Editorial
by David Stevens, MD, MA (Ethics) — Chief Executive Officer
Sound Levees If I heard one story about hurricane Katrina, I heard a hundred when I spent four days in New Orleans a few weeks ago. The narratives were even more gripping, since I was observing the actual places in question. The hurricane was such a pivotal event in people’s lives that many in the city use it as a dating system. Instead of A.D. or B.C., it is “before or after Katrina.” There is still evidence of the devastation — empty lots, piles of rubble, and buildings never repaired, including the enormous Charity Hospital standing vacant. As you travel down toward the bayous you see refrigerators and even cars that remain lodged in trees. The sad thing is that it was in large part a preventable disaster. The eye of the storm passed east of the city, sparing the worst of the heavy rain and wind damage. The culprit was the faulty design, incomplete sections, and substandard construction of the levees that surrounded the city. The levee project started in 1965 and was scheduled for completion in 1978. Twenty-seven years later when the hurricane hit, it was still only 60-90 percent completed.
The storm surge breached it at multiple sites, and 80 percent of the city was flooded. As a result, 1,464 people died. Government bureaucrats, companies, and ultimately the local people were so busy with living life that they ultimately destroyed it. They forgot the most basic things and ultimately paid too high a price. It is easy for you to do the same thing. You are running like a hamster on a circular treadmill in a race without end. Life is a blur of work, church, family, and friends. There are things you should be doing, want to be doing, and even advocate others be doing, but you never seem to make them a priority or allocate enough time. Are the sea walls in your life eroded by the constant waves of life in need of repair? Are you leaking joy and experiencing crumbling satisfaction? Are the levees you have constructed to keep back the unforeseen storm surges that could devastate you high enough? It is time for a thorough inspection and needed repairs. So turn the page and get back to the basics. It is foolhardy to wait any longer. ✝
“Balance has to do with equilibrium; margin has to do with load. Both are well-respected issues in the aviation industry. They are studied, taught, required, regulated, feared, and even preached.” Those who are wise apply the same principles in their lives. The tenets that keep airplanes from crashing may also prevent painful consequences in families.
In Search of Balance
Most of us live lives of “quiet desperation,” as Henry David Thoreau put it, except we’re no longer so quiet about it. When exactly did “all stress, all the time” replace the “green pastures and still waters”? And what can we do about it? We try to manage all the details thrown our way, but we often lack a sense of calm and steadiness at the center of our lives.
by Richard A. Swenson, MD
Dr. Swenson, also author of the best-selling book Margin, helps us understand the dangers of living in a post-balance world and gives us hope for recovering a foundational sense of equilibrium — hope in the form of prescriptions. Fully half of the book contains suggestions for different ways to combat proliferation, profusion, and escalation. Even if you only incorporate one or two, your balance will be improved . . . at least until escalation catches up with you again. Paperback. 232 pages. $15.99 Each book stands alone, but if you haven’t read Margin yet, it is also recommended. $14.99
Available from CMDA Life & Health Resources: 888-231-2637 or www.shopcmda.org
contents Today’s Christian Doctor
VOLUME 41, NO. 3
The cover art “The Difficult Decision” is by Nathan Greene, courtesy of the Hart Research Center (www.hartresearch.org)
Fall 2010
The Christian Medical & Dental Associations® – Changing Hearts in Healthcare – since 1931.
14 Balance: The Possible Impossible Dream
28 Make Truth-telling Your Life-long Practice
by Richard A. Swenson, MD
by Vincent Gardner, MD
Balance is possible if we reject the seduction of progress
If you commit malpractice, your responsibility is to admit it
18 Duplicatability by Autumn Dawn Galbreath, MD, MBA, FACP, FACPE
30 Doctor of Contract or Covenant? Sixth in a Six-Part Series
Time + Truth + Trust + Exhortation + Example = Mentoring
22 Competency vs. Excellence! by Mitchell W. Duininck, MD, and Edward E. Rylander, MD
We strive for excellence in order to honor God
25 Humility by David C. Thompson, MD
by Gene Rudd, MD
Why covenant is the core of a Christian doctor’s patient care Editor’s Note: Ordinarily, we select a theme and then produce a single issue on that theme. As “BACK TO BASICS” developed, however, we realized it would take more than one issue to address even the fundamental questions. So this is “BACK TO BASICS I.” Our next issue will be “BACK TO BASICS II.” We invite your feedback or proposals should you think “BACK TO BASICS III” is warranted.
Humility is caught, not taught
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Progress Notes Advertising Section
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EDITor
David B. Biebel, DMin EDITorIaL CoMMITTEE
Gregg Albers, MD Elizabeth Buchinsky, MD John Crouch, MD William C. Forbes, DDS Curtis E. Harris, MD, JD
Rebecca Klint-Townsend, MD George Gonzalez, MD Samuel E. Molind, DMD Robert D. Orr, MD Richard A. Swenson, MD
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Pulp CMDA is a member of the Evangelical Council for Financial Accountability (ECFA). TODAY’S CHRISTIAN DOCTOR®, registered with the US Patent and Trademark Office. ISSN 0009-546X, Fall 2010 Volume XLI, 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 © 2010, Christian Medical & Dental Associations®. All Rights Reserved. Distributed free to CMDA members. Non-doctors (US) 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. Undesignated Scripture references 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. Scripture references marked Living Bible are from The Living Bible© 1971, Tyndale House Publishers. All rights reserved. Scripture references marked (NIV) are from the Holy Bible, New International Version®. Copyright© 1973, 1978, 1984 by the International Bible Society. Used by permission. All rights reserved. Other versions used are noted in the text.
For membership information, contact the Christian Medical & Dental Associations at: P.O. Box 7500, Bristol, TN 37621-7500; Telephone: 423-844-1000, or toll-free, 1-888-230-2637; Fax: 423-844-1005; E-mail: memberservices@cmda.org; Website: http://www.joincmda.org. 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.
Modern Healthcare Magazine Lists CMDA Member James A. Avery, MD, Chief Medical Officer at Golden Living, has been named to the list of the most powerful physician executives in the nation by Modern Healthcare magazine. This honor is part of the magazine’s fifth annual ranking of the “50 Most Powerful Physician Executives in Healthcare.” Dr. Avery was ranked No. 29. Modern Healthcare and its sister publication Modern Physician co-sponsor the annual “50 Most Powerful Physician Executives in Healthcare” recognition program. The winners were selected through voting on a final ballot, for which more than 11,000 nominations were submitted. The final ballot was based on those nominations and nearly 70,000 were cast during the voting period.
Caring Physician Receives Prestigious “Barnabas Award” Steve Rice, MD was named recipient of the Barnabas Award presented by the Christian Medical & Dental Associations of the Mid South. The Barnabas Award is presented annually to a physician who through his or her practice, witness, and life, has brought encouragement to healthcare professionals and medical students in Memphis as well as other parts of the world. The award is named after Barnabas, who was the Apostle Paul’s companion on his first missionary journey. He provided Paul support when they both faced adversity, disappointment, and the threat of death. Dr. Rice is a psychiatrist who has held a practice in the Memphis area for a number of years. He currently serves as the Medical Director for the Partial Hospitalization and Intensive Outpatient Programs at Delta Medical Center.
l to r: Ken Nippert, Director of CMDA Mid South, Mary Hammons, CEO of Delta Medical Center, and Dr. Steve Rice.
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University of British Columbia Recognizes CMDA Member York Hunt Ng
Jenkins Receives the STFM Global Medicine Smilkstein Award
York Hunt Ng, BS, MS, PhD (Candidate), and CMDA member has been recognized for excellence by the University of British Columbia (UBC), Vancouver, Canada, as lead author and presenter of the best paper (a platform oral presentation) at their annual OB/Gyn academic day on March 10, 2010. His paper described his PhD research work. It was coauthored by C.D. MacCalman and entitled, “Identification of a key role for Twist in human cytotrophoblasts.” He also was recommended by his department for, and received, the UBC Faculty of Medicine Graduate Award for the Winter of 2009.
Chris Jenkins, MD, a twelveyear faculty member of In His Image Family Medicine Residency program at Hillcrest Hospital in Tulsa, OK, has been named winner of the annual Gabriel Smilkstein International Family Medicine award for 2010. This award is given to one recipient each year whose career exemplifies the qualities upheld by Dr. Smilkstein: those of furthering the development of family medicine education throughout the world, serving the needy, and emphasizing both medical excellence and compassion in the service of patients. Dr. Jenkins has had a long-standing passion for family medicine education and has helped develop a network of international conferences serving emerging countries on a regular basis. He spends four to six months a year overseas and has expanded his work into consulting with a network of residency programs, medical schools, and ministries of health in many countries. The impact he has is an excellent example of bringing change in healthcare by bringing family medicine education to poor countries.
Douglas Schiller Student DO of the Year Douglas Schiller of Greenville has been named the Student DO of the Year at Lincoln Memorial UniversityDeBusk College of Osteopathic Medicine (LMU-DCOM) in Harrogate, TN. Schiller is a second-year osteopathic medical student at LMU-DCOM who also was named Student DO of the Month in March. The Student DO of the Month is a program of the LMUDCOM Student Government Association and is designed to recognize an outstanding first- or second-year student. Schiller was selected as the male Student of the Year by the members of the Class of 2012. Among the criteria examined for the honor are: involvement in LMU-DCOM, leadership skills, community service, class attendance, initiative, attitude, and professionalism. Schiller is the president of the LMU-DCOM Emergency Medicine Club and a member of the Christian Medical & Dental Associations, the Student Osteopathic Medical Association, and Sigma Sigma Phi National Osteopathic Honor Society. 6
T o d a y ’s C h r i s t i a n D o c t o r
Other News “A Christian Legacy in Psychiatry” is a 3-CD audio series with interviews with Armand Nicholi, MD; Dan Blazer, MD, PhD; William Wilson, MD; James Mallory, MD; and Louis McBurney, MD. Each of these physicians has been a mentor to many. None of these individuals started out wanting to be a psychiatrist. Their journeys to psychiatry are unique, with unexpected twists and turns. In this series you will learn what factors shaped their careers and practice styles. To order Volume 1, 3-CD Series, call Dr. Alan Nelson at 970-963-1588 or e-mail: redstonedoc@gmail.com. Cost is $40 for those in practice, $25 for residents and students.
