numbers voicing their support. Many began to pray sacrificially for me and my family. I sensed that support. My spirits were lifted because others cared enough to pray for me. There was also a great surge of letter writing to the White House supporting my nomination. These intercessions made the difference as I battled the attacks from the left. How could I not succeed with so many people praying? The focus of each attack centered on the issues of my pro-life stance, my views on sexual abstinence outside of marriage and my writings indicating that a person of science can also be a person of faith. It wasn’t my qualifications at all, it was what I believed in—positions that are actually held by a majority of Americans according to most polls. Those who were lobbing the “bombs” indicated repeatedly that I could not be a person who engendered tolerance, yet they were intolerant of my faith and willingness to serve my country. They correctly categorized me as opposing elective abortion, being pro-life, promoting abstinence outside of marriage, writing that condoms do not prevent all STDs and questioning the safety of the medical abortion drug, mifepristone (RU-486). They incorrectly accused me of being scantily credentialed, being positioned to become the gynecologist for America’s women, recommending prayer alone as the cure for all diseases in women, believing that birth control pills are abortifacient, of embarrassing and demeaning women if they are
sexually active outside of marriage, of being an embarrassment to medicine and to gynecology, of not being research-oriented or able to evaluate research and of relying on the Bible for scientific information and never reading medical texts. In spite of all the criticism and controversy, the appointment was upheld and the Advisory Committee has been set. In addition, it has been estimated by others that over 200 million persons were exposed to the newspaper, magazine and broadcast articles about me, in every single one of which the name of Jesus Christ was mentioned. Thousands upon thousands of people rose to my defense and wrote articles, letters and called the White House in my support. Many wrote me and said that they had been opposed to my nomination, but after seeing how it was handled and how unfairly I was criticized they had changed their minds. I am so grateful to the leadership and members of CMA, Concerned Women for America and The American Association of Pro-life
“Father, I love You and no matter what You do to me or what happens to me, I will always serve You and never deny You.”
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Obstetricians and Gynecologists for their unfailing support and encouragement. No one relishes persecution, but as Christians we are told repeatedly in God’s Word to expect it. There is a concerted
Advice to others seeking similar appointments • Make sure you are prepared to face criticism and bitter attack. • Make sure you have no “skeletons in the closet.” • Ground yourself in prayer and God’s Word. • Notify persons and organizations willing to promote your nomination and to speak out for you. • Do not give interviews to those you do not know and trust. Use “off the record” for anything you do not want published. Better yet, don’t say anything you would not want published. • Be informed about your area of expertise and be objective in your evaluation of data. • Stand firm in the whole armor of God. ––W. David Hager, M.D.
UNCOVER
e n d u r i n g
effort—actually a war being waged—by radicals to oppose and destroy anyone who voices an opinion that stands in opposition to their own. Although tolerance is proclaimed as their buzz word, it is not practiced by those who proclaim it. If you are not experiencing persecution, you may not be venturing enough, or being bold enough in expressing your convictions. Persons and organizations are sensitized to our proclamation of faith in God and insist that if you believe, you cannot logically participate in scientific debate. “Oh,” they say, “it is fine to have your views and your faith. Just don’t express them.” Are you being persecuted for your faith? If not, are you really in the arena? Our persecution pales in comparison to that of our brothers and sisters in other nations in these days, to our brothers and sisters of former times and to that of our Lord. Become active, venture out, be bold and proclaim the truth. The world is dying for lack of hearing it. ✝
W. David Hager, M.D., practices obstetrics and gynecology in Lexington, Kentucky. He has authored numerous articles and books, including Women at Risk, Stress and the Woman’s Body and As Jesus Cared for Women. He has been a member of CMDA since 1993.
s t r e n g t h
WHEN YOUR DOCTOR HAS BAD NEWS offers Spiritual guidance toward peace, strength, and healing for those faced with disturbing medical news. Emerge stronger, richer, and more whole than ever before. AVAILABLE WHEREVER BOOKS ARE SOLD
How a word once banned from this doctor’s vocabulary became his tutor in key concepts of the Word of God.
F R O M FAILURE TO
FAITH W i l l i a m
J .
G e i g e r,
M . D.
How many physicians have said the
whatsoever in the 2001 Match. How was
words below in one form or another,
I going to respond? What was the Lord
either to themselves or out loud to others?
trying to teach me? Why have all these
Most physicians are high achievers who
circumstances occurred?
have struggled very little with failure
Early on, I realized that I faced a major
during their lives; therefore, failure
choice with eternal consequences. I could
amounts to a foreign experience to be
get angry at God, withdraw from Him
avoided like the plague.
and probably miss out on the eternal
None of us anticipate facing major fail-
work He was trying to do in my soul. Or,
ures in our professional lives. And when
I could embrace the situation as a gift
we do, we often respond with frustration
from God’s good, sovereign hand, draw
or denial, but not often enough with faith.
near to Him and learn what He wanted
I am no exception to this generalization. So when I began to experience failure essentially for the first time two years ago, a deep inner struggle ensued. I was the program director of a family practice resi-
to teach me and grow in Christ-
“Failure? That’s not in my vocabulary!”
dency that matched with no students
likeness. After toying for a few weeks with the first option, I am so glad that I finally chose the second. As a result, God has taught me “far more than I could ever ask or think.”
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PRIDE First of all, God had to show me the ugliness and subtlety of my pride. I have enjoyed success after success throughout most of my life: Eagle Scout, National Honor Society, all the men’s honorary societies in undergraduate school, early acceptance to medical school, my first choice for a residency in family practice. All these seemed to portend a highly successful career in medicine. I met the Lord in undergraduate school, and sincerely sought to keep Him pre-eminent in my life. But like the Apostle Paul (see Philippians 3:4-6), I had every advantage in my background and every reason to place my confidence in the flesh. After my residency, I established, with two partners, what quickly became a highly successful practice. My wife and I were active in our church, leading Bible studies and teaching adult Sunday school. But after a number of years, I slowly began to realize that I had climbed all the mountains in private practice and I found myself longing for some new challenges. Eventually, I left my practice to pursue academic family medicine and joined a residency faculty. There I experienced more success as a teacher and eventually became program director of that residency program. The program filled with residents every year, had strong institutional support and highly successful graduates. And I remained active in my church and worked with the CMDA students at the local medical school. Again, I had been successful! I had climbed the new mountains, met every challenge and found myself ready again for something more. Failure was not an option; indeed, the word was not even in my vocabulary. In 2000, we moved out of state and I took a position as a program director of a struggling residency, with the goal of restoring it to success. It had been poorly supported by the hospital and had experienced some difficulty filling with residents. But I looked forward to the challenges, and I felt I was up to meeting them because of my experience at a successful program. Many different people assured me that my knowledge, experience and leadership were just what the program needed to succeed in the future. And I believed them. However, I did recognize that my pride was being stroked, and that was a dangerous spiritual position to be in. Proverbs 16:18 says, “Pride goes before destruction, and a haughty spirit before a
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fall.” Nevertheless, I never gave failure a thought, worked hard to rebuild the program and felt we had a reasonable chance of matching well. However, when Match Day 2001 came, I never had felt the sting of failure so strongly. Zero students matched for six positions! We hadn’t convinced anyone to join the program! I took it quite personally and struggled emotionally for days with the pain of defeat. I spent long hours in prayer and the Word, crying out to God. Slowly, I began to realize that I was as capable of failure as anyone else, and that God had something to teach me from this failure. My pride had blocked me from seeing my own vulnerability to failure. My pride had pushed me to begin to trust in my own flesh, and not the Lord, to accomplish the task I had been given. My pride had convinced me that I was going to be the program’s savior, not merely the director. The Lord had to teach me that it was all about Him and what He would do, not about me or what I could do. I became a living “Exhibit A” of the fruitless vine, which could do nothing apart from the Lord (see John 15:4).
PRIORITY Immediately after this failure in the match, our department chairman decided to merge our residency with another nearby program since the hospitals had recently merged. He felt this change would enhance our recruiting efforts, and he appointed me director of both programs and charged me with designing the new merged program that would begin the following year. Talk about a challenge — three full-time jobs! As I looked at what lay ahead, I realized the magnitude of the job and the commitment I needed to make in order to accomplish the task. As I
“Pride goes before destruction, and a haughty spirit before a fall.” (Proverbs 16:18)
“If any one does not provide for his...immediate family, he has denied the faith....” (1 Timothy 5:8)
prayed about the situation, the Lord gave me the green light to pursue this goal. As I discussed it with my wife, we agreed together that I should give it a try, but I promised her that I would pull back in a year if it began to interfere with our relationship. But, smugly, I knew better than to let that happen! And so the roller coaster ride began, and at times, I seemed to enjoy the adrenaline rush of such a great challenge. But soon it became scary and all I could do was hold on and pray. My “to do” list was so long I couldn’t see the bottom. But I kept working feverishly at the tasks on my plate. I rarely worked excessively long hours, but I may as well have stayed at the office 24/7! My mind was constantly on the pressures and stresses of the job, and I had little emotional energy left over for my wife. Whenever we talked, we never connected very well. We usually talked about the situations at my work. Most of the time at home I either retreated to my den, or fell asleep on the couch while my wife watched the evening news. It was a miserable year for both of us, and our marriage began to show major signs of wear. At a Christian physicians’ marriage retreat halfway through that year, my wife and I had the first real opportunity to talk about our relationship and the toll my job was taking on it. I began to come out of denial and realize that the pace of my life was slowly destroying our marriage. I was skiing downhill in front of an avalanche! That afternoon, the Lord convicted me of the priority of my marriage —that my wife was more important than any job. After reviewing 1 Timothy 5:8, “If any one does not provide for his...immediate family, he has denied the faith...” I became deeply convicted that I had to cut back so I would have energy to provide for my wife and our marriage. Shortly after that marriage retreat, the 2002 Match result again left us with no students matching with us. And again I spent large blocks of time in the Word and prayer to get His perspective on the situation.
PERSISTENCE This time, as I cried out to the Lord, I wondered if He wanted me to do something else. Should I look for another program to lead? Should I go back into practice? Was there any hope in the present situation? As I debated back and forth, every time I went to the Scriptures, the Lord gave me an assurance that I needed to stay and persist in this situation. He finally capped off His leading with Jesus’ words to Peter in John 18:11, “Shall I not drink the cup my Father has given me to drink?” Jesus did not enjoy His trip to the cross. But He was willing to accept the sufferings and difficulties the Father had set before Him. He saw the eternal benefits and victories that would be won for His lost children if He persisted. I began to realize that God had called me to persist in my situation. I didn’t fully understand all that He was doing or going to teach me, but I decided that I would persevere on the job and learn the lessons. God also led me to persist in prayer. My wife and I regularly prayed about the residency program from the day we moved. But now, we both felt led to fast as well as pray. We set aside one morning a week to fast and pray specifically for the program. As we did so, we saw some amazing answers to prayer. Plans for a new building for the residency suddenly began to move forward after months of bureaucratic stalls. Good candidates began to apply for the open residency positions. Candidates appeared for our open faculty positions. Truly wondrous things began to occur as a result of our fasting and praying. One-by-one, positive things happened and morale improved. And for most, the only explanation was the Lord’s direct intervention. Jesus said, “But this kind does not go out except by prayer and fasting,” (Matthew 17:21) indicating that some spiritual battles can only be won only with the combination of both
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“Be strong and courageous; do not tremble or be dismayed; for the Lord your God is with you wherever you go”
disciplines. In the parable of the persistent widow in Luke 18, Jesus instructed His disciples “that they should pray and not give up.” Many victories were won that year as our persistence paid off. There seemed to be light at the end of the tunnel.
(Joshua 1:9)
PRESENCE
But, again, the 2003 Match came up empty for us. Still there was too much transition in our program to calm the fears of conservative medical students. So much hard work by so many and no fruit! What more could God possibly be teaching me? The answers have only started to become clear. As Job found out in his tragic circumstances, the key question in time of trouble is not “Why?” but “Who?” The one thing that is clear to me is that I wouldn’t want to go through these circumstances without knowing I am part of God’s family, and that I could turn to my Father at any time. I know He wants to build a more intimate relationship with me through His Scriptures and prayer. I know I am going to continue to grow in many ways that “better” times would not have allowed. I have been able to recognize His presence with me day by day and moment by moment. I am enjoying getting to know Him for who He is, not for what He can do for me. I have found a shoulder to cry on, a strength to tap into daily and a peace that surpasses all human understanding to guard my heart and mind (Philippians 4:8). He has become my true Comforter and Redeemer, and I know He will redeem this situation and deliver us in some form in the future. In a deeper and more profound way than I could have ever imagined, I have sensed the promise of Joshua’s words to the people before they crossed into the Promised Land: “Be strong and courageous; do not tremble or be dismayed; for the Lord your God is with you wherever you go” (Joshua 1:9). Knowing that He is there with me is really all I need! ✝
Unique Help for Your Addicted Patients HOLY SMOKES Inspirational Help for Kicking the Habit Jean Flora Glick “Embedded within this Christian mother's letters to her smoking addicted daughter, are the scientific do’s and don’ts of breaking this addiction. These are strengthened by interspersed Bible verses.” —Fred S. Stockinger, MD, FACS, FCCP, FACC Assistant Professor of Thoracic and Cardiovascular Surgery The Ohio State University
is a native of Ohio. He graduated from the Ohio State University College of Medicine in 1972. After residency, he practiced in Mansfield, Ohio, for 12 years. Subsequently, he taught for 11 years in a Family Practice residency in Toledo, Ohio. Dr. Geiger currently is the program director of a residency in Milwaukee, Wisconsin. He and his wife, Lynn, have two grown daughters. 22
T o d a y ’s C h r i s t i a n D o c t o r
Available from most local and online booksellers or from Kregel at 800-733-2607.
Paid Advertisement
William J. Geiger, M.D.,
by Pierre Arty, M.D.
How a terminally ill patient helped a first-year intern place his own challenges in proper perspective as his patient faced her own deterioration and pain with hope in something far greater than death, deeper than despair and stronger than anything of purely human origin.
I
looked at my watch and realized with a sense of hopeless resignation that it was 2:30 A.M., and getting to sleep was becoming a lost cause. Approximately ten minutes earlier, a nurse at the nursing station A-11 had paged me to report that
an intravenous line had just come out of another patient’s arm. After examining and eventually admitting three prior patients with various medical problems, I had dared to entertain the remote possibility that I would be able to get some rest. But rest was becoming more and more an elusive concept rather than a concrete reality. After inserting what seemed like the hundredth I.V., I began to suspect that the nurses were conspiring to sabotage my life. It was November 1990. I was working the night shift, on call at Kings County Hospital in Brooklyn, New York, and trying to live through my first year of military training otherwise known as a medical residency.
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From the first night on call, I had begun to realize how my life would be for the next three years. During the transition from medical student to intern, time suddenly had taken on a new meaning. It became loose change in a pocket full of holes. I never knew where I lost it. I was convinced that a day was far less than the 24 hours I was used to before starting the residency program. Also, there was never a shortage of patients to treat. Day and night patients entered the emergency room with all types of ailments. Although they came from many different countries and islands, their faces spoke the same language of pain. Their eyes expressed hope as they looked unto the doctors and nurses in white coats. At times this was overwhelming. I tried not to dwell on my feelings of apprehension and loneliness, which accompanied me to the hospital every night like faithful friends. As I walked into the small one-bedded room on A-11, I quickly glanced over the patient, lying on her bed, to get an idea of approximately how long I would be there trying to reinsert the intravenous access. With a heavy sigh, I realized that this intravenous was going to take awhile. The patient, an elderly woman possibly in her late 70s, looked very emaciated. She was resting quietly on her back. Her eyes were closed and I presumed she was asleep. Her thin frail arms were above the bed sheet that covered her body. From a distance, I couldn’t detect any obvious veins that would readily surrender to a needle and catheter. I also noticed a wool hat that covered what I suspected to be a balding head. She was most probably a cancer patient receiving chemotherapy. I was to find out later from her chart that this admission was a last desperate attempt to arrest a quickly spreading ovarian cancer. After examining this one more obstacle to my rest, I went to look for the catheter and tubing needed to insert the I.V. Coming back into the small and dimly lighted room, I expe-
rienced a sense of peace and comfort as I turned on the lights. Most of the patients’ rooms that I entered either had a framed representation of a famous painting placed on one of the walls by the hospital administration or one or two personal pictures of someone special to the patient sitting on a dresser. This room was different. The walls were decorated with various get-well cards signed by family members and friends. On a chair next to the patient’s bed were two carefully folded blankets. Taped on the wall above an old sink were pictures of several children smiling and apparently involved in play. A thick Bible with some obvious torn pieces at the edges of its black cover and inner pages was lying on the dresser, close to her bed. I looked over at the patient who seemed to have been awakened by my presence. Our eyes met and I introduced myself. “Good morning Ma’am,” I said. “I’m the doctor on call. I’m sorry to wake you, but I came to replace your I.V.” She winced in pain while removing the sheet from across her body, looked at me and responded with a surprisingly stern voice, “You didn’t wake me, young man. The nurses told me to expect you. I just couldn’t sleep thinking about that needle going back into my arm. My Lord, as often as they put those things in my arm, I just can’t get used to it. Well, let’s get this over with.” Then she added, “Why don’t you put those blankets on my bed so you can sit down and be comfortable? It’s so hard to find my veins, you know.” Looking at her thin arms, I knew she was telling the truth. There were multiple puncture marks on both her hands and arms, evidence of previous unsuccessful attempts. As I was examining her arms, carefully looking for an access, she again let out a silent moan of pain and my eyes fell on her face. It was a haggard, tired looking, wrinkle-scarred face. It looked as if the sum of all her life’s troubles and afflictions
“Good morning Ma’am. I’m the doctor on call. I’m sorry to wake you, but I came to replace your I.V.”
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were etched on each wrinkle. But the eyes and the smile were an entirely different story. Looking at them, I didn’t notice any evidence of turmoil. What I saw was a vibrant woman inside touching the world outside with a smile. “I hope you’re good and don’t have to poke around too much to find my veins” she said, breaking my stare. “Well Ma’am,” I replied, “I don’t intend on hurting you any more than I have to, but if I find a vein quickly, it’ll be a miracle.” “Well son,” she replied, “you just do what you have to do.” After a few moments of palpating her arms and doing all I could to bring a vein to the surface, I said, “Are you ready Ma’am? I think I may have found a vein here.” “Go on, I’ve been through worse than this,” she replied. Her courage was admirable, but unfortunately for both of us, her veins were not. Her small vein couldn’t tolerate the intrusion of the catheter and decided to collapse. This meant that I wasn’t going to get to sleep for awhile. “Ma’am,” I said, “I’m afraid I’m going to have to hurt you again. Your vein didn’t take the catheter.” “Son,” she replied, “through all this chemotherapy, the vomiting, the radiation, seeing my hair fall out . . . my Lord and Savior Jesus the Christ has kept me going. I know as sure as I’m speaking to you now that He’ll bring me through this little fire. I don’t like getting stuck, but I need my medication. So you best just try again or come back later when you catch yourself some rest.” I was blown away by what she said and how she said it. This decrepit sick person was telling me, the young healthy doctor, to come back later after I “catch some rest.” Had someone suddenly reversed our roles without telling me? Even as these thoughts went through my mind, the strength and resolve emanating from this wasted looking woman commanded my attention. I wondered where she got this vitality in the face of a slow and miserable death? Up to that year of my life, I had witnessed people dying in various ways; quietly, loudly, with much anger and peacefully...but never with a smile. To face death head on, day after agonizing day, and still have the inner fortitude of this woman was beyond my understanding. She was an enigma. The multiple puncture marks on her thin arms spoke of daily agony of physical intrusions. Her wool hat told me tales of side effects and disappointing treatment failures. And her painfully limited mobility reflected the burden of chronic aches and pains on a body rejecting its host. But her voice resonated an inner fortitude and faith that was far beyond my understanding. She startled me from my drowsiness and commanded my attention. I felt a compelling desire to get to know her, befriend her, learn from her. She did not disappoint me. In the nights that followed, I took several opportunities to visit her, not only to see how she was doing, but in order to
glean some of her encouragement and strength. It was only too easy for me to get discouraged due to lack of sleep, not eating properly and being constantly under the stress that someone might die due to something I might do or fail to do. With these self-doubts in mind, I certainly appreciated her encouragement. I would enter her dark and peaceful room like the very first night. She would welcome me with words like, “How’s it going tonight, doc? They keeping you busy enough? Now don’t you worry none. God Himself has put you here for a reason and He sure ain’t gonna leave you now. Remember how He delivered those three Jewish boys from that fiery furnace? That King Nebuchadnezzar looked in that furnace and saw four men in there, not three. And then he said the fourth man looked like the Son of God. Son, that means that God is in there with us, in the middle of our troubles. He’s no respecter of persons. What He did for those three Jewish boys, He’ll do for us if we’re servin’ Him. There ain’t no trouble or furnace hot enough that He can’t deliver you from. You just keep that in mind.” Well there I was, a medical intern, a physician supposedly endowed with the knowledge to alleviate sickness, in short, to make people feel better, being comforted and encouraged by an old woman dying of cancer. Can you spell humility, doctor? It starts with an “H.” This woman helped me put my internship year in focus
“I hope you’re good and don’t have to poke around too much to find my veins,” she said, breaking my stare.