Women in Medicine & Dentistry to Hold Conference September 23-26 The 2010 Women in Medicine & Dentistry Conference will be held in Providence, RI, September 23-26 at the beautiful Marriott Providence Downtown with its AQUA lounge and spa, indoor/outdoor pool, restaurants, free shuttle to downtown, and Wi-Fi included in our wonderful group rate. We will have a reception Thursday night at the outdoor AQUA lounge. Playwright Linda Gray Kelley is scheduled to perform “A Lady Alone,” a play about Dr. Elizabeth Blackwell, the first American woman doctor, during our luncheon on Friday. You can count on lots of laughs during the Coffee House, where many talented WIMDers will share their skills on Friday night! During free time on Saturday we will have a privately chartered bus take us to Newport, on the Rhode Island coast south of Providence, where we can go shopping, boating, or take a tour of a historic mansion! Saturday night there will be a banquet with delicious food, a superb speaker, and live music. Speakers include astronomer and author Jennifer Wiseman, PhD; Clydette Powell, MD, with USAID; and author Elaine Eng, MD. Dr. Wiseman is an astrophysicist at the NASA Goddard Space Flight Center in Greenbelt, Maryland. She has studied star-forming regions of our galaxy using radio, optical, and infrared telescopes, including lead NASA science positions for the Hubble Space Telescope. She is president of the American Scientific Affiliation, a network of Christians in science, and she directs the dialogue on science, ethics, and religion program for the American Association for the Advancement of Science. Dr. Powell serves as medical officer for the US Agency for International Development (USAID) in Washington, DC. Her work focuses on TB/HIV, human trafficking, and civilian-military coordination in health. Clinically, she volunteers at Children’s National Medical Center’s pediatric HIV clinic in DC. A graduate of Johns Hopkins Medical School, she did her residencies in pediatrics and child neurology in Pittsburgh, and her MPH at UCLA. Dr. Eng is a Distinguished Fellow of the American Psychiatric Association. She is currently clinical assistant professor of psychiatry in the Department of Obstetrics and Gynecology at Weill Cornell Medical College, and teaches at the Alliance Theological Seminary’s Graduate School of Counseling. Trained in the lay ministry program of Concordia College, she has authored three books, including The Transforming Power of Story: How Telling Your Story Brings Hope to Others and Healing to Yourself (March 2010). For more information visit www.cmda.org/wimd and click on “upcoming events.”
Leaders Wanted to Transform Doctors, to Transform the World If you are interested in serving CMDA as a volunteer leader in the House of Representatives, on a council or commission, and through those ultimately on the CMDA Board of Trustees, you can go to our website at www.cmda.org and click on “About” and then “Leadership” and choose either “House of Representatives” or “Board of Trustees” to find out more and get involved. Be prepared to submit a current CV via e-mail (preferably) or fax to the Executive Assistant, Debra Deyton, at: executive@cmda.org; phone: 423-844-1000; fax: 423-8441017. The House of Representatives meets once a year to approve bylaw changes, receive reports, and approve the ethical positions of the organization. During the year, they serve as two-way channels of communication
between CMDA and its members. There is one representative from each state and from many of our local ministries. New trustees are nominated by a joint committee of the House of Representatives and the Board of Trustees. They look at the service record of potential nominees to CMDA, their leadership capabilities, expertise, and Christian testimony. The nominees are then approved by both the House and the Board. Trustees, who may serve up to two consecutive four-year terms, pay all their own expenses. The Board meets three times a year to set policies, approve the budget, oversee finances, and provide supervision to the CEO. The Trustees’ page lists qualifications and offers the option of self-referral: www.cmda.org/trustees.
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Information on New Ethics Statements by Nick Yates, MD — CMDA Ethics Commission Chair At the April 2010 Annual Meeting, the CMDA House of Representatives approved three statements that had been prepared and presented by the Ethics Commission. This column presents a brief discussion of each of these statements.
Assisted Reproductive Technology (Drs. Gloria Halverson and Gene Rudd, revision authors)
Human Research Ethics (Drs. Tom Beam and Nick Yates, primary authors)
Physician and Industry Relationships (Dr. John Dunlop, primary author)
This document is a revision of the prior statement that was passed by the HOR in the early 1990s, and the primary reason for the updating was to be more current with present reproductive technology. The statement reaffirms the importance of marriage and the family being the basic social unit designed by God. In addition, it acknowledges that children are a gift and a responsibility from God to the family and that the parents are responsible for providing protection and spiritual training along with other important teachings. The statement also provides principles that should guide the use of reproductive technologies noting that the biblical design is the fertilization resulting from the union of the wife’s egg and the husband’s sperm. The new statement offers a categorical approach of some of the current medical options relative to assisted reproductive technologies — presenting them under groupings that CMDA suggests are: 1) consistent with God’s design for the family, 2) morally problematic, and 3) inconsistent with God’s design for the family. This revised statement concludes by affirming the need for continued moral scrutiny of reproductive technologies. In addition, there is extensive medical and biblical background information that accompanies this statement.
This statement gives a framework for the consideration of research ethics in the human subject. Scriptural principles inform the statement and provide clear juxtaposition of biblical directives and the medical response that CMDA suggests. The statement offers the following examples: 1) Gen. 1:28 — as wise stewards in the world, the research may be a way to respond to God’s calling to alleviate suffering and to assure that the benefits of research outweigh the burdens, 2) Gen. 1:27 — being made in the image of God directs that the researchers exercise compassion, dignity, fairness, and respect for human life, and 3) 1 Cor. 4:2 — the research team must be cognizant of its obligations and actions. The statement uses three large categories in its consideration of appropriate ethical guidelines: the individual research subject, the research team, and the specific host country or culture. Whereas there may be considerable overlap of issues and concerns among these distinct aspects of a research protocol, there are also specific and unique distinctions that define each division. CMDA acknowledges that there are identifiable duties, responsibilities, and protections that both define and mandate the research carried out on human subjects. This new statement endorses research that uses proper consent, has transparent implementation, and is non-exploitive.
In the present medical climate, the choice of which pharmaceutical or medical device to use is typically made by the physician, although this decision is often influenced by large institutions such as pharmaceutical companies and insurance companies. These large organizations impact the decision-making process through educational opportunities, gifts, services, and through the credentialing process and observation of practice patterns. This thoughtful and informative statement provides biblical warnings for the medical professional: 1) Mark 12:30-31 — to love both God and our neighbor, 2) 1 Tim. 5:7 — to live our lives above reproach, and 3) Prov. 18:16 — a warning from Solomon about how gifting influences behavior. The ethical principles are the importance of the welfare of the patient, the effort to avoid personal gain, and for the professional to be aware of how integrity and behavior may be compromised. Through the statement, CMDA recognizes that there are categories of gifting that are ethical, unethical, and some that demand extreme caution. The statement concludes with a clarion call for the physician to be aware of undue influence from industry and to practice in accordance with biblical principles. In addition, this statement provides a useful bibliography of references that are germane to the topic of industry’s impact on physicians.
The CMDA website homepage has a link to these statements.
SCAN Marks Twenty-five Years of Service by Reneé Hyatt, SCAN Coordinator After twenty-five years of publishing SCAN, readers still communicate with comments such as, “Thank you so much for this!” or, “I have already used information published in SCAN.” In the beginning these came through the postal system, but now they are delivered by e-mail.
2010 Dinner honoring SCAN volunteers, seated are (left to right) Donna Wisdom, Steve Wisdom, and Dr. Richard Roach
Paid Advertisement
In November 1985, Christian Medical Society missionary members received the first issue of Current Medicine Scan — three pages, front and back, of articles Dr. John S. Bagwell had reviewed the month before. Dr. Bagwell, a retired internist who practiced in Dallas for over forty years, had a vision to continue ministering in the area of foreign missions. So he pioneered this ministry — a monthly medical/dental newsletter — to keep his missionary colleagues abreast of what had been published in medical literature. Dr. Bagwell enlisted several local physicians to supply literature that would be of value to missionaries. Nothing delighted Dr. Bagwell so much as to hear the ecstatic responses from overseas missionaries as they received this newsletter targeted specifically to them. Dr. Bagwell’s death in October 1987 brought Dr. Jeffrey S. Wilson, another Dallas internist and Current Medicine Scan departmental editor, to assume the position of editor of Current Medicine Scan. Dr. Wilson’s knowledge of technology and publishing enabled Current Medicine Scan to move to the next level. With many subscribers and others calling it the SCAN instead of Current Medicine Scan, the February 1992 issue produced a new masthead entitled the SCAN, a three-hole-punched, twenty-four-page newsletter with different paper colors designating the different medical specialties. In April 1992, SCAN readers read about the sudden death of the second SCAN editor as this publication grew in readership, length, and ministry. The leadership of CMDS was once again looking for an editor for this unique ministry to missionaries. In September 1992, another doctor with a
heart for missions, Dr. Richard R. Roach, assumed the role as editor of SCAN, a position that he still holds. SCAN has undergone several changes in the past twenty-five years. SCAN is no longer a paper newsletter covering as many specialties as possible, but a monthly e-mail newsletter publishing articles targeted toward diseases, issues, and problems missionary doctors encounter. Every month Dr. Roach reviews many journals with the missionary healthcare professional in mind. With a very small budget and mostly volunteer help, Dr. Roach, with the assistance of SCAN Coordinator Renee’ Hyatt, continues to produce the e-newsletter of the SCAN on a monthly basis. Our purpose remains to serve missionary healthcare personnel with current medical literature. Here is an excerpt of thanks from one subscriber, “. . . for many years it was an important source of up-to-date information. Quite a number of articles came at just the right time to answer questions I had just then. God had certainly been directing this work.” Another missionary doctor wrote, “I have benefited greatly from receiving the SCAN during these years. SCAN often has articles which are extremely relevant to us.”
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from the
CMDA
President
George Gonzalez, MD
Back to Basics/Balance in Life As a Family Physician I often counsel my patients to try to eliminate unhealthy habits, usually things done in excess such as eating and drinking, and begin a healthier lifestyle including exercise, good sleep habits, and a low calorie diet. Essentially, no matter what the disease process, whether it is diabetes, hypertension, or depression, I tell them they have to get back to basic good health habits and balance their lives better. I admit to them that daily balance is my struggle, too. I often work too many hours and don’t allow time for other important activities. The most common excuse I hear for not exercising is lack of time. Interestingly, the most common excuse I hear for not reading and praying is lack of time. Just as we get imbalanced in our physical selves, we can get imbalanced in our spiritual beings. To keep spiritually healthy, we must have a daily diet of Scripture, prayer, and service to others. In prayer we should always include worship. To serve and care for others, you must love them enough to share the love of Jesus that brings healing, repentance, and salvation. If you truly care for someone, you want heaven and eternal healing for them above all else. To get strong, we must exercise our spiritual muscles regularly. Last, the balance includes a heavy dose of fellowship with fellow believers. It’s so much more fun to advance God’s kingdom as a team. It also is safer for us individuals for protection against pride and error. We need each other for accountability and encouragement. Balance is not partly indulging in the world and partly being Christian. Enjoy what God has given you as gifts from above (James 1:17). We should live our lives as full-time Christians, reflecting Christ’s character in all we do, whether at home or work or on the golf course. God’s way is the only way that brings fullness of joy and happiness. I believe, ultimately, as our faith grows, we are called beyond this notion of balance and comfort to self-denial and martyrdom. Our days are numbered. We should make them count, as did the anonymous missionary who penned the following words: I’m a part of the fellowship of the unashamed. The die has been cast. I have stepped over the
line. The decision has been made. I’m a disciple of His and I won’t look back, let up, slow down, back away, or be still. My past is redeemed. My present makes sense. My future is secure. I’m done and finished with low living, sight walking, small planning, smooth knees, colorless dreams, tamed visions, mundane talking, cheap living and dwarfed goals. I no longer need preeminence, prosperity, position, promotions, plaudits, or popularity. I don’t have to be right or first or tops, or recognized, or praised, or rewarded. I live by faith, lean on His presence, walk by patience, lift by prayer and labor by Holy Spirit power. My face is set. My gait is fast. My goal is heaven. My road may be narrow, my way rough, my companions few, but my guide is reliable and my mission is clear. I will not be bought, compromised, detoured, lured away, turned back, deluded or delayed. I will not flinch in the face of sacrifice or hesitate in the presence of the adversary. I will not negotiate at the table of the enemy, ponder at the pool of popularity, or meander in the maze of mediocrity. I won’t give up, shut up, or let up until I have stayed up, stored up, prayed up, paid up, and preached up for the cause of Christ. I am a disciple of Jesus. I must give until I drop, preach until all know and work until He comes. And when He does come for His own, He’ll have no problems recognizing me. My colors will be clear! This quote is convicting but inspiring as a goal to have our lives totally sold out to our Lord, whose promises and rewards are great, both here on earth and in heaven. ✝
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Global Health Outreach (GHO) FOR INFORMATION ABOUT GHO OPPORTUNITIES, VISIT:
WWW. CMDA . ORG / GHO
Finding What You’re Looking For by Christopher Perry, DO CMDA Global Health Outreach ENT Specialty Coordinator
Dr. Perry found a way to fill “the hole in our gospel” during a short-term mission to Mexico.
I am a long-time fan of the Irish rock band U2 and their frontman, Bono. Bono has done so much over the years to raise awareness of extreme poverty and AIDS, and to stimulate action from governments and individuals with his involvement in the One campaign. Arguably, U2’s best and best-known album is still “The
Joshua Tree,” which hit record stores when I was in high school. The spirituality of U2’s music is unmistakable. One song that everyone has heard is, “I Still Haven’t Found What I’m Looking For.” What I think Bono is “looking for” is “heaven on earth.” I am in my fifth year of private practice in otolaryngology and facial plastic surgery. Since I have finished my training and settled in to my practice, I have begun to wonder: Is this it? Is this what God created me to do with my life? I have a comfortable life, but why am I still not comfortable? So in this context, I began reading a fascinating book by Richard Stearns called The Hole in Our Gospel. It is no coincidence that Bono provides a commentary and is quoted prominently by the author. The principal idea of the book is creating “heaven on earth,” or, in other words, each of us taking a small but active role of becoming the hands, feet, and mouth
of Christ to impact our world for God’s kingdom. All who call themselves “Christian” have a role to play. It is our job to figure out our own roles. For some it may involve a national or international medical missions trip. If you have ever considered going on a short-term trip, I would encourage you to take the first step. I warn you, though, that the experience will forever change you. I have had the privilege of serving on two medical/surgical mission trips to Mexico with Global Health Outreach through the Christian Medical & Dental Associations. I have come to realize that only when I am serving God for no more payment than a smile and a handshake do I truly feel at peace with God’s will for my life. I challenge you to read The Hole in Our Gospel, and then to do your part to fill the hole. In doing so you can help bring “heaven on earth,” and you may just find what you’re looking for, too.
The Ludhiana Christian Medical College (CMC) Board USA, Inc., is searching for a new Executive Director. The LCMC board is an independent support board for the Christian Medical College & Hospital in Ludhiana, Punjab, India founded in 1891. Though there are no longer missionary faculty and staff on site, the LCMC board continues to support projects that serve the people of North India with Christian compassion and care through medical, dental, and nursing education, clinical care, and research. LCMC seeks a person as Executive Director who is: * a mature, dedicated Christian * passionate about world missions * an excellent communicator * willing to make a commitment for five to seven years * willing to learn and do fund-raising with some travel * experienced in administration and management * ability to work with churches, denominations, and other cultures Contact Dorothy Barbo, MD, at: barbodm@comcast.net. Information shared will be held in confidence.
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T o d a y ’s C h r i s t i a n D o c t o r
Medical Education International (MEI)
In Mongolia I learned that “I can do all things through Him who strengthens me” (Philippians 4:13). by Linda Wrede-Seaman, MD
Drs. Gantuya Tserendorgj & Linda Seaman, Palliative Care Symposium, National Cancer Center, Mongolia (April, 2010)
I’ll never forget the day spent doing bedside teaching at the inpatient hospice unit at the National Cancer Center. Dr. Tserendorj (Ganna) and the two other physicians, Zaya and Zoro, and I were discussing patient care, addressing the common problem of constipation in patients on opioids for pain relief. When I brought up a recommendation for the Yakima Fruit Paste recipe, an easy, patient-friendly recipe for a palatable, cost-effective way for patients and their families to manage this common side effect, Dr. T. said she knew of Yakima. She left the room for a moment and returned with the second edition of a book, Symptom Management Algorithms: A Handbook for Palliative Care, by Linda Wrede-Seaman, MD, and turned to the last page of the book. There was the Yakima Fruit Paste recipe. I blushed and told her that I was from Yakima, and it was my hospice team and I who had developed the contents of that book. Her eyes became wide. She looked at me and, pointing at the book, said, “So this is YOU?” I replied,
FOR INFORMATION ABOUT MEI OPPORTUNITIES, VISIT: WWW.CMDA.ORG/MEI
“No, that must be God!” We all giggled, as there was this sudden acknowledgment of who I was and the practical expertise I had cultivated over my years as a hospice medical director for Sisters of Providence’s Hospice of Yakima. She described it as her “Bible” of practical guidance for her team and for learning hospice care. It was one of those “God” experiences and a fun-filled moment! Dr. T. then immediately took me downstairs to a hall brimming with patients and pointed to a huge long corridor. The walls of the hallway were filled with Cyrillic writings and small pictures used for posting patient educational guidelines to read while waiting to be seen by the doctors. She pointed to a section on the wall that had a small picture of a child sitting on a toilet and gleefully said, “There is the Yakima Fruit Paste recipe for all our patients to see and hopefully use.” I couldn’t read a thing, but there it was. Somehow the Yakima Fruit Paste recipe had made its way all the way around the world for all to read! It was then, on day two of my trip, that I knew that God had come ahead and prepared this trip for me. Halfway around the world, Yakima, and a book cultivated by a small rural hospice team, had made a mark in the arena of improving end-of-life care! God had called me to go and had prepared in advance an open door for these relationships to evolve! The other incredible spiritual reward was found in the fellowship of kind, caring, devoted colleagues, with whom I enjoyed meeting every
morning. Strangers off a plane on April 2, we left as friends and brothers and sisters in the Lord on April 22. Each seemed to have a role. We were enriched each morning hearing from others who had wonderful ministries in Mongolia. These morning meetings validated God’s presence, brought focus to our group’s activities, and prepared us for each day. I believe the relationships that evolved also prepared me for receiving the news of my father’s unexpected death two days before we were scheduled to fly home. My tears flowed nonstop through the next morning’s devotion, and my grief was “allowed” by the group. What wonderful unspoken and spoken support was provided just by allowing me to openly grieve. Sometimes the devil tries to derail us when we are trying to serve the Lord, but I’ve learned that God “trumps” those attacks and gives us strength and support to carry on.
Praying with a patient, Omega Hospice home visit, Mongolia
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Balance is a fundamental principle pre-ordained by God throughout His created order.
B A L A N C E : The Possible Impossible Dream by Richard A. Swenson, MD
I
t’s trendy to be a bomb-thrower regarding balance. “Destructive,” says one Christian author. “A myth,” claims an inspirational speaker. Impossible, undesirable, unrealistic, and unattainable are other accusations hurled in the balance direction. The business magazine Fast Company ran an article headlined “Balance is Bunk!” The global economy is antibalance . . . . Someday, all of us will have to become workaholics, happy or not, just to get by. . . . Great leaders, serial innovators, even top sales reps may be driven by a kind of inner demon. . . . anxiety is a central part of our existence. . . . Can any couple facing two full-time jobs, kids, aging parents, groceries, the dog, the bills, and telemarketers at dinnertime expect anything but all stress, all the time? Successful professionals [find] ways to switch the focus of their full attention with lightning speed . . . an exercise in continuous redesign, in adapting to ever-changing circumstances and priorities. For couples, this also requires constant rebalancing of roles and responsibilities. . . . They don’t make decisions once or twice, but all the time.1
“Accept the craziness of your life,” says a leadership trainer in the Harvard Management Update. So, balance is now an impossible, destructive, bunk of an excuse for being a bum — and craziness is the new normal. Somehow we’ve lapsed into the casual opinion that our post-modern world should also be post-balance. It’s a natural accommodation to an obvious fact, perhaps like
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Europe being post-faith or post-family. But can we really afford to throw balance and other important principles away so easily, to define them away so matter-of-factly? Let’s make the same point from a different direction. A recent eighteen-year study “Adherence to Healthy Lifestyle Habits”2 in The American Journal of Medicine examined five health habits and reported steadily worsening behaviors: those with overweight body mass increased eight percent, those with moderate alcohol use increased eleven percent, those achieving appropriate physical activity decreased ten percent, and those meeting target fruit-andvegetable consumption decreased sixteen percent. The only habit that did not worsen was cigarette smoking, holding at twenty-six percent. Should we deduce from this study — and nearly every other study on this topic — that it is impossible for people to comply with healthy lifestyle habits and therefore we should all quit trying? Since we live in a postHealthy Lifestyle Habits world, let’s just cozy up on the sofa with our chips and watch another movie marathon. Among healthcare professionals, such a scorning of balance is a longstanding attitude. We’ve never taken balance seriously — not on a personal, professional, or spiritual level. Doctors are preselected for high levels of productivity and stoicism (let the record show: I approve of productivity and stoicism), while those interested in balance are shuffled into the humanities. On one level this is understandable — our professions are rigorous and demanding. But as seen from another perspective, such an attitude is inconsistent with both science and faith. We are surrounded continuously by the requirement of balance throughout the created order.