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when I couldn’t see beyond my next admission. She never gave me the impression that she was too weak to give me a portion of what was left of her strength. I began to look forward to the nights on call when I would take a break from either admitting patients or writing orders and go to her room. There I would sit and listen to countless stories of how good her God had been to her. Once in awhile, for maybe a second or two, I somehow imagined that I could see beyond that frail old body and actually get a glimpse of her essence, her light, the radiance that was truly her. On one exceptionally busy night, something very interesting happened in that peaceful little room that I will never forget. I had decided to rest and sit momentarily in what had now become my favorite chair in the hospital. I quietly entered the patient’s room. Since she didn’t greet me as she was accustomed to do and her light was turned off, I assumed she was asleep and decided to just sit and close my eyes for a few seconds. I was enjoying the stillness of the darkened room, which contrasted with the busyness of a night on call. I eventually dozed off and when I opened my eyes, I was surprised to see this sickly woman sitting up on her bed in the darkness. To my recollection, I had never seen her sit up and I had reasoned that due to the spread of the cancer to her bones, every physical movement led to excruciating pain. And then it dawned on me that I was unknowingly involved in her incentive to sit up. While sitting up in bed, her thin arms with hands open were stretched out in my direction. She looked 26
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like she was either about to give me something or present me to someone. Her eyes remained tightly shut while her lips were quietly moving, as if holding conversation with someone in silent whispers. After a moment she raised both hands toward the ceiling, looked up and opened her eyes with a look of triumph or jubilation. She was praying. She was praying for me with all the passion and fervor her small frame could rouse. Actually, she might have been praying for world peace and everyone from Brooklyn to Miami, but I know I was on that prayer list. When she finished praying, she quietly laid back in bed and covered her torso with her blanket. She was apparently exhausted and in pain, but even with the poor lighting her face appeared very content. I didn’t pay much attention to the words of her prayer, and even if I had wanted to, I couldn’t hear them. I didn’t respond to her in any way. My unresponsiveness was not due to fear or rudeness. I was so captivated by the moment, all I could do was sit back, take notice and wonder. I continued to sit, as if in a trance that was broken only by the sound of my beeper reminding me that I was still on call. Several nights later, I became more busy than usual replacing intravenous and nasogastric tubes, and responding to various complaints of chest and abdominal pain. After the morning rounds with the attending physician during which we reviewed each admission, the only thing on my mind was to get home and go to sleep. A week passed by like this. One morning I decided to stop by and see how the patient was doing. After all, I had interrupted her rest enough times at night, I thought that I might as well visit her in the morning before I went home. On the way to her room, I couldn’t help but smile, thinking about how surprised she was going to be to see me in the daytime. Halfway down the hall on A-11, I could see the entrance to her room. I entered her room and opened my mouth to say, “Good mornin’ young lady” but the words never came. The room was empty. Inside my head, in the deepest cavern of my mind, a little voice was whispering to me a secret that I didn’t want to hear. It was whispering my greatest fear. As quickly as it spoke, I muffled it. Maybe the nurses changed her room, I thought. Maybe she was discharged to spend her last days with her family. So many maybes raced through my mind, while my heart already knew the truth. With my heart beating a little faster than usual, I walked over to the nurses’ station. “Good morning. Where is the patient in room ten?” I asked.
“There ain’t no trouble or furnace hot enough that He can’t deliver you from. You just keep that in mind.”
“Oh, she died three days ago,” came the reply. “Her family came yesterday to pick up her belongings from the room. Were you her doctor?” “No” I said. “She was my friend.” As I turned to leave, a well of emotions stirred within me. Why did she have to die now? I asked myself. I felt so very sad and alone. Leaving the hospital, I passed through the pediatrics emergency room. I was deaf to the sound of screaming children. I saw their crying faces, but could not hear their cries. I was a walking bag of anger. I was angry with myself for not being there when she died. Why didn’t I go to see her earlier? She had died three days ago. Was I really that busy? By the time I got home, I couldn’t think and didn’t want to deal with any emotions. I finally found rest in the gentle and comforting arms of sleep. As my consciousness slowly succumbed to sleep’s consoling embrace, my last thoughts were that I would not see my friend again for a very long time. Through the ensuing years, I have come to realize the reason for my intense anger. I was angry at this woman for whom I had come to care. And then she had died. But I have also come to appreciate the treasure I have because of her, the lessons she laced into my life. For so many of us, death is a fearful, painful territory to traverse, and to approach it by any means can be a psycho-
logically and emotionally traumatic experience. This we understand almost instinctively. The idea that one day we ourselves will no longer be is also very unsettling. But to face one’s death by way of a slow, physically deteriorating and painful disease and yet daily express love goes beyond our base instincts. This elderly woman had stepped out of her pain to show a young intern the power of hope in something far greater than death, deeper than despair and stronger than ourselves. It is a hope that is sure to quench the scorching flames of any fiery furnace. ✝
Pierre Arty, M.D., was born in Cap-Haitien, Haiti, but he was raised in the East Flatbush section of Brooklyn, N.Y. He graduated from Downstate Medical School in Brooklyn in 1990. After completing an internal medicine residency, he did a fellowship in Addictive Medicine, followed by a residency in psychiatry, because he believed that to be God’s direction for his life. He is acting Director of the Addictive Disease Services at Kings County Hospital. He lives in Brooklyn, N.Y.
family and I now live overseas as I train local “ Mydoctors and students for medical mission work throughout Central Asia. We are carrying out the vision God gave us while at IN HIS IMAGE Family Practice Residency Program. I had never dreamed of this type of medical missionary work. Without my medical education and training at IN HIS IMAGE I know that I would never have had this opportunity. The support and encouragement that I received at IN HIS IMAGE were truly amazing. I am so grateful for my residency training, and we treasure the friendships God gave us there. Those relationships continue to be a blessing and encouragement as we follow God’s call in Central Asia.
”
- Matt Acker, M.D.
Central Asian Medical Students and Dr. Acker
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Peter Singer has said that killing a newborn is morally equivalent to killing an unborn child. The authors agree, appealing to those who find infanticide replusive but abortion acceptable, that there is no difference between killing unborn children and infants already born (“defective” or otherwise). Today, as always, believers remain the key to holding back humanity’s insane drive to kill its own offspring, for whatever reason.
by Alva B. Weir III, M.D., and David B. Biebel, D.Min.
A Thin Red Line It is an autumn day, not long before winter, still bright with sun, and warm enough to walk the path in sweaters with a smile. Angelique watches a leaf in color float gently from above to brush against her baby’s face. Nestled in his mother’s arms, wrapped against the breeze, the six-month-old awakens and smiles. As Angelique steps onto the wider road, Jolene, her friend for years, steps down from her porch, also with a baby in her arms. Jolene waves and calls out, “May I walk with you?” “Of course,” Angelique replies, “I’d love to have you with me.” “Have you made up your mind?” Jolene asks. “Yes,” Angelique replies. “There’s no way I can raise this child and care for the others. John’s job pays too little, and I’m working my feet off for school and sports and lessons so Mary and Edward can keep up. It’s not fair to bring another little one into a world where we can’t really help him succeed.” “I understand. It’s the same for us,” sighs Jolene. “But, it is a shame. They have such lovely faces, almost ….” Her voice trails off as she looks again at her son. Almost angelic… Angelique thinks, glancing briefly at her child. Even with your funny eyes that will never see the world as
others see it, you’re still angelic…maybe more so. Stillness reigns as the mothers progress down the road, until Angelique breaks the silence once again. “My mother never got to walk this road,” she says. “Back then, women had to choose without ever having seen their infants. But how could that be ‘choice,’ if they were choosing for or against something they’d never seen? That wasn’t really fair. Choice is not real choice unless you see the possibility before your eyes and test it for awhile, don’t you think? At least now it’s more reasonable—you decide after they’re born. It much fairer to all concerned.” “I’m with you,” says Jolene. “Surely there is little difference in an infant three months before it breathes and three months after it breathes, except for the air in its lungs and the trouble or joy it brings its mother. I can’t believe it took a generation to understand the obvious.” Angelique speaks then almost to herself, “Well, we’ve had six months, long enough to make a rational choice.” Angelique’s eyes drift to those of her son and she catches a sparkle of recognition and joy. She looks away. She and her husband have agreed—it wouldn’t be fair to the child; it wouldn’t be fair to their other children or to society even; and, he’s not a normal baby after all. She thinks of her own mother, who raised three children without a father around, fighting for every penny, wearing herself out for Angelique’s education—a hard life. She
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thinks of her younger brother, who has finally made it after moving in and out of trouble for so many years. If only Momma had made the choice to not let him be, all of us might have been spared so much grief, she thinks. The two young women step from the forest road onto a bridge across a deep green flowing stream. Two older ladies, volunteers who understand the right and necessary rule of choice, are there to help, concerned for those who come to choose. As Angelique and Jolene step upon the bridge, before them lies a thin red line. This line, once crossed, will make the choice permanent. Both mothers stop before the line, the older women smiling gently on the other side, by law not allowed to encourage those who come in any way. “Are you ready?” asks Jolene. “I’ll be right behind you,” says Angelique. Jolene crosses the line. Standing at the rail that overlooks the stream, she wraps the baby snug against the cold below. “I’m sorry, little one,” she says. “But I choose to let you go.” Her baby falls as if in slow motion toward the creek below. The only sound, a coo of baby wonder, is silenced by a splash, as the little bundle plunges through the surface of the stream. Angelique watches, one foot over the line. Then, as she shifts her weight to take the other step, her baby’s hand touches her cheek and all is changed. For Angelique, the child has made the choice. As her friend escapes the bridge, Jolene moves to offer words of comfort; for she thinks she sees a good friend’s pain. “It’s okay for you to keep your baby, Angelique; just as it was right for me to let mine go,” she says. “What matters is that we exercised our right to choose.” Angelique replies, with sadness in her smile, “I know,” she says, “but it would have been nice to see them play together—like us, when we were young.”