Nowhere is this principle more evident than in the human body itself. We’d better hope our bodies never join the post-balance chorus. That, in short order, would turn out the lights on the human race. Hyper and hypo are expensive and painful modifiers, and an uncorrected failure of homeostasis (Greek: “staying the same”) is often fatal. “If an organism is to survive, every activity within it must in some way be part of the effort,” writes Yale surgeon Sherwin B. Nuland in How We Live. “The essence of success is the dynamism that allows each cell to respond instantaneously to even the most minor threat to its integrity and therefore to the integrity of the entire organism. . . . A high degree of radical readiness . . . is required to allow the immediate change that corrects a tendency toward imbalance. . . . There can be no chemical complacency.” The record God has written in the human body is that balance is commended as normative, the position of health and sustainability. Dr. Nuland repeatedly speaks to this theme using not only the terms balance and homeostasis but also equilibrating steadiness, constancy, order, integrated coordination, stability, sustained harmony, and consistency.3 Healthcare workers depend on this self-balancing design of Providence more than we realize. “Practical therapeutics,” Voltaire wrote, “is the art of keeping the patient entertained until nature effects a cure.” Actually, the sustainability of the entire created order is contingent on this same principle. “In the various fields of physics and astrophysics, classical cosmology, quantum mechanics, and biochemistry, discoveries have repeatedly disclosed that intelligent carbon-based life on Earth requires a delicate balance of physical and cosmological quantities,” says William Lane Craig. “If any one of these quantities were slightly
altered, the balance would be destroyed, and life would not exist.”4 If balance has been thus ordained throughout all creation, isn’t this an indication for us to similarly respect balance in our personal lives and social infrastructures? God is speaking not disorder to us, but order: Find the center and rest in it.
The Etiology of an Imbalance Epidemic Having first maintained that balance is a fundamental principle pre-ordained by God throughout His created order, I now readily concede that balance has become a rapidly moving target. Why? The answer lies at the feet of our good friend, progress. As I’ve written extensively elsewhere, progress works by giving us more and more of everything, faster and faster at exponential rates — always, automatically, and irreversibly. In addition, the processes that lie behind progress and its resultant profusion (the generalized phenomenon of more) have become hyper-dynamic. If profusion in the past was a trickle, today it is a torrent. Profusion is already exponential in the extreme, yet relentlessly accelerating. Initially, we were thrilled by the more of progress. Profusion was exactly the kind of miracle that people expected from progress. We all wanted more, and it quickly became our definition of happiness: more than I have now. Eventually, however, it evolved into a different kind of more, the kind that leads to imbalance and overload. All systems have limits, and humans have limits in time, finances, intellectual capacity, physical strength, and emotional energy. These limits, designed by God, are relatively fixed. As we have seen, however, progress is hyper-dynamic. This mismatch is the key to understanding the etiology of our epidemic. When this ever-accelerating progress first exploded through our static limits, it created a massive world-changing collision. Since that
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Balance: The Possible Impossible Dream
Balance and the Created Order
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time, humans have been pushed ever deeper into imbalance and overload. Going with the flow in this matter is dangerous. Depth, worship, gentleness, rest, patience, solitude, waiting, quiet, contemplation, relationship, and prayer are replaced by speed, stress, interruptions, noise, multitasking, clutter, alarms, advertisements, distractions, and twitching. God designed the human body to function best within a range of tolerances, a kind of middle zone — the pace of faith. When we understand where the limits are and learn to stay within that range of tolerances, we thrive. This is the benefit of balance — to find and remain in the zone of health, sustainability, and priorities.
Guidelines for Restoring Balance The task of restoring balance is daunting — but then, so is physical conditioning, or clinical competence, or Christ-likeness. It seems we’re surrounded by challenging demands requiring disciplined choices. The following guidelines will help us begin erecting a balance infrastructure supportive of our journey. Focus on Timeless Priorities Balance does not exist for balance’s sake. It exists to serve us, especially our priorities. Each person has priorities, but they are increasingly a jumbled mess. Some are trivial, pure fluff. Others are temporary, easily dissipated by the tsunami of contemporary change. That leaves the timeless, determined by God and discovered by us.
The closer we come to the end of our lives, the more these eternal priorities will clarify. Our death bed sweeps away the confusion, clutter, and distraction of our busy day-to-day and replaces it with the transcendent. It will be to our eternal benefit if we visit our death beds in advance and contemplate Jesus’s words in Luke 10: “Only one thing is needful.” Then, if we are wise, we’ll balance our lives in a stable orbit around this inviolable center. Counter the Escalation of the Norm We live in the age of escalation. For whatever reason, people want bigger, better, and fancier, without regard to cost, consequences, or contentment. Of course we’ve always had a tendency to grab upward — but never at the levels seen today. Its effect on balance has been devastating. What we are experiencing is a continuous escalation of the norm followed by a normalization of the escalation that then becomes the new normal. Celebrations, rituals, holidays, sports, shopping, fashion, cars, houses, cameras, computers, healthcare — nothing is exempt. At some point, if we wish to regain balance — to say nothing of economic stability or common sense — we’ll need to confront this pattern. We can have escalation or we can have balance, but we can’t have both. Do the Math Math is our friend. The math is always right, always tells the truth, and always wins. If we apply it wisely, math will keep us balanced in our time and finances. In fact, good math will help keep us balanced in all our expenditures of energy and resources because our limits are essentially mathematical limits. If we ignore the math, however, it will not ignore us. For example, if we buy a house three times larger than we can afford and then work eighty-hour weeks to pay for it, we’ve used up all our math. Our assets are locked up, and we have zero liquidity in our balance account. One of my biggest concerns today is that on personal, professional, national, and international levels we are witnessing a massive abdication of the universal laws of mathematics on a truly cataclysmic scale. This will not only end in imbalance, it will end in tears. Calculate the Opportunity Cost Opportunity cost is the principle that whenever we spend time, money, or energy on something, we lose the opportunity to spend that same time, money, or energy on anything else. And it is lost forever. As compelling and commonsensical as this principle is, it’s still surprisingly overlooked on a large scale.
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ties.” But progress is much better at playing its game than we will ever be at playing ours. At some point, we need to declare that we’re not playing the “increasing more vs. increasing capacity” game any longer. We’re switching to the balance game. This reality does not threaten God. He designed the entire system in such a way that we would need His power and wisdom. As Paul taught, the multiplication coefficient for our capacities is through the Spirit of God: “When I am weak, then I am strong.”
Obey God’s Decent Minimums
Bibliography
_________________________ Balance can direct us toward simplified lifestyles, anchored contentment, nourished relationships, reasonable expectations, and manageable work. Balance can model for us the pace of faith with its gentleness and goodwill. Balance can equip us with a gyroscope that stabilizes our orbit securely around our timeless priorities. And, in the end, it’s all about priorities. ✝
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God is not shy about requiring “decent minimums.” He requires, for example, that a certain minimum of time, energy, and resources be devoted to work and finances. Likewise, we are to care for our families and other relationships, for our emotional lives, physical lies, and spiritual lives. We need a certain minimum of rest and leisure. Failure to balance these minimum requirements will lead to pain. When God set up these non-optional areas of life, at that precise moment He required balance. It’s best not to insult His creation wisdom. Own the (Uncomfortable) Zero Sum Without factoring in the supernatural, life is essentially a zero-sum calculus: We only have so much to spread around. Our resources are limited. We can’t buy more time. We can’t hire someone to love our families. If we need to exercise or sleep, we must do it for ourselves. Accepting limits is a sign of maturity, but many never get this far. We keep entertaining the fiction that life is elastic, that we can stretch it like spandex. Of course we can modify some of our resources, but using efficiencies, training, and technology will carry us only so far. Perhaps we might gain 20 percent more capacity, but then we’ll discover that we’ve simply relocated the threshold for zero-sum, and we must confront it all over again at the new level. Progress is programmed to play its game of “more and more,” while we play our game of “increase our capaci-
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Keith H. Hammonds, “Balance is Bunk!” Fast Company, December 19, 2007. Dana E. King, MD, MS, et al., “Adherence to Healthy Lifestyle Habits in USD Adults, 1988-2006,” The American Journal of Medicine, vol.122, issue 6, June 2009, 528-534. Sherwin B. Nuland, MD, How We Live (New York: Vintage Books — Random House, 1997), xviii, 30, 33, 41. William Lane Craig, “Cosmos and Creator,” Origins & Design 17:2.
Balance: The Possible Impossible Dream
Balanced living requires that we bias our opportunity costs in the direction of the priorities that matter most. A Seattle man e-mailed me when offered an International VP position in his financial services firm. As a part of the job, he’d be required to answer his Blackberry within five minutes for any important message, 24/7/365. As he considered the honor and advantages of the promotion, he also thought about his family. Finally, with his children’s violins playing in the background, he turned it down. His balance would have been destroyed, and his time with the family would have suffered. The opportunity cost was just too high.
Richard A. Swenson, MD, futurist-physician, researcher, author, and educator, has written seven books including the best-selling Margin and The Overload Syndrome, both award-winning. His newest book, In Search of Balance, was released in February, 2010. He has presented widely, including national and international settings, on the themes of margin, stress, overload, life balance, complexity, societal change, healthcare, faith, and future trends. A representative listing of presentations include a wide variety of medical, professional, educational, governmental and management groups, most major church denominations and organizations, members of the United Nations, Congress, NASA and the Pentagon. Dr. Swenson and his wife Linda live in Menomonie, Wisconsin. They have two sons, Matthew and Adam, daughters-in-law Suzie and Maureen, and a granddaughter Katja.
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Duplicatability Duplicatability by Autumn Dawn Galbreath, MD, MBA, FACP, FACPE
Mentoring students is essential if we wish to see Christian values practiced by healthcare professionals in the future. Dr. Galbreath (3rd from left) with some of her student friends
M I look across the table as Ashley* tells me that there are things no one knows about her, and that her Christian friends would never accept her if they knew . . . that she can’t really believe that God can accept her, since He knows. For some reason, she decided to share them with me. I attend my medical student Bible study though today it is inconvenient, and I have a bad attitude. I almost cancelled, but I’m so glad I didn’t. When Megan* asks to meet with me after the study, she says, “I’ve been holding out for three days till I could talk to you. I kept telling myself, ‘I just have to make it till Tuesday so I can talk to Dr. Galbreath.’” I brush back tears listening to Madeleine’s* shame over choices she has made. I hear her pain and wish I could erase the hurt. I cry with her as she talks, and I sit with her in the midst of her pain. I swell with pride as I watch Sarah* stand in front of the WIMD conference giving a talk about managing a disease in her sub-specialty. Having led a small group she was in for five years during her medical school and internship, I continue to feel maternal, even though she now has more medical training and better credentials than I do.
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entoring. We hear about it a lot, but what is it, really? Mentoring can be defined as a personal relationship between two people in which a more experienced (usually older) person teaches, encourages, or counsels a less experienced one.** The word actually originated from Greek mythology: Odysseus put his friend Mentor in charge of his son Telemachus and his palace while he was fighting the Trojan War. Mentor served as a resource and guide for Telemachus while his father was away. This definition implies that the mentor sacrificially gives time and expertise for the sole benefit of the mentee. And since I know your life is just as crazy and full as mine, I hear you protesting: • “I just don’t have time for that. My family needs my time right now.” • “I don’t know what I would teach medical students anyway. I certainly don’t have it together enough to show anyone else how to do it!” • “Someone else can do this. What about the faculty at the medical school, the local CMDA staff, the pastors at church . . . aren’t they paid to do this?” If these are your ideas about mentoring, you don’t have the whole picture. The vignettes above are conglomerates of some of my most meaningful mentoring moments. They are meaningful not because I was spiritual enough to set aside time from more important things in order to minister to medical students in need. They are meaningful because they were moments spent with my friends, with women who have become precious to me and who happen to be a number of steps behind me on the path of life and career. They are meaningful to me because they were special moments in my
1) Time — This is the commodity in shortest supply in all of our lives, and, therefore, the first concern we raise when thinking about mentoring. Our time is in demand by God, our spouses, our children, our aging parents, our patients, our colleagues, our administrators, our churches, our volunteer ministries . . . and the list goes on. How do we make time for one more thing? I have found that mentoring is not a separate compartment in my life. Students need to see my life in action. Over the years, I have led student Bible studies, sharing my time in the Word with them. I have had students in my home, sharing my family life with them. I have had students in my clinic, sharing my professional life with them. There have certainly been occasions when a student needed me to make time to sit with her face-toface. But if my schedule can’t accommodate an hour here or there to meet with a person in need, maybe I need a little more margin in my life! 2) Truth — Obviously, as Christian mentors, we should be speaking truth to the students with
Duplicatability
life, not because I was participating in a one-way relationship with these women. As I have mentored medical students over the past fifteen years, I have celebrated joys, weathered challenges, lived alongside them — I have had the privilege of playing a small part in their lives. And I have been richly rewarded. I can’t say that I have ever been mentored in the way that I hoped, so much of the mentoring that I do is based on what I always wanted someone to do for me. As a student and resident, I longed for a woman who was “doing it well” to show me how she juggled her roles as wife, mom, doctor, and Christian. There was a dearth of women in medicine ahead of me, and few of the ones I met appeared to share my definition of “doing it well.” The ones who did were far too busy to spend time with me. And so I stumbled along, trying to forge my own path, often looking back thinking, “If I had only known, I would have. . . .” Of course, I have since learned that “doing it well” is a lot messier than I had hoped and that there is no simple answer to life as a Christian in medicine. But I don’t have to have it all together in order to have something to offer to the students around me. In fact, students don’t even want me to give them a plan for how to fix their lives. They want me to give them my time, to speak the truth to them, and to earn their trust. Only after that will I become a part of their lives and a source of exhortation. As with most things, ultimately I must lead them by example.
whom we interact. Even with students who are not Christians, and even in settings where we cannot easily share our faith, we can still impart Biblical principles about medical practice and personal life choices. However, I believe that the idea of truth-in-mentoring goes beyond this. I have found that I must have an honest, authentic relationship with students in order to develop a meaningful relationship with them. If they see me as one who has everything together and has all the answers, then they aren’t seeing the real me. In addition, the more together they think I am, the less willing they will be to share their own struggles and failures. This makes the relationship superficial, and it dramatically lessens my impact on the lives of the students. Of course, discernment is required to determine how much to share in a mentoring relationship versus the personal accountability relationships in my life. But if I am putting on a face before students that does not reflect who I really am, I am not speaking truth to them.
Interaction regarding clinical issues presents opportunities for mentoring
3) Trust — As I spend time and speak truth, trust naturally develops. Trust is a two-way street, but it has to be initiated by the mentor. As I trust students with the truth of my failings and struggles, they will trust me with theirs. As they trust me with their struggles, I have the joy of walking alongside them in the midst of their pain.
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Duplicatability
4) Exhortation — Sadly, in Christian circles we often try to jump into a mentoring relationship at this step, skipping the first three. Someone asks for our help, or we think they need our help, and we step up to the plate with Scripture and instructions to get them back onto the right path. However, without authentic relationship as the foundation, exhortation can be intrusive and can even push someone further from the right path. Exhortation is legitimized by a relationship of care and concern, by walking alongside someone in their struggles. Only then will they be able to hear the love and concern from which we speak.
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5) Example — This is both the first and the last step. I am ill-equipped to mentor others if the primary purpose of my own life is not glorifying God in word and deed. This does not equal having it all together. I, for one, absolutely do not have it all together. I continue to struggle mightily in several different areas, and I do not have easy answers for students. But I do know The Answer to all of life, and if I am living in and through Him in the midst of my struggles and imperfections, I can continue to point students to Him. No mentoring relationship is forever, and eventually they will move on.
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But if my example is a life infused with Christ, I can equip them to take the Ultimate Mentor with them as they move to the next stage of life. _________________________ * Names and details changed. **While not necessarily true of workplace mentoring, Christian mentoring involving spiritual and emotional issues is most effective and most appropriate when mentor and mentee are the same gender.
Autumn Dawn Galbreath, MD, MBA, FACP, FACPE, is an internist in San Antonio, Texas. She serves as Clinic Medical Director for the Texas MedClinic and teaches part-time at the University of Texas Health Science Center at San Antonio, where she loves working with medical students. She also leads a weekly Bible study for female medical students through the local CMDA chapter. She and her husband, David, have three children: Coggin, Mary Eleanor, and Norah.
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Competencyvs
Excellence!
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hen Marie* came to Family Medical Care a few years ago, she was in the third trimester of pregnancy and suffering from pancreatitis caused by gallstones. We admitted her to the hospital for the last month of her pregnancy and immediately got to work trying to determine the cause of her pancreatitis. We delivered the baby, removed Marie’s gall bladder, and thought the problem would be solved; but the condition continued. Three months and four specialists’ opinions later, we were no further along than when we started, and so we had a prayer meeting for Marie among our staff. During that meeting, one of us had a clear, distinct word from the Lord that Marie’s problem was an obstruction to the normal drainage of her pancreas due to scar tissue. She had some drainage from a fistula tract on her left flank but not enough to prevent her recurrent episodes of pancreatitis. As a result of this word from God, we improvised a solution, inserting a Foley catheter through the fistula tract, all the way to the pancreas, and drained off the fluid. It worked, and her condition turned around completely. She recovered enough to be able to have surgery to permanently correct the condition.
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By Mitchell W. Duininck, MD and Edward E. Rylander, MD
Perfection may not be possible, but excellence is a goal worth striving for.
We tell this story not to seek your applause, but because it so clearly illustrates the line all Christian doctors walk between medical competency and spiritual sensitivity. This is the line that must be navigated successfully to reach the true excellence God has planned for your life as a physician Christian. The Roots of Competency vs. Excellence First, let’s admit that the word “competency” is hardly adequate to describe the topic of our conversation. The word can connote mere adequacy or acceptability — doing just enough to get by. Would you really want to overhear a patient describe you as only being just a “competent doctor?” Of course not! So when we talk about practicing as unto the Lord, we’re talking about being more than adequate, more than acceptable, more than marginal; we’re talking about practicing at as high a level of excellence as we can. This demands we use all we have medically and spiritually to help those who are brought into our areas of responsibility. There is a huge onus on us as physicians to do our
The Banner We Carry The name of our family medicine residency is “In His Image.” That is not a subtle name, so if we’re going to wear that on our lab coats and carry His name, then we need to remember that people are going to evaluate us — and may even evaluate our faith and our Savior — based on how well we do our jobs. Therefore, we have a responsibility to be good at what we do — not for our own glory or recognition, but to bring honor to God. It’s tempting sometimes to just be a little lazy and settle for a B- when we could get an A; but as Christian doctors, what motivates us isn’t self — or at least it shouldn’t be. The truth is, when it comes to competency, we must be skilled at our trade so even the quality with which we practice medicine is honoring to God. Incorporating prayer with the medicine we provide is important, and it brings a responsibility. It would dishonor the Lord and what we’re about if we had less than excellence in our practice. In general, we as doctors
have a drive to be correct and competent. You don’t want to dishonor God and provide advice or medications or care in any way less than excellent. When you put the Lord’s name on the care you’re providing, it’s an added emphasis to put everything you can into what you’re doing, which naturally leads to the age-old question for the Christian doctor: is everything I do for men done in order to get great respect from them, or is it to honor God through my life and my work? Why do we do what we do? Do we work as hard in private when we know no one will see it as we do in a public arena? It shouldn’t matter whether our competency is outwardly seen or not. Our goal should not be recognition by men — from our patients, from our peers, from review boards and awards committees. Our goal should not be human attention; it should be to honor God. He sees. He knows. Our reward and our fulfillment will come from knowing that we’re doing what we’re supposed to be doing — what He’s called us to do. When God says He rewards those who diligently seek Him (Hebrews 11:6), we can know the things we do are pleasing to Him. Medicine is naturally an egotistical field of work, where it’s easy to think that if you have letters behind your name, you’re more important than other people. That’s not true. If we’ve been given this opportunity to practice medicine, we only have it as a gift from God — a privilege. Our lives are not our own; we’ve been bought with a price (1 Corinthians 6:19b-20). We need to do our best to honor God with this gift, and we do not honor Him with a half-hearted, average effort, either in our practice or our preparedness.
Competency vs. Excellence!
due diligence, to study, to stay on top of the latest advances in order to increase our level of competence, and an even greater responsibility to maintain our spiritual sensitivity to the Father’s direction. We should not allow ourselves to be distracted by the world or anything of it as we seek to find God’s best for those He entrusts to our care. In Marie’s case, we had four specialists and their colleagues, all of whom were highly competent, all of whom took their craft very seriously, and all of whom put their all into solving Marie’s recurrent problems, without a positive result. As physician Christians we have the opportunity to turn to a Higher Authority, to pray to the God who created the very body we are attempting to treat, Who designed exactly how it functions and Who knows exactly what’s preventing it from operating according to that design. At its core, excellence is about letting God enhance our own skills, talents, and learning as he did the craftsmen of the Old Testament. As Christians, we talk about kindness and compassion and the like — that’s important — but we also need to be good at what we do. Your patients come to you because they want to be well. They want to be restored to health and go home. They want to live longer. If they just needed prayer, they could go to church or visit a fellow believer. They trust their lives to you because they need medical excellence as well as spiritual excellence working hand in hand, something that is unobtainable from anyone who does not know the true Healer.