Clement of Alexandria (150-211 A.D.) strongly condemned infanticide. JudeoChristian opposition to infanticide is founded on the doctrine that every human bears the image of God, the Creator (Genesis 1:26); and that He alone holds the keys of life and death. In about 320 A.D., the Christian Emperor Constantine enacted two laws aimed at ending the practice. Nearly three centuries later, Mohammed’s reforms included a prohibition of infanticide. Mohammed asked how a father would account to God for such an action “when the female child that has been buried alive shall be asked for what crime she was put to death.” Islamic teaching is consistent with Judeo-Christian efforts to prohibit infanticide. In spite of this ethic, even in “Christianized” societies this scourge has been difficult to hold back. For example, in the 1800s, infanticide was so rampant in England that the practice was debated in the press, both popular and medical. An editorial in Lancet proclaimed, “to the shame of civilization it must be avowed that not a State has yet advanced to the degree of progress under which child-murder may be said to be a very uncommon crime.” 1 Infanticide continued to be quite common worldwide until the advent of surgical abortion. When an unintended pregnancy occurred prior to this, reluctant parents had to wait until the child was born to dispose of him or her. Abortion changed this by preventing the unwanted child’s birth, lessening the perceived need for infanticide. As a result, we are still killing babies; we’re just killing them younger. Many in our culture seem to feel a great comfort in using the birth canal as the dividing line between moral and immoral killing. That comfort may not last for long. The story of Jolene and Angelique may not be as unlikely in the future as we might wish—and assuming that such atrocity will not come near our tent may well hasten its coming. Peter Singer (Princeton University) wrote in Practical Ethics:
The Continuum of “Choice” Throughout human history, people in various cultures have practiced infanticide for many reasons, including poverty, gender, illegitimacy and population control. The methods have included exposure, burial alive, head trauma, strangulation and drowning. In the Graeco-Roman era, exposure was commonly practiced as the mode of choice for killing female children. By the second and early third century A.D. the Christian Church began to raise its voice in opposition to this practice. Church leaders including Justin Martyr (114-166 A.D.) and
“I have argued that the life of the fetus is of no greater value than the life of a nonhuman animal at a similar level of rationality, self-consciousness, awareness, capacity to feel, etc., and that since no fetus is a person no fetus has the same claim to life as a person. Now it must be admitted that these arguments apply to the newborn baby as much as to the fetus. A week-old baby is not a rational and self-conscious being, and there are many nonhuman animals whose rationality, self-consciousness, awareness, capacity to feel, and so on, exceed that of a human baby a week, a month, or
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Singer’s logic only extends our presently accepted abortion ethic. Killing a newborn child (“defective” or otherwise) is no less rational than killing an unborn child (“defective” or otherwise), and killing an unborn child is no less life-ending than killing a newborn child. The children we face across the breakfast table were no less our children when they rested in their mother’s wombs. Before they took their first breath these unborn children had the same potential for love and joy and
tears that we see in them at two or ten or twenty years of age. They carried the same genes from their moms and dads and the same image of God. We may read Singer’s words and cry, “No! That is too much!” when in truth, it’s just the same. This ethic of killing is nothing new. It is almost as old as time, riding into human choice on the serpent’s oily lie, questioning God’s truthfulness: “You will not surely die. For God knows that when you eat of it your eyes will be opened, and you will be like God, knowing good and evil.” Not long after Eve chose to believe this lie, humans began to kill each other, and eventually their offspring, for reasons also cloaked in lies. Today, we sons and daughters of Eve have perfected this art—both the killing and the lying. The rhetoric may sound sophisticated and refined, dressed up in words like “choice,” or “necessity” or “freedom.” Yet the naked truth remains that killing a child is killing a child. A second truth follows: Throughout history, people of faith have been the primary force restraining humanity’s insane drive to cross that thin red line. Killing our children at any age is wrong. The question is: Can the Church stand together in these days and protect our children from a society where little ones are sacrificed to lessen the hardships of adults? How many more infants, when asked why their lives were terminated, will have to say: “I don’t know. I thought they were my parents!” ✝ Notes: 1. From the Web site: http://www.infanticide.org/history.htm. 2. Peter Singer. Practical Ethics (Cambridge: Cambridge University Press, 1979): 122-123, 136-7, 138.
Alva B. Weir III, M.D., (left) practices medicine in Memphis, Tennessee. He is the immediate Past President of CMDA. His book, When the Doctor Has Bad News is now available at bookstores, or via CMDA’s Resource Department at (888) 231-2637. David B. Biebel, D. Min., (right) is a minister who lives in Colorado. He has edited Today’s Christian Doctor since 1992. His latest book, coauthored with Harold G. Koenig, M.D., New Light on Depression—Help and Hope for the Depressed and Those Who Love Them, is due out in December 2003. 30
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PutYour Faith Into
Practice
THE PURPOSE
The Valley Baptist Family Practice Residency exists to prepare physicians to reach the world for Christ. Our international community on the Texas-Mexico border provides the setting. Our high-tech, busy clinic and hospital provide the resources. The Word of God provides the vision.
THE PREPARATION Paid Advertisement
even a year old. If the fetus does not have the s a m e claim to life as a person, it appears that the newborn baby does not either, and the life of a newborn baby is of less value than the life of a pig, a dog, or a chimpanzee…. “If defective newborn infants were not regarded as having a right to life until, say, a week or a month after birth it would allow us to choose on the basis of far greater knowledge of the infant’s condition than is possible before birth…. Killing a defective infant is not morally equivalent to killing a person. Very often it is not wrong at all.” 2
An energetic, experienced faculty works sideby-side with the residents in our apprenticeship-model teaching environment. Procedures, surgeries, deliveries, and plenty of pathology are the daily fare of our Family Medicine team. Discipling of residents and their families occurs during daily prayer times, weekly Bible studies, spousal support groups and retreats.
THE PRACTICE
Residents are encouraged and trained to share the Gospel and to pray with patients. We believe that medical outreach should be a part of the resident’s routine. Our weekly Mexico Mission trips, monthly health fairs, abstinence programs, and sports medicine events provide the backdrop for exciting and effective evangelism.
Valley Baptist Family Practice Residency 2222 Benwood Street • Harlingen, Texas 78550 956/389-2448 • Fax: 956/389-2498 • www.vbfpr.com
Advertising Section Dental 2 Christian Dentists have immediate opening for full-time associate leading to partnership. Full range of general dentistry serving all ages. Domestic and overseas missions encouraged. Contact Dr. Bob Zimmerman; 750 S. Potomac St., Waynesboro, PA 17268; e-mail: rrzdds@pa.net; H: 717-762-4706; W: 717-762-1515. 343/0331/2190 Partnership Opportunity - Greater Kansas City. 5 operatory practice in stand-alone facility is an outstanding practice in a smaller Kansas City community. Immediate partnership opportunity available. Seeking like-minded committed Christian dentist. Contact: Dr. Paul Mabe: 913707-5337. 343/0617/2187 Join practice in Godfrey, IL. Need hard worker with good technical skills. Opportunity to make $200,000 or more/yr. working 35 hours/week. If interested, please call 618-466-0229, or e-mail: 343/0409/2194 lcrocker@charter.net. Bellevue, Washington. Dentist seeking committed Christian to buy large 28-year established family practice based on biblical principles. This energetic practice, grown around committed long-term staff and patients is located next to the Microsoft Corp. Owner desires to work part-time in the practice while also seeking mission opportunities. Contact Dr. Lawrence Bouma evenings; 425-883-8507 or e-mail; lmbouma@earthlink.net. 341/0588/2045
Christian dentist wanted for associateship with buy-in potential. Busy, solo general practice in Chattanooga is expanding into new office facility, so associate position will be available by June/July. Wonderful staff, owner is missionsminded and is looking forward to a like-minded associate/partner. First year income very realistic over $110k. Please call Tim Blackiston at 423432-5364 (cell); 423-821-6106 (home). 343/0618/2188 Part- or full-time dentist. Partnership or buy-out opportunity of a practice grossing $300,000, using digital radiography, located in Joliet, IL. Send resume to Thomas Zupancic, 1022 67th St., Downers Grove, IL 60516. 342/0600/2126
Miscellaneous Single Christian Women: Live vibrantly. Grow faithfully. Develop professionally. Connect relationally. Chicagoland Conference: “Live Here Now!” October 4, 2003. Here Now! Ministriesequipping single women to live vibrantly in Christ. See: www.herenowonline.org; e-mail: info@herenowonline.org; 440-716-8417. 343/0620/2191
Overseas Missions Dentist Desperately Needed: The Christian Dental Society of Honduras needs a North American dentist to help them as a missionary. Interested parties please contact: BHambrick@pol.net. 342/0603/2134
Physician Registry. Greensboro, NC has begun a program of physician registry to help provide medical care to missionaries while they are in the US. They are also available for consultation to the foreign MD or the missionary while they are out of the country. Contact Open Door Action Ministries via their Web site: www.odaministries.org. 343/0615/2183
Positions Open
Group of 4 physicians and 6 mid-levels in a growing southwest Kansas practice, seeking additional Christian colleague. Practice fullrange of family medicine combining ministry with medicine. Developing multiple sites. Shortterm missions encouraged. Great familyoriented rural communities offering excellent schools. Competitive package. If interested, please contact Mrs. Janet Enlow; 620-885-4202. 343/0619/2189
ADDITIONAL OPPORTUNITIES AVAILABLE! ALLERGY, DERMATOLOGY, ENDOCRINOLOGY, HEMATOLOGY, ONCOLOGY, NEPHROLOGY, ENT, PATHOLOGY, PULMONOLOGY, CRITICAL CARE, RHEUMATOLOGY, UROLOGY. CONTACT AARON PAULUS AT 888-690-9054 OR e-mail: ajpaulus@cmdahome.org. 343/0059/2200
Anesthesia Northwest New Mexico (MS-103). In the heart of Indian Country, large multi-specialty practice needs anesthesiologist. Contact Cathy Morefield at 888-690-9054, fax CV to 423-844-1005, or e-mail: cathy@cmdahome.org. 343/0059/2207 LET CMDA PLACEMENT SERVICES FIND A POSITION FOR YOU! OPENINGS IN FL (AN-131), (AN-
124), NM (MS-103), OR (MS-213), TX (AN-128), WA (AN-134), (MS-182). CONTACT CATHY MOREFIELD AT 888-690-9054, FAX CV TO 423-844-1005, OR e-mail: cathy@cmdahome.org. 343/0059/2206
CARDIOLOGY! EXCELLENT OPPORTUNITIES IN: NC, LA, TX, FL, CA, IN, IL, GA, NC, ETC. FOR COMPLETE LIST OF OPENINGS CONTACT AARON PAULUS AT 888-690-9054 OR e-mail: ajpaulus@cmdahome.org. 3436/0059/2195
Family Practice Connecticut (FP-301). Practice consisting of 2 physicians and 1 Physician Assistant searching for FP with OB. Mission-minded group. Contact Allen Vicars for more information: 888-690-9054; fax CV to 423-844-1005; or e-mail: allen@cmdahome.org. 343/0059/2215 FOR MORE INFORMATION ON NATIONWIDE OPPORTUNITIES IN FAMILY PRACTICE, CONTACT ALLEN VICARS: 888-690-9054; FAX CV TO 423-844-1005; OR e-mail: allen@cmdahome.org. 343/0059/2221 Group of nine family physicians in SE Kentucky seeks additional colleagues who desire to “minister the love of God through healthcare.” Two sites - Barbourville and Corbin. Group provides the full range of family medicine including operative obstetrics. OB optional. For more information please contact Steve Toadvine; 606-546-9287. 334/0521/1934
Missouri (FP-848). Six family physicians and four Nurse Practitioners searching for FP associate with OB. Practice operates 2 clinics. Both inpatient and outpatient work are required with a call schedule of 1:6. Contact Allen Vicars for more information: 888-690-9054; fax CV to 423844-1005; or e-mail: allen@cmdahome.org. 343/0059/2218
Need solo family practitioner, internist or both. Excellent, modern office - equipped, 2000 sq. ft. and basement. Best hospital in Ohio, 112 beds; 850 personnel/ 80 medical staff members. Near Turnpike midway between Cleveland and Toledo, eighteen miles south of Sandusky (Cedar Point). Superb, new schools. Family doctor retiring after 48 years in practice at same location. 419-668-8282; 419-668-8283. 343/0614/2182
Northern Indiana (FP-856). Single-specialty group with 3 physicians seeking Family Practice physician, OB optional. Call is every 4th week on weekdays and every 6th on weekends. Average number of patients per day: 25. Contact Allen Vicars for more information: 888-690-9054; fax CV to 423-844-1005; or e-mail: allen@cmdahome.org. 343/0059/2216 South Carolina (FP-828). Independent practice near Charleston consisting of 1 family physician and a Physician Assistant searching for family practice associate, no OB. Both inpatient and outpatient are required with a call schedule of 1:5 weekdays and every fourth weekend. Contact Allen Vicars for more information: 888-690-9054; fax CV to 423-844-1005; or e-mail: allen@cmdahome.org. 343/0059/2217 West Virginia (FP-835). Independent practice consisting of 5 family physicians and 2 physician assistants searching for FP, no OB. Both inpatient and outpatient work are required with a call 1:5 per week and 1:7 on the weekends. Willing to consider full-time or part-time physicians. Contact Allen Vicars for more information: 888690-9054; fax CV to 423-844-1005; or e-mail: allen@cmdahome.org. 343/0059/2220 FP, IM, PD & other specialties. Openings in NC, SC, TX, PA & other states with Christian physician practices. Good call, compensation & mission. Go to: www.integritymedplace.com; call 888-558-0114; e-mail: service@integritymedplace.com. 342/0182/2122
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Advertising Section GASTROENTEROLOGY! GROWING PRACTICES SEEKING PHYSICIANS IN: AL, IN, TX, NY, MI, FL, SC, NC, AND HI! FOR FURTHER DETAILS AND COMPLETE LISTING CONTACT AARON PAULUS AT 888-690-9054 OR
e-mail: ajpaulus@cmdahome.org.
343/0059/2196
Infectious Disease Excellent opportunity in beautiful Ft. Lauderdale, FL. Christian practice. Great compensation. Immediate need. For details and complete list of other opportunities contact Aaron Paulus at 888-690-9054 or e-mail: ajpaulus@cmdahome.org. 343/0059/2197
Internal Medicine Looking to relocate? Growing list of opportunities in over 22 states! Contact Aaron Paulus at 888-690-9054 or e-mail: ajpaulus@cmdahome.org. 343/0059/2198
Medical Associates of the Black Hills in Rapid City, South Dakota, a twenty-provider multispecialty clinic is seeking an internist to join its four-person internal medicine department (one in eight call). The clinic features full lab and radiology services, bone-densitometry, and mammography, in a 1-1/2 year old building. Physicians begin as associates with a guaranteed salary and benefits for up to two years and then partnership is available. If interested, contact djordahl@mabhllc.org or fax information to (605) 718-3427 attention David Jordahl, CEO, Medical Associates of the Black Hills, LLC. 343/0621/2191
Miscellaneous Adventist Health—a not-for-profit West Coast health care system, oversees operations in 20 hospitals in California, Hawaii, Oregon and Washington. Many hospitals have openings for BC/BE primary care and specialty physicians. For information on current practice opportunities, visit us at www.adventisthealth.org or e343/0310/2185 mail: heilib@ah.org.
NURSE PRACTITIONER! OPPORTUNITIES IN CT, GA, NC, OH, TN, VA, WA. CONTACT ROSE COURTNEY FOR MORE INFORMATION: 888-878-2133; FAX CV TO 423-844-1005; OR e-mail: rose@placedocs.com. 343/0059/2223
Ob/Gyn
OPENINGS IN GA, TX, FL, MD, TN, CA & OTHER STATES WITH CHRISTIAN PHYSICIAN PRACTICES.
GOOD CALL, COMPENSATION & MISSION. GO TO WWW .INTEGRITYMEDPLACE.COM; CALL 888-558-0114; e-mail: 342/0182/2124 service@integritymedplace.com. North Carolina (OB-255). Maternal-Fetal Medicine Specialist opportunity in Western North Carolina. Service to a rural region. Travel in a beautiful mountainous terrain to hospitals; private offices and health departments coordinated with a rewarding private practice at the home base. Liability insurance less than national average. Contact Rose Courtney for more information: 888-878-2133; fax CV to 423-844-1005; or e-mail: rose@placedocs.com. 343/0059/2225 OPPORTUNITIES IN AL, CA, CO, FL, GA, IL, IN, MD, MN, MO, OH, OK, TN, VA, WA, WI. CONTACT ROSE COURTNEY FOR MORE INFORMATION: 888-878-2133; FAX CV TO 423-844-1005; OR e-mail: rose@placedocs.com. 343/0059/2224
Oncology Central California opportunity associated with new hospital. Income potential of $317,000. Service area population of 76,000. Potential cancer center directorship. Call Aaron Paulus at 888-690-9054 or e-mail: ajpaulus@cmdahome.org.
Ophthalmologist Seeking fellowship-trained Retinal Specialist, Pediatric Ophthalmologist, or General Ophthalmologist to join 5-doctor practice in Virginia. Send CV to ET# 258, PO Box 7500, Bristol, TN 37621; e-mail: advertising@cmdahome.org, subject ET#258. 333/0349/1927 CONTACT ROSE COURTNEY FOR MORE INFORMATION: 888-878-2133; FAX CV TO 423-844-1005; OR e-mail: rose@placedocs.com. 343/0059/2227
Orthopedic Colorado (OS-157) Independent practice seeking full-time or part-time surgeon with an interest in spine, foot or ankle surgery. Contact Cathy Morefield at 888-690-9054, fax CV to 423-8441005, or e-mail: cathy@cmdahome.org. 343/0059/2210
New Mexico (MS-103) Large multi-specialty practice. Hospital has 700 employees. Contact Cathy Morefield at 888-690-9054, fax CV to 423844-1005, or e-mail: cathy@cmdahome.org. 343/0059/2209
East Tennessee (OB-242). Single-specialty OB/Gyn group searching for someone to join their practice. Currently there are 2 OB/Gyns in the practice. Call is currently 1:2, but have plans to expand that to 1:3. Contact Rose Courtney for more information: 888-878-2133; fax CV to 423844-1005; or e-mail: rose@placedocs.com. 343/0059/2226
Tennessee (MS-154). Four Orthopedic Surgeons in department are interested in new associates to assist with the referrals in and out of the group. They are also open to adding a group who might be interested in relocating due to managed care/malpractice insurance/other regulatory problems in their area. Contact Cathy Morefield at 888-690-9054 or e-mail: cathy@cmdahome.org. 343/0059/2211
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Orthopedic - needed to join a six physician orthopedic practice committed to providing orthopedic care with compassion as well as excellence. Time off for short term missions supported. Kearney Orthopedic and Fracture Clinic would like to talk with general and subspecialty orthopedists about the possibility of joining us in practice. The clinic has been in existence 30 years. Clinic owns an on-site, JCAHO accredited Surgery Center. The Clinic and Good Samaritan Hospital are co-sponsors of the Nebraska Joint Replacement Center. Good Samaritan Hospital (207 beds) and its staff of 130 physicians provide tertiary care to a largely rural population in Central and Western Nebraska and Northern Kansas. Kearney, NE, is home to the University of Nebraska Kearney, the Museum of Nebraska Art, USHL hockey team, NIFL football team, the Great Platte River Road Archway Monument and Good Samaritan Health Systems. We can help with financial aspects of relocation, sub-specialty training and/or school loan repayment. Please contact our Medical Director, Dr. Steve Brestin at 308-865-1407 or sbrestin@kofc.kearney.net. Our business manager, Vicki Aten, can be reached at 308-8652512 or at: vaten@kofc.kearney.net. 342/0467/2119
LET CMDA PLACEMENT SERVICE FIND A POSITION FOR YOU! OPENINGS IN CA (MS-192), CO (OS157), (MS-220), IN (OS-148), MN (MS-133), NC (OS-156), NE (OS-179), NM (MS-103), OR (OS178), SC (OS-172), TN (MS-154), MS-195, TX (MS-143), (MS-221), WA (OS-163). CONTACT CATHY MOREFIELD AT 888-690-9054, FAX CV TO 423-844-1005, OR e-mail: cathy@cmdahome.org. 343/0059/2208
Pediatrics Florida. BC/BE pediatrician for growing, central west-cost community. Good referral base w/hospitals nearby. Excellent benefits & call. CV to Manatee Pediatrics, 712 39th St. W., Bradenton, FL 34205; or fax 941-747-9230; e-mail: 332/0537/1857 mail@manateepediatrics.com. North Carolina. BC Pediatrician needed for Hispanic pediatric practice in Burlington, NC. Must be bilingual. Competitive salary and benefits. Reply to infamclin@aol.com. Phone 336-5700010; fax 336-570-0012. 331/0551/1727 New Jersey (PD-206). Pediatric, independent practice seeking another pediatrician to join this two-person group, one of which will be retiring in 2004. Outpatient only. Call is 1 night per week and 1:5 weekends. Admit to one hospital, which has 20 ped beds. 24-hour in-house pediatric coverage. Level II Nursery with full-time neonatologist. Contact Rose Courtney for more information: 888-878-2133; fax CV to 423-844-1005; or 343/0059/2231 e-mail: rose@placedocs.com.