Excellence vs. Perfection We remember the time in our lives we crossed the threshold and graduated from residency to be on our own as physicians. Do you remember how prepared
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Treat the whole person. When you take care of patients, don’t just treat their symptoms or their condition — treat the whole person. Who are they? What are they dealing with that isn’t physical, but spiritual? Have a target. It’s too easy to slip into a pattern of Christian fatalism, thinking that God will do whatever He wants to do and that you can’t make a difference. God has given you a task in this world, so have a diagnostic target. Keep up with new techniques and technology. Our world is full of constant change and updates, with new techniques, new technologies, and new medicines being introduced. Do your best to stay abreast with new options in both knowledge and skill. Prioritize. Serve God first, then your patient. Be a follower of Jesus first, then a doctor. Stay spiritually grounded and you’ll see the benefit in the area of your competency. Do all you can, then trust God for the rest. Even as we work for health and wellness, we all know that eventually death will come, and our patients will achieve their wholeness in God’s arms. So do all you can with your knowledge and skill, then entrust your patients into God’s care. Expect to hear from God. Remember the call on your life, and know that you have a good and loving heavenly Father that would not call you to do something without providing what you need to do it with excellence. Expect Him to meet you in your need, acknowledge you are not sufficient in and of yourself, be still and listen for His input, His ideas, and His way of doing things. He will surprise you!
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you felt? We had the latest technology, the best training, the most up-to-date information. That’s the time we think, as doctors, we are naturally the most competent. As we get older and more experienced, we realize our own natural entropy. We have two choices to make in our ongoing practices: we can either continue to grow and learn and develop our skills and knowledge; or we can continue practicing based on what we knew when we graduated and allow our skills to remain set at that level — or even deteriorate. You know the old saying from medical school: {C=MD}, right? The idea that you can graduate with a C- average, go right out of school, and be a practicing doctor. This is the opposite of true competency. We must strive for excellence in everything we do. At the same time, we have to realize the difference between excellence and perfection. As humans, perfection is unachievable. If your aim is perfection, you will eventually miss, and then what will you do? You’ll be frustrated and unhappy. Perfection cannot be attained, which is a good thing. If we aim for perfection, we get our focus off our God and onto ourselves. Then life becomes about us and our degree of self-fulfillment, our self-recognition, the stroking of our individual egos. That doesn’t honor God. No, God hasn’t even called us to perfection — only He is perfect (Psalm 18:30). He has called us to excellence, which is something we can definitely achieve, provided we’re willing to put in the work on our part and let God do His work on His part. Working together with God, we can achieve more than competence. We can achieve excellence. Then the question becomes: Will we be careful to give God the glory when that excellence is recognized? *Name changed to protect the privacy of the patient.
Mitchell W. Duininck, MD and Edward E. Rylander, MD, live in Tulsa, OK, where they graduated from ORU School of Medicine and now practice family medicine at Drs. Ed Rylander (l) and Mitch Duininck (r) Family Medical Care of Tulsa. Dr. Duininck has been married to Leah for twentyfour years, and they have six children. He is the Residency Director of In His Image Residency and has a strong interest in international health. Dr. Rylander has been married to Shelley for twenty-nine years. They have two children. He has special interests in palliative care and obstetrics. They both teach in the In His Image Residency Program.
humility by David C. Thompson, MD
If God is humble, who are we not to be?
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’ve always thought that humility was a wonderful thing, especially in others. I have never purposefully pursued humility because the path to it is not like a walk in the park, but more like a stumble through a dark forest without a flashlight. What’s even worse is that once it seems to be attained, there are unexpected relapses. The saying, “There is more hope for fools than for people who think they’re wise,” is just as true about humility as it is about wisdom. For the experienced diagnostician, pride and arrogance are easier to recognize than humility. We can almost see these ugly attitudes when we bump into them. The classic signs are “haughty eyes” (Proverbs 1:4), pleasure in mocking others (Proverbs 21:24), and “proud talk” (Proverbs 14:3). Other signs are more subtle and can easily be missed by specialists on the subject (such as me) who invariably suffer from the disease themselves. Back when I was a young missionary and full of myself (there’s plenty left), a woman with leprosy got pneumonia and died. Her family had abandoned her. We had started building our hospital only a few years earlier, and I was the only doctor for hundreds of miles in any direction. The woman died early one morning. By 4 pm no one from the community had volunteered to bury her. In tropical Africa, decay sets in rapidly, and the smell was becoming fearsome. I realized that if I wanted her buried that evening, I would have to take charge and do something. Our nurses helped me load the body in the back of my Land Rover, along with several picks and shovels. I drove down to the village and to the home of one of our church elders. He took one look at the body and said he wasn’t
feeling well. I stopped at the homes of the pastor and several other elders, and they all gave their excuses. Burning with anger, I drove to the graveyard and started to dig the grave myself. The thought that was shouting in my mind was, “This is unbelievable! Since when do doctors bury their own patients? This is NOT what I came here to do! Maybe these people need to get another doctor!” By the time others came to help, the grave was half dug, my hands were bleeding, and my righteous indignation had reached its glory. When the body was covered, I stomped to my car and drove angrily home. On the way, the Lord said to me, “Aren’t you my servant? Since when are you too good to bury an old woman who died alone and abandoned by her family?” I was seeing myself as God’s heroic missionary doctor, an elite member of our community, and much too grand to do a manual labor of love. What God saw was filthy rags and an unwilling servant. Humility is of paramount importance to God — not because it helps Him control us or because it is useful to keep humans working harmoniously with each other, but because God Himself is humble! How on earth can the Creator and sustainer of the universe, a being with immeasurable power, knowledge, wisdom, and resources, be humble? In Matthew 11:29 Jesus says to His disciples, “Take my yoke upon you. Let me teach you, because I am humble and gentle at heart, and you will find rest for your souls.” Just like us, the disciples probably wondered why Jesus was saying this to them and not to the proud Pharisees. Weren’t they humble fishermen and His followers? Hadn’t they left everything to tramp around the countryside with Jesus and sleep on the ground? Jesus knew that they still did not understand what God had said in Isaiah 64:6 about man’s righteousness: “We I n t e r n e t W e b s i t e : w w w. c m d a . o r g
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Humility are all infected, and impure with sin. When we display our righteous deeds, they are nothing but filthy rags.” More than 400 years before God the Son came to Earth, the prophet Zachariah wrote about God’s humility: “Look, your king is coming to you. He is righteous and victorious, yet he is humble, riding on a donkey — riding on a donkey’s colt.” Moses is considered one of the greatest leaders in history. Yet in Numbers 12:3 he describes himself as “more humble than any man on earth.” (Well, he wrote Numbers, didn’t he?) We should not be surprised that God is even more humble than Moses. Where else could Moses have learned something so antithetical to the training he received as a prince in Pharaoh’s palace? To God, pride is a plague that is destroying the human race. Consider how apt a comparison that is: starting with one being (Lucifer), the plague of pride spread to a third of the angels, then to the first two humans shortly after God created them, and finally to all of their progeny. Like any good doctor who is confronted by a plague, God’s documented response in Proverbs, Isaiah, and James is to detest the proud, disgrace them, destroy them, and oppose them. In Isaiah 13:11, God says He will “crush the arrogance of the proud and humble the pride of the mighty.” In Proverbs 29:23, He says He will “bring them down to the dust and humiliate them!” This is precisely what God has to do to humble the people of Israel. In Ezekiel 20:43-44, after destroying their nation and making them slaves in Babylon, God says, “You will look back on all the ways you defiled yourselves and will hate yourselves because of the evil you have done. You will know that I am the Lord, O people of Israel, when I have honored my name by treating you mercifully in spite of your wickedness.” In contrast, God delights in those who are humble. “Though the Lord is great, he cares for the humble”
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(Psalms 128:6a). He rescues them (Psalms 18:27), teaches them, and leads them in doing right (Psalms 25:9). He protects them from His anger on the day of destruction (Zephaniah 2:3), hears them (2 Kings 22:19), cares for them (Psalms 138:6), supports them (Psalms 147:6), exalts them (Luke 1:52), fills them with fresh joy (Isaiah 29:19), and is gracious to them (Proverbs 3:34). He crowns them with victory (1 Corinthians 15:25), lifts them up in honor (James 4:10), promises to give them the earth as their inheritance (Matthew 5:5), lives with them (Isaiah 57:15), restores their crushed spirits, and revives their repentant hearts (Isaiah 57:15). He reveals to them His works so they’ll be glad (Psalms 69:31), hears them from heaven, forgives their sins and restores their land (2 Chronicles 7:14), and promises to make them great in the kingdom of Heaven (Matthew 18:4)! So what exactly is this elusive trait that God loves so much? Why is God so willing to crush those He loves in order to replace their arrogance with humility? Could it be that He wants us to become like Him? Perhaps the most revealing answers to this question are found in the gospel of Matthew (18:4) when Jesus says, “Anyone who becomes as humble as a little child is the greatest in the Kingdom of Heaven,” and Mark (10:15) when Jesus says, “I tell you the truth, anyone who doesn’t receive the Kingdom of God like a child will never enter it.” What attitudes in a child resemble the humility of God? Here are just seven that come to my mind, all of which are expressed far more perfectly in God than in even the smallest child. • Love: Children love their mothers in the same way that God loves the other persons in the Trinity. • Trust: Children trust those who love them in the same way that Jesus entrusted Himself to the Father and the Holy Spirit, even as He endured the crucifixion and received the blame for the sin of the entire world. • Innocence: Young children are guileless because they do not yet know evil experientially. God does not know evil experientially either, though He knows what it is. He himself is morally perfect in His dealings with angels, demons, men, and all that He has created. He is the only truly innocent being in the universe, even as children are the most innocent beings in our world. • Delight: Children delight in beauty and in discovery in the same way that God delights in all that He has created.
So how do we get this thing called humility? 1 Peter 5:5 says, “clothe yourselves . . . with humility toward one another.” Jesus says in Luke 14:11, “Those who humble themselves will be exalted.” It turns out that we can only clothe ourselves with humility and humble ourselves if we are with God. God is quite willing to deliver us from pride and arrogance, but only if we will accept the trials He brings into our lives to break our pride, and only if we stay close enough to be infected with His humility. In other words, humility is caught, not taught! Can physicians, dentists, medical students, and others of our elite class turn from pride to embrace humility? Can humility — rather than arrogance — be something that characterizes us? It can if we will choose to submit ourselves to God and stay close to Him! ✝
David C. Thompson, MD, attended the University of Pittsburgh School of Medicine, where he became active in CMDA. In 1977, Dr. Thompson and his wife accepted a call from the Christian & Missionary Alliance to establish a new medical work in central Africa. He returned to the States for more training shortly thereafter, then returned to Africa in 1981 where, along with his wife and colleagues, he transformed a small dispensary into a one hundred twenty-bed, full-service hospital. Of the tens of thousands of patients who received care, more than 7,000 entered into a relationship with Jesus Christ. In 1996, Dr. Thompson helped establish the PanAfrican Academy of Christian Surgeons (PAACS). As one of the ministries of CMDA, PAACS is dedicated to establishing surgical training programs for African doctors at existing Christian hospitals. Dr. Thompson also serves as the Medical Director and Chief of Surgery of Bongolo Hospital, and he is the PAACS Director for Africa. Dr. Thompson has authored three books: On Call — his testimony/ biography; Beyond the Mist — the story of the beginning of the church in south Gabon; and The Hand on My Scalpel — a collection of stories from his work. A fourth book on the theology of mercy, based on what he has learned in thirty years of serving, is currently being written. In 2010, Dr. Thompson received the Servant of Christ award from CMDA.
Humility
• Dependency: Children are totally dependent on their parents for their physical and emotional needs in the same way that each member of the Trinity is fully dependent on their other members. • Joy: Children laugh more in their first few years than at any other time in their lives. If they are loved, their joy bubbles up as laughter. The God who created children is a God who rejoices in the love of His Father and of the Holy Spirit. Like children, God loves to laugh — at us, at beauty, and someday in heaven, with all of the redeemed people that He loves. • Gratitude: Young children respond to kindness with love, devotion, and gratitude. In the same way, each member of the Trinity is thankful for the other and appreciates all that the others do.
This is not just a book about surgery — or even about surgery in a remote jungle station — it is about God and His unpredictable working in the life and ministry of a missionary kid from Cambodia who ends up as a medical doctor at an isolated hospital in Gabon, West Africa. The first four chapters are excerpted from Dr. Thompson’s autobiography, On Call, but the other 18 chapters are new material. You’ll enjoy Dr. Thompson’s sense of fun and God’s wonderful love. ($12.99) A fatal bus accident and the murder of missionaries: it’s not the way you’d choose to start a career in medical missions . . . but that was the jumping-off point for Dr. Thompson, whose parents were killed by the Viet Cong in 1968. With God as his father, David completed college, medical school, and eventually, surgical training. On Call is the faithful recording of what God has done in the lives of Dr. Thompson, his family, and the people they serve in the West African country of Gabon. ($12.99) To order, call 1-888-231-2637 or go to: www.shopcmda.org.
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Make Truth-telling Your Life-long Practice
by Vincent Gardner, MD
Sixty years of hiding the truth taught this doctor a very hard lesson.
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bout five years ago I received a tap on my shoulder. “Who tapped me?” I asked. The answer came very clear. “I’m God.” “But why are you tapping me?” God’s answer was very specific. “About sixty years ago you told a lie that you have never confessed.” God said no more, but my memories were turned on. What was the lie that I had told and refused to confess for sixty years? I looked to see what I was doing at that time. Had I realized that I had lied, certainly I would have confessed it and attempted to make it right, I reasoned. Now my memory became more specific. Sixty years earlier I was taking care of a young couple from a prominent family. The husband was very attentive to his wife. This was her first pregnancy. There had been no complications during the pregnancy. Now she was in labor and complaining bitterly about labor pains. I had read that intravenous procaine would be helpful. So I started an IV, which didn’t seem to control the pains of her labor at all. I had also read that saddle block anesthesia was very effective and practical. I had experience with that type of anesthesia for surgery. So I did a saddle block, being careful to make it anesthetize only the lowest nerves in the spinal cord. The labor pains quit and she rested. In a little while her pains began again and continued to what seemed a normal delivery. I came to believe that had I checked the mother’s blood pressures like I should have, the baby would have been born alive. But the baby never took a breath. I gave it artificial respiration, but it never began breathing on its own. The baby was dead when it was born. But the pregnancy had been normal. The county commissioners had made me the county health officer. But since no pathologist was available, they also had made me county coroner. So when I pronounced the baby dead, I asked for the permission to do an autopsy. I examined the tissues carefully. I found everything normal except that the kidneys appeared abnormal, even polycystic. I was so overjoyed to have found something abnormal that could be blamed for that infant’s death, that I told the parents that polycystic kidneys was the cause. I didn’t even look inside the kidneys to see 28
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if they really were polycystic. I subsequently learned that in newborns, the kidneys will frequently look polycystic, but when examined inside, they are normal. They just look abnormal. The technical name for these kidneys that look polycystic when they aren’t is “fetal lobulation.” I became convinced that my coroner’s report was wrong, and that I should not have performed a coroner exam on this particular baby due to the conflict of interests, but I never told the parents. Since the false coroner’s report had been accepted by the parents, this is the reaction I imagined the mother may have had, “Dear husband, I married you on the basis that you were a male like all the others I knew. But if you have congenital kidney problems that our baby inherited and caused his death, I don’t want you to father any more babies for me.” Sex ended, and the marriage collapsed. As I look back on it now, it seems that it was my pride that kept me from admitting my malpractice. During the earlier of those sixty years, I was a member of a three doctor medical group. We all belonged to the same church in which we were active. We all held different offices such as elder, deacon, teacher, etc. But these church activities did not cause me to confess that I had withheld the truth in that one case. And as far as I am concerned, withholding the truth is the same as lying.
Now by a tap on the shoulder, I was being asked by God to express repentance and to ask for forgiveness from the father. For God loves me enough to tap my shoulder while I still have one to tap. I knew that I must repent in order to receive forgiveness. I was able to obtain the father’s phone number, in a nearby city. So I called him and confessed the lie I had told him sixty years earlier. “I did an autopsy and then told you that polycystic kidneys caused the baby’s death. Now, sixty years later, I am calling to tell you I came to believe that the true cause of death was low pressure produced by the saddle block anesthesia, which I had not properly monitored. It was my fault, but I never shared this with you. I’m asking you to forgive me for that sixty-year-old lie. Being active in my church did not protect me from lying. But, recently, God gave me a tap on the shoulder, and that is why I have called.” He replied immediately, “I forgive you.” Praise the Lord! The weight of my unconfessed sin and the shame that went with it was lifted. This has been very humbling for me. My friend, if you have any unconfessed sins in your life, don’t wait any longer; confess them now. I am writing especially to young doctors just graduating from medical school. God might not tap on your shoulder like He did on mine. My mistakes were made in medical practice, unintentionally. When the result was the
death of that baby, I covered it up. That was my malpractice. I know that you intend to do everything perfectly so that there will be no malpractice for you. That’s what I thought when I started medical practice, but mistakes do happen. Make a decision now that you will be truthful about any malpractice. Covering it up or being deceitful about it in any way is the same as lying. If you have already told a lie, confess it now. Don’t wait for God to tap your shoulder. It might never happen. ✝
Vincent Gardner, MD, born in 1920, finished medical school at the age of twenty-four and served as a general practitioner in Colorado for twenty-five years. During that time, he and his partners helped to establish and man a clinic for the Navajo Indians in Monument Valley, Utah. Guilt over his malpractice caused him to quit any type of medical practice. In 1971 he moved to Philadelphia to work in a doctor/minister team doing health education, which he did for the next thirty years in various places including New York City and Weimar, California. He joined CMDA in 1972. He has now retired.
Editor’s Note: This is the final article of six in the series “Professionalism in Peril.”
PROFESSIONALISM IN PERIL by Gene Rudd, MD Part 6 Doctor of Contract or Covenant? You Decide. We cannot accept (or continue in) agreements that do not allow us to fulfill our professio, our moral obligation.
With this article we conclude our series on Professionalism in Peril. Previously we examined: 1) autonomy, its limitations and abuses, and God’s response to autonomy (free will) as a model for how doctors should respond to patients; 2) the abomination of unjust scales (God’s choice of words) as it applies to our medical pricing systems that take advantage of those with the least resources; 3) professional adultery, how third parties have corrupted the sacred patient-doctor relationship; 4) how individual character forms the essential foundation for a profession and a personal commitment to those we serve; and, 5) our obligation (professional, ethical, and biblical) to help the poor. This sequence of articles was adjusted to coordinate with other articles in the editions of Today’s Christian Doctor in which they appeared. In this final submission we will review how the business agreements of medicine have undermined our covenant relationship with patients, and how we must return to the covenant concept of professio, our moral obligation.
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our hundred years before Christ, Greek culture was plagued by corruption. Moral decay was ubiquitous, including moral decay within medicine. The chief determinate of the quality of healthcare was the individual’s ability to pay. Without ample payment, you were ignored, treated poorly, or possibly even harmed. It was common for doctors to take advantage of patients in various ways. But there were some who saw a better way. One physician in particular inspired others by his compassion and commitment to patients. Motivated by his high ideals, his followers institutionalized an oath that declared their intent to follow his standards. The physician was Hippocrates. The oath has guided Western healthcare for nearly 2,500 years.