Advertising Section OPPORTUNITIES IN CA, FL, GA, IL, KS, KY, MA, NJ, NM, NC, PA, TN, WA, WY. CONTACT ROSE COURTNEY FOR MORE INFORMATION: 888-878-2133; FAX CV TO 423-844-1005; OR e-mail: rose@placedocs.com. 343/0059/2229 Southern California (PD-207). Solo pediatric practice. Physician searching for someone to join him and eventually take over the practice. Call is about 1 day a week and one weekend every 6 weeks. Contact Rose Courtney for more information: 888-878-2133; fax CV to 423-8441005; or e-mail: rose@placedocs.com. 43/0059/2230
MED/PEDS! CONTACT ROSE COURTNEY FOR MORE INFORMATION: 888-878-2133; FAX CV TO 423-844-1005; OR e-mail: rose@placedocs.com. 343/0059/2222
Physician Assistant! Opportunities in CT, GA, NC, OH, TN, VA. Contact Rose Courtney for more information: 888-878-2133; fax CV to 423-844-1005; or e-mail rose@placedocs.com. 343/0059/2232
Psychiatry California. Immediate opportunity for Christian psychiatrist to join a well respected and established group. Opening is available to replace retiring physician. Beautiful Napa Valley location. Contact Ingrid Heil, Director of Physician Services, Adventist Health, 800-8479840, fax CV to 916-774-3390, or e-mail: heilib@ah.org. 343/0310/2184 CONTACT ROSE COURTNEY FOR MORE INFORMATION: 888-878-2133; FAX CV TO 423-844-1005; OR
e-mail: rose@placedocs.com.
General - Alabama (MS-226). Solo Practice, very flexible schedule and hours. Medical center will offer assistance in securing quality office personnel, provide office space to be rented at a reasonable market price, promote practice and the introduction of the physician. Contact Cathy Morefield at 888-690-9054, fax CV to 423-8441005, or e-mail: cathy@cmdahome.org. 343/0059/2202
GENERAL SURGERY LET CMDA PLACEMENT SERVICE FIND A POSITION FOR YOU! OPENINGS IN - AL (MS-226), AZ (SG-223), CA (SG-226), FL (MS-228), IA (MS187), (SG-212), IN (FP-284), (SG-181), (SG181), (SG-207), KS (SG-171), MD (SG-157), MI (SG-169), (SG-210), MN (MS-233), (SG-221), MO (SG-222), NC (SG-166), (SG-177), NY (SG-220), OH (MS-150), (SG-206), (SG-225), OR (MS-213), (SG-215), TX (MS-186), (MS221), UT (SG-224), WA (MS-182), (SG-178), (SG-202), (SG-205), WI (MS-229). CONTACT CATHY MOREFIELD AT 888-690-9054, FAX CV TO 423-844-1005, OR e-mail: cathy@cmdahome.org. 343/0059/2201 General - North Carolina (SG-177). Singlespecialty practice growing seeking a BE/BC General Surgeon. Call coverage 1:4. Only surgical group in town serving 175 bed hospital. Contact Cathy Morefield at 888-690-9054, fax CV to 423-844-1005, or e-mail: cathy@cmdahome.org. 343/0059/2203
Practice for Sale California - Established, growing Family Practice. Wonderful patients, good payer mix, no obstetrics. Dedicated staff. Paperless, integrated EMR/billing system. Nurse Practitioner student with option to hire. Second Physician being recruited. Call 1:8 Income guarantee/loan repayment through local hospital. Northern California: On 1000 miles of waterways to ocean. Two hours to San Francisco, Monterey Bay, Pacific Ocean, Yosemite, Lake Tahoe, Sierra Mountains, and Napa Valley. Contact Andrew Wilke, M.D. Home: 209-477-4342. 343/0622/2192 MOH’S SURGEON - Thriving 7 figure solo Derm/Cosmetic Surgery practice in an expanding medical/shopping center NE of Dallas. Over 400 skin cancer surgeries performed last year. Five year old custom designed 6,000 sq ft building and practice For Sale. Present Derm willing to transition to retirement. 903-785-8300; e-mail: pbandel@1starnet.com. 343/0616/2186 Orthopedic Practice for Sale - Georgia. Seeking Orthopedic surgeon to purchase prosperous orthopedic practice in Georgia. Practice incorporates strong referral base, attractive call schedule, and practice growth opportunity. Contact: Health Systems Strategies; e-mail: H.S.S.@mindspring.com; 770-551-8211; fax 770-643-8692. 343/0613/2181
Plastic Surgeon - Tennessee (MS-154). BC/BE Plastic Surgeon needed. Currently 1 on staff. Contact Cathy Morefield at 888-690-9054, fax CV to 423-844-1005, or e-mail: cathy@cmdahome.org. 343/0059/2212
343/0059/2233
343/0059/2199
Surgery General/Gastroenterologist - Seeking evangelical Christian BC/BE general surgeon and gastroenterologist to join GS group in south central PA. Excellent opportunity for short-term missions each year. Call or send CV with cover to Mark D. Roth, MD; 717-762-7155; fax 717-7626929; 45 Roadside Ave., Waynesboro, PA 17268; e-mail: mdroth@desupernet.net. 292/0163/0661 SURGERY OPENINGS IN NC, AR, FL, GA SC, WA, MD & OTHER STATES WITH CHRISTIAN PHYSICIAN PRACTICES. GOOD CALL, COMPENSATION & MISSION. GO TO WWW .INTEGRITYMEDPLACE.COM; OR CALL 888-558-0114; e-mail: service@integritymedplace.com. 342/0182/2123
Spine Surgeon- Tennessee (MS-154). BC Spine surgeon. Clinic currently does not have a spine surgeon on staff. Contact Cathy Morefield at 888-690-9054, fax CV to 423-844-1005, or e-mail: cathy@cmdahome.org. 343/0059/2214 Vascular - Ohio (VS-106). Surgical practice needs specialist to treat a full range of vascular and chest diseases. Vascular & Thoracic surgery is done at hospital. Call schedule is 1:3. Admitting hospital has 300 beds. Contact Cathy Morefield at 888-690-9054, fax CV to 423-8441005, or e-mail: cathy@cmdahome.org. 343/0059/2234
VASCULAR SURGERY Let CMDA Placement Service find a position for you! Openings in OH (VS-106), VA (SG165), MN (SG-221). Contact Cathy Morefield at 888-690-9054, fax CV to 423-844-1005, or e-mail: cathy@cmdahome.org. 343/0059/2204
Internet Web site:
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RADIOLOGY! PRACTICE IN A CHRISTIAN ENVIRONMENT! OPPORTUNITIES IN TX, KY, NC, CA, AZ, AND MORE. CONTACT AARON PAULUS AT 888-690-9054 OR e-mail: ajpaulus@cmdahome.org.
Whether short-term or full-time, Blessings International assists Medical Missions by being a source for: 1. Pharmaceuticals and medical supplies 2. Expertise in selecting needed medications 3. Guidance in building medical teams and operating short-term clinics For a pharmaceutical application and bulletin, contact:
Blessings International P.O. Box 35292, Tulsa, OK 74146-0292 918-250-8101; BlessingsInt@blessing.org www.blessing.org
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Custom Tailored
®
12 Accudose strengths. All color-coded and easy to titrate. ®
LEVOXYL®’s thyroid gland-like shaped Accudose® tablets are scored for simplified dose titration. For customized hypothyroid therapy, there is no substitute for LEVOXYL®. Time after time, LEVOXYL®’s proven stabilized formation is always on the level. 25 mcg
50 mcg
75 mcg
88 mcg
100 mcg
112 mcg
125 mcg 137 mcg
LEVOXYL® is indicated for thyroid hormone replacement or supplemental therapy for hypothyroidism. LEVOXYL® is contraindicated in patients with untreated thyrotoxicosis, uncorrected adrenal insufficiency, or hypersensitivity to any of its inactive ingredients. Adverse reactions are primarily those of hyperthyroidism due to overdose. Use with caution in patients with cardiovascular disease.
150 mcg
175 mcg
200 mcg
300 mcg
A C C U D O S E TA B L E T S
†Patent pending.
WARNING: Thyroid hormones, including LEVOXYL®, either alone or with other therapeutic agents, should not be used for the treatment of obesity. In euthyroid patients, doses within the range of daily hormonal requirements are ineffective for weight reduction. Larger doses may produce serious or even life-threatening manifestations of toxicity, particularly when given in association with sympathomimetic amines such as those used for their anorectic effects. Please see brief summary of full prescribing information on adjacent page for a more detailed discussion of important safety information. 34
T o d a y ’s C h r i s t i a n D o c t o r
™
Brief Summary (for full prescribing information see package insert). For Oral Administration LEVOXYL® (levothyroxine sodium tablets, USP)
WARNINGS WARNING: Thyroid hormones, including LEVOXYL®, either alone or with other therapeutic agents, should not be used for the treatment of obesity or for weight loss. In euthyroid patients, doses within the range of daily hormonal requirements are ineffective for weight reduction. Larger doses may produce serious or even life threatening manifestations of toxicity, particularly when given in association with sympathomimetic amines such as those used for their anorectic effects. Levothyroxine sodium should not be used in the treatment of male or female infertility unless this condition is associated with hypothyroidism. PRECAUTIONS General Levothyroxine has a narrow therapeutic index. Regardless of the indication for use, careful dosage titration is necessary to avoid the consequences of over- or under-treatment. These consequences include, among others, effects on growth and development, cardiovascular function, bone metabolism, reproductive function, cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism. Effects on bone mineral density – In women, long-term levothyroxine sodium therapy has been associated with decreased bone mineral density, especially in postmenopausal women on greater than replacement doses or in women who are receiving suppressive doses of levothyroxine sodium. Therefore, it is recommended that patients receiving levothyroxine sodium be given the minimum dose necessary to achieve the desired clinical and biochemical response. Patients with underlying cardiovascular disease – Exercise caution when administering levothyroxine to patients with cardiovascular disorders and to the elderly in whom there is an increased risk of occult cardiac disease. In these patients, levothyroxine therapy should be initiated at lower doses than those recommended in younger individuals or in patients without cardiac disease (see WARNINGS; PRECAUTIONS, Geriatric Use; and DOSAGE AND ADMINISTRATION). If cardiac symptoms develop or worsen, the levothyroxine dose should be reduced or withheld for one week and then cautiously restarted at a lower dose. Overtreatment with levothyroxine sodium may have adverse cardiovascular effects such as an increase in heart rate, cardiac wall thickness, and cardiac contractility and may precipitate angina or arrhythmias. Patients with coronary artery disease who are receiving levothyroxine therapy should be monitored closely during surgical procedures, since the possibility of precipitating cardiac arrhythmias may be greater in those treated with levothyroxine. Concomitant administration of levothyroxine and sympathomimetic agents to patients with coronary artery disease may precipitate coronary insufficiency. Patients with nontoxic diffuse goiter or nodular thyroid disease – Exercise caution when administering levothyroxine to patients with nontoxic diffuse goiter or nodular thyroid disease in order to prevent precipitation of thyrotoxicosis (see WARNINGS). Associated endocrine disorders Hypothalamic/pituitary hormone deficiencies – In patients with secondary or tertiary hypothyroidism, additional hypothalamic/pituitary hormone deficiencies should be considered, and, if diagnosed, treated (see PRECAUTIONS, Autoimmune polyglandular syndrome) for adrenal insufficiency. Autoimmune polyglandular syndrome – Occasionally, chronic autoimmune thyroiditis may occur in association with other autoimmune disorders such as adrenal insufficiency, pernicious anemia, and insulin-dependent diabetes mellitus. Patients with concomitant adrenal insufficiency should be treated with replacement glucocorticoids prior to initiation of treatment with levothyroxine sodium. Failure to do so may precipitate an acute adrenal crisis when thyroid hormone therapy is initiated, due to increased metabolic clearance of glucocorticoids by thyroid hormone. Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens when treated with levothyroxine (see PRECAUTIONS, Drug Interactions). Other associated medical conditions Infants with congenital hypothyroidism appear to be at increased risk for other congenital anomalies, with cardiovascular anomalies (pulmonary stenosis, atrial septal defect, and ventricular septal defect,) being the most common association. Drug Interactions Many drugs affect thyroid hormone pharmacokinetics and metabolism (e.g., absorption, synthesis, secretion, catabolism, protein binding, and target tissue response) and may alter the therapeutic response to LEVOXYL®. In addition, thyroid hormones and thyroid status have varied effects on the pharmacokinetics and action of other drugs. A listing of drug-thyroidal axis interactions is contained in Table 2. The list of drug-thyroidal axis interactions in Table 2 may not be comprehensive due to the introduction of new drugs that interact with the thyroidal axis or the discovery of previously unknown interactions. The prescriber should be aware of this fact and should consult appropriate reference sources. (e.g., package inserts of newly approved drugs, medical literature) for additional information if a drug-drug interaction with levothyroxine is suspected. Table 2: Drug-Thyroidal Axis Interactions Drug or Drug Class Effect Drugs that may reduce TSH secretion – the reduction is not sustained; therefore, hypothyroidism does not occur Dopamine / Dopamine Agonists Use of these agents may result in a transient reduction in TSH secretion when administered at Glucocorticoids the following doses: Dopamine (> 1 mcg/kg/min); Glucocorticoids (hydrocortisone > 100 mg/day Octreotide or equivalent); Octreotide (> 100 mcg/day). Drugs that alter thyroid hormone secretion Drugs that may decrease thyroid hormone secretion, which may result in hypothyroidism Aminoglutethimide Long-term lithium therapy can result in goiter in up to 50% of patients, and either subclinical or Amiodarone overt hypothyroidism, each in up to 20% of patients. The fetus, neonate, elderly and euthyroid Iodide (including iodine-containing patients with underlying thyroid disease (e.g., Hashimoto’s thyroiditis or with Grave’s disease Radiographic contrast agents) previously treated with radioiodine or surgery) are among those individuals who are particularly Lithium susceptible to iodine-induced hypothyroidism. Oral cholecystographic agents and amiodarone are Methimazole slowly excreted, producing more prolonged hypothyroidism than parenterally administered Propylthiouracil (PTU) iodinated contrast agents. Sulfonamides Long-term aminoglutethimide therapy may minmally decrease T4 and T3 levels and increase TSH, Tolbutamide although all values remain within normal limits in most patients. Drugs that may increase thyroid hormone secretion, which may result in hyperthyroidism Amiodarone Iodide and drugs that contain pharmacologic amounts of iodide may cause in euthyroid patients Iodide (including iodine-containing with Grave’s disease previously treated with antithyroid drugs or in euthyroid patients with thyroid Radiographic contrast agents) autonomy (e.g., multinodular goiter or hyperfunctioning thyroid adenoma). Hyperthyroidism may develop over several weeks and may persist for several months after therapy discontinuation. Amiodarone may induce hyperthyroidism by causing thyroiditis. Drugs that may decrease T4 absorption, which may result in hypothyroidism Antacids Concurrent use may reduce the efficacy of levothyroxine by binding and delaying or preventing - Aluminum & Magnesium Hydroxides absorption, potentially resulting in hypothyroidism. Calcium carbonate may form an insoluble - Simethicone chelate with levothyroxine, and ferrous sulfate likely forms a ferric-thyroxine complex. Administer Bile Acid Sequestrants levothyroxine at least 4 hours apart from these agents. - Cholestyramine - Colestipol Calcium Carbonate Cation Exchange Resins - Kayexalate Ferrous Sulfate Sucralfate Drugs that may alter T4 and T3 serum transport – but FT4 concentration remains normal; and, therefore, the patient remains euthyroid Drugs that may increase Drugs that may decrease serum TBG concentration serum TBG concentration Clofibrate Androgens / Anabolic Steroids Estrogen-containing oral contraceptives Asparaginase Estrogens (oral) Glucocorticoids Heroin / Methadone Slow-Release Nicotinic Acid 5-Fluorouracil Mitotane Tamoxifen Drugs that may cause protein-binding site displacement Furosemide (> 80 mg IV) Administration of these agents with levothyroxine results in an initial transient increase in FT4. Heparin Continued administration results in a decrease in serum T4 and normal FT4 and TSH Hydantoins concentrations and, therefore, patients are clinically euthyroid. Salicylates inhibit binding of T4 and Non Steroidal T3 to TBG and transthyretin. An initial increase in serum FT4 is followed by return of FT4 to Anti-Inflammatory Drugs normal levels with sustained therapeutic serum salicylate concentrations, although total-T4 levels - Fenamates may decrease by as much as 30%. - Phenylbutazone Salicylates (> 2 g/day) Drugs that may alter T4 and T3 metabolism Drugs that may increase hepatic metabolism, which may result in hypothyroidism Carbamazepine Stimulation of hepatic microsomal drug-metabolizing enzyme activity may cause increased hepatic Hydantoins degradation of levothyroxine, resulting in increased levothyroxine requirements. Phenytoin and Phenobarbital carbamazepine reduce serum protein binding of levothyroxine, and total- and free-T4 may be Rifampin reduced by 20% to 40%, but most patients have normal serum TSH levels and are clinically euthyroid. Drugs that may decrease T4 5’-deiodinase activity Amiodarone Administration of these enzyme inhibitors decreases the peripheral conversion of T4 to T3, leading Beta-adrenergic antagonists to decreased T3 levels. However, serum T4 levels are usually normal but occasionally be slightly - (e.g., Propranolol > 160 mg/day) increased. In patients treated with may large doses of propranolol (> 160 mg/day), T3 and T4 Glucocorticoids levels change slightly, TSH levels remain normal, and patients are clinically euthyroid. It should be - (e.g., Dexamethasone > 4 mg/day) noted that actions of particular beta-adrenergic antagonists may be impaired when the hypothyroid Propylthiouracil (PTU) patient is converted to the euthyroid state. Short-term administration of large doses of glucocorti-
Anticoagulants (oral) - Coumarin Derivatives - Indandione Derivatives
Antidepressants - Tricyclics (e.g., Amitriptyline) - Tetracyclics (e.g., Maprotiline) - Selective Serotonin Reuptake Inhibitors (SSRIs; e.g., Sertraline) Antidiabetic Agents - Biguanides - Meglitinides - Sulfonylureas - Thiazolidediones - Insulin Cardiac Glycosides Cytokines - Interferon-α - Interleukin-2
Growth Hormones - Somatrem - Somatropin Ketamine Methylxanthine Bronchodilators - (e.g., Theophylline) Radiographic Agents Sympathomimetics
Chloral Hydrate Diazepam Ethionamide Lovastatin Metoclopramide 6-Mercaptopurine Nitroprusside Para-aminosalicylate sodium Perphenazine Resorcinol (excessive topical use) Thiazide Diuretics
Addition of levothyroxine to antidiabetic or insulin therapy may result in increased antidiabetic agent or insulin requirements Careful monitoring of diabetic control is recommended, especially when thyroid therapy is started, changed, or discontinued.