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Initially most Greek doctors did not embrace the new ideals or take the oath. But the few who did became the doctors that people could trust. They became the doctors that patients wanted caring for them. And as patients voted with their feet (and funds), economic and social pressure caused nearly all doctors to conform to these ideals. The administration of the Hippocratic Oath established a covenant relationship between doctor and patient. It established trust. It changed history. Traditionally, as young doctors were released to care for patients, they covenanted to be a certain type of person and to behave in a certain manner. As cited in a previous article in this series, in the first century A.D., the physician to the Emperor Claudius coined the Latin term professio to indicate his moral obligation to serve his patients. In doing so, he inaugurated the concept of professions, and being professional. At its root is the promise to be and behave rightly toward others. Such a covenant was to be unconditional, not dependent on the characteristics of the person needing our care. With that history in mind, let’s consider whether covenant remains the guiding principle in healthcare today. I do not think so. Sadly, the controlling principle in healthcare today is contract. A contract is an agreement made in suspicion. Because the parties cannot depend on or trust each other, they seek to define the limits of the other’s responsibilities. In contrast, a covenant is an agreement or commitment made in trust between parties that value the other. At a practical level, which of these (contract or covenant) is the primary operative in our modern profession? While we would like to answer “covenant,” the reality is that contract has a dominate role in controlling the provision of healthcare in Western society. Notice that the presence or absence of trust distinguishes between contract and covenant. How would
from the patient’s visit. Compensation no longer flowed from the patient’s pocket to the doctor’s pocket. Consequently, the interpersonal dynamic no longer controlled the transaction. This created an opportunity for medicine to escalate charges to an inanimate third party payer rather than the patient directly. While not the sole reason for rising costs, the ease of increasing charges to a distant party certainly contributed. This also provided fertile ground for other business interests to enter the field of medicine, with their influence extending into the exam and consultation rooms. While some of these changes brought about improved care, they all contributed to double-digit healthcare inflation. As payers became burdened by rising costs, various systems were put in place to challenge and control costs. Employers, seeing profit margin disappear as a result of the cost of employee health benefits, also demanded changes. And not the least, state and federal governments became keenly interested in healthcare costs. More bureaucracy resulted. Doctors had to justify their decisions. By the ‘80s we saw “reasonable and customary,” DRGs, CPTs, HMOs, PPOs, and other alphabet soup — all complicating the practice of medicine. Doctors and healthcare systems had to hire more staff to manage the complexity. Frustration grew. Doctors had to spend more time interacting with others about the patient’s care, and less time caring for the patient. In this environment grew the new business of medicine. Hospital systems became more competitive for
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you rate the level of trust that exists in healthcare today? Compared to a generation ago? Are patients more apt to understand and forgive when there is an unexpected outcome? Do you consider all your colleagues honorable, trustworthy? In addition to competency questions, are shady business practices too often part of medicine? What about your employer (if you are employed as are the majority of physicians today)? Can you trust that person or corporation to reliably look out for the interests of your patients? What about their commitment to your interests? As the answers to these questions illustrate, if trust were a patient, it would need to be hospitalized. Consequently, our response to this lack of trust is to draft written agreements. Contracts were needed to protect each one’s interests. We have partnership agreements. We have employment agreements. We have HMO and PPO agreements. We have insurance agreements. We have government agreements. We even have patient care agreements. Each of these is designed to protect someone’s welfare because the parties cannot always trust the other to look out for their best interests. How unfortunate. How did we get here? While the following may seem to be a rather simplistic answer, there is a trail of crumbs. Prior to the 1960s there was relatively little outside involvement in the profession of medicine and the patient-doctor relationship. Quality oversight was the responsibility of doctors. We were the guardians of the profession. We had to supervise ourselves. Such was the traditional expectation of a profession. There were a few bad apples, but by and large, the profession did a credible job of self-government. Additionally, there was little outside business influence. Most healthcare was “cash-onthe-barrelhead.” But things changed. Coincidental with the cultural upheavals of the ‘60s, Congress passed the Social Security Act of 1965, paving the way for both Medicare and Medicaid. (I remember one Senator at the time complaining that, “Before we know it, this bill will cost $3 billion a year.” In 2008 Medicare costs alone were $599 billion!) Along with the government’s accelerated involvement in the business of medicine, private insurance grew dramatically during that era. More and more the financial transactions of healthcare were removed
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business — sometimes pitting doctor against doctor — adding costly services to attract both doctor and patient. Healthcare plans consolidated and began to exert more power due to their size and control. The complexity overwhelmed many physicians. Fewer physicians were willing to manage the daily logistical minefield. Many gave up or gave in. More and more became employees. Today, the majority of practicing physicians are beholding to a parent organization. Today, most physicians are either employees or they have contracts that control how they are to practice. Many of these contracts contain nothing that reflects the traditional covenant obligations of medicine. While the organizations that took control of the daily business of medicine claimed to be committed to patient primacy, experience has shown that the driving force within these systems is bottom line, not beneficence. As more systems, rules, persons, and distractions flowed into medicine, contracts became the means to control the various relationships. Insidiously, contracts replaced covenant. They now control healthcare. I grieve that it happened in my generation! Is there a way back? I am not naïve enough to think that all the business systems and contracts can be wished away. I think it will get worse. But the very nature of a contract is that the parties have to agree. That is where we have an opportunity. My admonition is that we more wisely consider what we agree to. We should no longer accommodate the current paradigm, one that obligates us to do business in a way that conflicts with our obligation to serve the best interests of our patients. We cannot accept (or continue in) agreements that do not allow us to fulfill our professio, our moral obligation. Additionally, we must seek to reestablish ourselves as guardians of the profession. In abrogating this role, we have allowed others to step in. These “others” include insurance companies, administrators, and governments. They do not share the same moral obligation we must bear. We must accept the responsibility of accepting into training only those men and women whose character has been adequately shaped at the formative time in their lives. It is too late for medical and dental education to form character. We must return to our obligation to care for the poor. It will require personal sacrifice. One of the greatest obstacles in truly reforming healthcare (not just the financial reform that government seeks) and reestablishing professionalism is a lack of hope — a lack of vision. The French historian, Baron de Montesquieu, in writing about the Spanish conquest of the American Indians, explained that the Incas and Aztecs had sufficient forces to overwhelm
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the invading army, but they simply lacked the vision to do so. The strangeness and complexity of the Spaniards paralyzed them. Since they could not see the possibility of success, they could not adequately organize themselves to defend their way of life. I fear the same is true among doctors today. Too many of us cannot see the possibility of success. As a result, we simply fail to organize ourselves to protect our profession, our moral obligation. That is one of the reasons for the existence of the Christian Medical & Dental Associations: We organize doctors of faith to stand against the moral decay in our profession. I am not sure if our efforts will turn the tide, but it is the right thing to do. And regardless, I have hope. Ultimately my hope is in our God who cares about us as individuals. He has promised to never leave or forsake us. And He has given us a glimpse into the last chapter. But in addition to that, I foresee a day when our society will reach a tipping point. As in ancient Greece, our healthcare system is slipping into moral decay. And as in ancient Greece, money is the chief determinate of the quality of care. But as in past times, there remain those loyal to higher ideals. They are doctors who have pledged to be committed to and behave by noble standards toward those they serve. When society finally becomes disenchanted with a system controlled by contracts, they will look around to find those doctors who are different — those who accept the covenant obligation of our profession — a moral commitment to serve the best interests of their patients. I foresee a day when people will once again vote with their feet. They will say, “That’s the kind of doctor I want.” When that happens, doctors of covenant will once again alter the course of history. What about you? Will you be a doctor of contract or a doctor of covenant? ✝
Gene Rudd, MD, co-author of Practice by the Book, serves as Senior Vice President of the Christian Medical & Dental Associations. A specialist in Obstetrics/Gynecology, Dr. Rudd has experience in maternal-fetal, medical education, and rural healthcare. He has garnered numerous awards including the Gorgas Medal. While working with World Medical Mission, he established the Christian Medical Mission of Russia, directed the rehabilitation of the Central Hospital in Kigali, Rwanda, and served in Belarus, Bosnia, and Kazakhstan.
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General Dentist – Excellent opportunity for a highly motivated general dentist to work in a thriving practice in Cambridge, Maryland. We offer a state-of-the-art facility and exceptional compensation. Please e-mail resume to: rhiersdds@comcast.net.
Internal Medicine – Hospital and Office Practice Multispecialty group in Springfield, Illinois seeks full time MD for split practice with equal concentration in hospital and office. www.pgaclinic.com. Fax resume and contact information to: 217391-0392. Obstetrics – Seeking Family Medicine Obstetrics physician desiring expansion of skills for mission hospital activities. Established fellowship program for development of skills in OB/Gyn ultrasound, office surgery, and Spanish. Modules are available on Cesareans, EMR, digital X-ray, and others. Accepting applications for faculty and fellows. Send CV and goals to: wmrodney@aol.com. Orthopedics – Well-established practice of three orthopedists and one podiatrist committed to providing care with compassion as well as excellence. Time off for short-term missions. Would like to talk with general and subspecialty orthopedists about the possibility of joining us in practice. On-site surgery center; local hospital within walking distance. Located in a family-oriented city where many recreational and cultural activities are available. Less than a 10 minute commute from any area of the city. Low malpractice rates and cost of living. Vacation at the mountains and the beach; live here and enjoy all four seasons. Please contact our Medical Director, Dr. Chris Wilkinson at: 308-627-4664 or cwilkinson@kearneyortho.com. Our clinic manager, Vicki Aten, can be reached at: 308-865-2512 or vaten@kearneyortho.com. Orthopedic Surgeon – Christian-centered five physician Orthopedic Surgery and PM & R practice in Plano, Texas seeking orthopedic surgeon who shares our vision “To Love and Serve Others” by providing quality care, access and convenience to our patients. Family-centered practice primarily outpatient with optional hospital involvement/call. Opportunity for partnership in 2 years including Surgery Center, Imaging Center and Physical Therapy. Practice recognized by D MAGAZINE for last three years as a center of excellence in the community. Our practice has a strong primary care referral support for elective orthopedic cases. Generous competitive compensation package offered including benefits. Interested candidates please forward CV and contact information to: email.hr100@gmail.com. Otolaryngologist – Beautiful North Cascades area of Washington State. Located between Seattle, Washington and Vancouver, B.C. The area offers quick access to the San Juan Islands or the Cascade Mountains for hiking, fishing, kayaking, to name just a few of the exceptional outdoor recreational opportunities available. An excellent partnership opportunity to join a well established five-physician practice in Washington State. We are seeking a board eligible or board certified physician. Please contact: Human Resources Department, Brooke Herzberg, Director, Cascade Medical Group, 360-336-2178, brookeh@cascademedicalgroup.com.
I n t e r n e t W e b s i t e : w w w. c m d a . o r g
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Fall 2010
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CHRISTIAN MEDICAL & DENTAL ASSoCIATIoNS P.o. Box 7500 Bristol, TN 37621-7500
Nonprofit Org. US Postage
PAID Bristol, TN Permit No. 1000
2011 National Convention Dr. Jim Garlow Pastor, Skyline Wesleyan Church in La Mesa, California
April 28 – May 1, 2011 Mount Hermon Conference Center Mount Hermon, California (Santa Cruz area)
James Tour, PhD T. T. and W. F. Chao Professor Chemistry, Professor of Computer Science, Professor of Mechanical Engineering and Materials Science, Rice University, Smalley Institute for Nanoscale Science and Technology, Houston, Texas Richard Swenson, MD Futurist, Researcher, Educator, Author, Menomonie, Wisconsin
David Stevens, MD, MA (Ethics) CEO, Christian Medical & Dental Associations, Bristol, Tennessee
Danny Byram Worship Leader, Danny Byram Ministries, Evergreen, Colorado
NUMEROUS BREAKOUT SESSIONS: ?WV[US^ 6W`fS^ >WUfgdWe Love the Lord your God with 8S[fZ Fab[Ue all your heart, and with all your 7fZ[Ue soul, and with all your mind, and with all your strength. ?[ee[a`e Mark 12:30 (NIV) ?Sdd[SYW 8S_[^k
For more information, call the Meetings Department at 1-888-230-2637 or visit the website at www.cmda.org.