Serum digitalis glycoside levels may be reduced in hyperthyroidism or when the hypothyroid patient is converted to the euthyroid state. Therapeutic effect of digitalis glycosides may be reduced. Therapy with interferon-α has been associated with the development of antithyroid microsomal antibodies in 20% of patients and some have transient hypothyroidism, hyperthyroidism, or both. Patients who have antithyroid antibodies before treatment are at higher risk for thyroid dysfunction during treament. Interleukin-2 has been associated with transient painless thyroiditis in 20% of patients. Interferon-β and -γ have not been reported to cause thyroid dysfunction. Excessive use of thyroid hormones with growth hormones accelerate epiphyseal closure. However, untreated hypothyroidism may interfere with growth response to growth hormone. Concurrent use may produce marked hypertension and tachycardia; cautious administration to patients receiving thyroid hormone therapy is recommended. Decreased theophylline clearance may occur in hypothyroid patients; clearance returns to normal when the euthyroid state is achieved. Thyroid hormones may reduce the uptake of 123I, 131I, and 99mTc. Concurrent use may increase the effects of sympathomimetics or thyroid hormone. Thyroid hormones may increase the risk of coronary insufficiency when sympathomimetic agents are administered to patients with coronary artery disease. These agents have been associated with thyroid hormone and / or TSH level alterations by various mechanisms.
Oral anticoagulants – Levothyroxine increases the response to oral anticoagulant therapy. Therefore, a decrease in the dose of anticoagulant may be warranted with correction of the hypothyroid state or when the LEVOXYL® dose is increased. Prothrombin time should be closely monitored to permit appropriate and timely dosage adjustments (see Table 2). Digitalis glycosides – The therapeutic effects of digitalis glycosides may be reduced by levothyroxine. Serum digitalis glycoside levels may be decreased when a hypothyroid patient becomes euthyroid, necessitating an increase in the dose of digitalis glycosides (see Table 2). Drug-Food Interactions – Consumption of certain foods may affect levothyroxine absorption thereby necessitating adjustments in dosing. Soybean flour (infant formula), cotton seed meal, walnuts, and dietary fiber may bind and decrease the absorption of levothyroxine sodium from the GI tract. Drug-Laboratory Test Interactions – Changes in TBG concentration must be considered when interpreting T4 and T3 values, which necessitates measurement and evaluation of unbound (free) hormone and/or determination of the free T4 index (FT4I). Pregnancy, infectious hepatitis, estrogens, estrogen-containing oral contraceptives, and acute intermittent porphyria increase TBG concentrations. Decreases in TBG concentrations are observed in nephrosis, severe hypoproteinemia, severe liver disease, acromegaly, and after androgen or corticosteroid therapy (see also Table 2). Familial hyper- or hypo-thyroxine binding globulinemias have been described, with the incidence of TBG deficiency approximating 1 in 9000. Carcinogenesis, Mutagenesis, and Impairment of Fertility – Animal studies have not been performed to evaluate the carcinogenic potential, mutagenic potential or effects on fertility of levothyroxine. The synthetic T4 in LEVOXYL® is identical to that produced naturally by the human thyroid gland. Although there has been a reported association between prolonged thyroid hormone therapy and breast cancer, this has not been confirmed. Patients receiving LEVOXYL® for appropriate clinical indications should be titrated to the lowest effective replacement dose. Pregnancy – Category A – Studies in women taking levothyroxine sodium during pregnancy have not shown an increased risk of congenital abnormalities. Therefore, the possibility of fetal harm appears remote. LEVOXYL® should not be discontinued during pregnancy and hypothyroidism diagnosed during pregnancy should be promptly treated. Hypothyroidism during pregnancy is associated with a higher rate of complications, including spontaneous abortion, pre-eclampsia, stillbirth and premature delivery. Maternal hypothyroidism may have an adverse effect on fetal and childhood growth and development. During pregnancy, serum T4 levels may decrease and serum TSH levels increase to values outside the normal range. Since elevations in serum TSH may occur as early as 4 weeks gestation, pregnant women taking LEVOXYL® should have their TSH measured during each trimester. An elevated serum TSH level should be corrected by an increase in the dose of LEVOXYL®. Since postpartum TSH levels are similar to preconception values, the LEVOXYL® dosage should return to the pre-pregnancy dose immediately after delivery. A serum TSH level should be obtained 6–8 weeks postpartum. Thyroid hormones do not readily cross the placental barrier; however, some transfer does occur as evidenced by levels in cord blood of athyreotic fetuses being approximately one-third maternal levels. Transfer of thyroid hormone from the mother to the fetus, however, may not be adequate to prevent in utero hypothyroidism. Nursing Mothers – Although thyroid hormones are excreted only minimally in human milk, caution should be exercised when LEVOXYL® is administered to a nursing woman. However, adequate replacement doses of levothyroxine are generally needed to maintain normal lactation. ADVERSE REACTIONS Adverse reactions associated with levothyroxine therapy are primarily those of hyperthyroidism due to therapeutic overdosage. They include the following: General: fatigue, increased appetite, weight loss, heat intolerance, fever, excessive sweating; Central nervous system: headache, hyperactivity, nervousness, anxiety, irritability, emotional lability, insomnia; Musculoskeletal: tremors, muscle weakness; Cardiac: palpitations, tachycardia, arrhythmias, increased pulse and blood pressure, heart failure, angina, myocardial infarction, cardiac arrest; Pulmonary: dyspnea; GI: diarrhea, vomiting, abdominal cramps; Dermatologic: hair loss, flushing; Reproductive: menstrual irregularities, impaired fertility. Pseudotumor cerebri and slipped capital femoral epiphysis have been reported in children receiving levothyroxine therapy. Overtreatment may result in craniosynostosis in infants and premature closure of the epiphyses in children with resultant compromised adult height. Seizures have been reported rarely with the institution of levothyroxine therapy. Inadequate levothyroxine dosage will produce or fail to ameliorate the signs and symptoms of hypothyroidism. Hypersensitivity reactions to inactive ingredients have occurred in patients treated with thyroid hormone products. These include urticaria, pruritus, skin rash, flushing, angioedema, various GI symptoms (abdominal pain, nausea, vomiting and diarrhea), fever, arthralgia, serum sickness and wheezing. Hypersensitivity to levothyroxine itself is not known to occur. OVERDOSAGE The signs and symptoms of overdosage are those of hyperthyroidism (see PRECAUTIONS and ADVERSE REACTIONS). In addition, confusion and disorientation may occur. Cerebral embolism, shock, coma, and death have been reported. Seizures have occurred in a child ingesting approximately 20 mg of levothyroxine. Symptoms may not necessarily be evident or may not appear until several days after ingestion of levothyroxine sodium. Acute Massive Overdosage – This may be a life-threatening emergency, therefore, symptomatic and supportive therapy should be instituted immediately. If not contraindicated (e.g., by seizures, coma, or loss of the gag reflex), the stomach should be emptied by emesis or gastric lavage to decrease gastrointestinal absorption. Activated charcoal or cholestyramine may also be used to decrease absorption. Central and peripheral increased sympathetic activity may be treated by administering β-receptor antagonists, e.g., propranolol (1 to 3 mg intravenously over a 10-minute period, or orally, 80 to 160 mg/day). Provide respiratory support as needed; control congestive heart failure; control fever, hypoglycemia, and fluid loss as necessary. Glucocorticoids may be given to inhibit the conversion of T4 to T3. Because T4 is highly protein bound, very little drug will be removed by dialysis. MANUFACTURER JONES PHARMA INCORPORATED (A wholly owned subsidiary of King Pharmaceuticals, Inc.) St. Louis, MO 63146 Revised December 2001
Wholly Owned Subsidiaries of King Pharmaceuticals™, Inc.
Publication 1-2015-1 © 2003 King Pharmaceuticals, Inc., 501 Fifth Street, Bristol, TN 37620. All rights reserved. LEVOXYL is a registered trademark of Jones Pharma Incorporated. Monarch Pharmaceuticals®, Inc. and Jones Pharma™ are wholly owned subsidiaries of King Pharmaceuticals Inc. For more information call 1-866-LEVOXYL or visit us at www.LEVOXYL.com.
Internet Web site:
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CONTRAINDICATIONS Levothyroxine is contraindicated in patients with untreated subclinical (suppressed serum TSH level with normal T3 and T4 levels) or overt thyrotoxicosis of any etiology and in patients with acute myocardial infarction. Levothyroxine is contraindicated in patients with uncorrected adrenal insufficiency since thyroid hormones may precipitate an acute adrenal crisis by increasing the metabolic clearance of glucocorticoids (see PRECAUTIONS). LEVOXYL® is contraindicated in patients with hypersensitivity to any of the inactive ingredients in LEVOXYL® tablets. (see DESCRIPTION, INACTIVE INGREDIENTS.)
coids may decrease serum T3 concentrations by 30% with minimal change in serum T4 levels. However, long-term glucocorticoid therapy may result in slightly decreased T3 and T4 levels due to decreased TBG production (see above). Miscellaneous Thyroid hormones appear to increase the catabolism of vitamin K-dependent clotting factors, thereby increasing the anticoagulant activity of oral anticoagulants. Concomitant use of these agents impairs the compensatory increases in clotting factor synthesis. Prothrombin time should be carefully monitored in patients taking levothyroxine and oral anticoagulants and the dose of anticoagulant therapy adjusted accordingly. Concurrent use of tri/tetracyclic antidepressants and levothyroxine may increase the therapeutic and toxic effects of both drugs, possibly due to increased receptor sensitivity to catecholamines. Toxic effects may include increased risk of cardiac arrhythmias and CNS stimulation; onset of action of tricyclics may be accelerated. Administration of sertraline in patients stabilized on levothyroxine may result in increased levothyroxine requirements.
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Every day, more hypothyroid patients are getting the custom dosage their doctors prescribed.
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CHRISTIAN MEDICAL P.O. Box 7500 Bristol, TN 37621-7500
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