Doctor; Your Diagnosis. My Death


copyright © 2010 Betsy L. Angert.

Dearest Doctor, I have come to my senses.  Days ago, when you offered your diagnosis, I died.  No, not literally.  Had you done me in, I would not be here to write what I hope will help inform your bedside manner.  Well, in my case only the way in which you approach a patient who merely sits in an examining room chair near you is the concern.  You may recall our time together began so innocently. We sat down to review the results of annually scheduled blood-work.  I had not felt sick all year or on that day.  You had even expressed, it had been so long since we last saw each other.  You scanned the pages, and proclaimed, that I must have returned to my bulimic ways. My spirit perished.  I had done nothing of the sort!  Yet, you said you were sure I had.

The pain you inflicted killed what could have been a relationship built on trust.  Today, I realize your proclamation was but part of a pattern.  Indeed, you reminded me that during our last consultation, a year ago, you also decided that I must be near death.  In August 2009 you insisted that I arrange for an appointment, which you openly stated, would affirm your fears. I must be seriously ill. Yet, once that test was done, it affirmed that I was as I am better, than fine.

Upon further reflection, and after the telephone conversation I initiated hours after my appointment, I thankfully, feel more serene.  No, you did not change your diagnosis nay your assertion that I must be vomiting.   Still, the talk helped me, although it seemed to alienate you.  I wonder if you now have a sense of how I felt and feel since you pronounced me dead and a liar, or do you merely believe of me, “The lady doth protest too much.”

Might you ponder that my grievance is grounded.  Oh, how little you know of bulimia, and me.  In the two plus years we have had an acquaintance, I see you for maybe, ten minutes a visit.  Since only once did I come to your office for other than a check up, what you observed this week is true. I rarely visit.  When I do, you are booked.  Patients arrive back-to-back.  We chat for a bit, but not really.  All is said and done rapidly.  I wonder, might the speed of conversation and the shallow nature of a consultation affect your appraisal.  After all, you too are human; although from what you said to me today, it seems at times such as this you define yourself as a trained medical professional, more perceptive than a mere mortal.

During my most recent appointment you admitted, you did not even recall what I had shared so often; I disdain exercise.  I was never amongst the anorexic/bulimics who think they must work out endlessly. Only injuries incurred late in life took me to my current routine, a daily swim in the pool.

I know you recall that I swim, only because I often come dressed to swim.  Even that concerns you, exposure to the sun.  Do you remember that I switched to an indoor facility.  Probably not.   While the truth of the locale and my loathing exercise may not be memorable or visible in an office visit, what can be seen is a sign of bulimia.  My teeth.  

Doctor, did you notice what my Dentist and Dental Hygienist have?  My once translucent boney choppers are now denser.  The color has returned to white.  For so long, even when you and I first met, the hue was dark gray.  Other dental conditions were already on the mend when I first entered your sphere.  Deep groves, once etched into the enamel, gone.  With my tongue, or a look, I can tell, the surface is smooth once more.  As I said in our phone conversation, less than twelve hours after you declared me dead,   Charlene stated with delight, “Your teeth finally look alive.”

Funny. Charlene, my dental hygienist, detects a difference in my body and being since I left bulimia behind.  Yet, you are intent on my being ill.  Charlene sees and speaks of how my life without food benders and bile has helped me be healthier.  Yet, you dear Doctor, only see standards, the stats that you think are real, more real than me.  

You do not see, hear, or open your mind to who I might be.  I marvel as recall the day Charlene had expressed a doubt.  She offered, in Dental School professors taught the conventional wisdom.  Teeth do not substantially re-mineralize.  Enamel and density loss are permanent.  However, Charlene wonders aloud.   She has come to accept that what she learned may not be valid.  Months earlier she mused, “Well” after much assessment, “I have witnessed the metamorphosis.”  There is a change.  

Transformation from bulimia to health has occurred for Charlene, for me.  Then there is you, dear Doctor. Apparently, what was, will always be in your mind.  Oh, Doctor, if only you had truly engaged me in the past two years . Had you looked and listened or even spent more than a scant few minutes with me in any of our sessions, just maybe you would have learned that supposed facts and figures may not mean whatever it is medical professionals teach.  

Might you think to speak to me rather than seek the “expertise” of more and more specialists [sic] before you declare me to be on my deathbed?  I know not what to say.

I tried to talk to you, to share my reality, my family history, and myself.  My words fell on deaf ears. You so sweetly fight me at every turn.  When I worked to offer an analogous story, you scoffed.  Might I assume that you see me as less knowledgeable, credible, or just crazed.  Perchance, I might try to tell the tale again?  Perhaps, the read will help you to authentically relate.  

As I said, the day after you delivered your diagnosis I traveled to the dentist to have my teeth cleaned.  By the way, dental visits last for well over an hour and I go every few months.  Charlene and I talk the entire time.  This week, since I had just seen you and was so devastated, my exam and your evaluation were the topics of discussion.

Charlene smiled and stated she is all too familiar with Doctors such as you.  While she has had her own experiences her Mom’s was most worrisome to her.  While under the care of her Doctor, Charlene’s mother’s organs were forever damaged.   The Doctor thought it wise to bring this adult female’s blood levels to “normal.”  However, with age her heredity set in.   What had been usual for the patient was no longer as it was.  

Yes Doctor, I acknowledge that you listened to this story, for seconds, and then, abruptly interjected your disregard of my attempt to share personal accounts, or the details of my family history.  Doctor, you preferred the argument, “Charlene is not a Physician.”  Might you trust the words of others Physicians, those who have misdiagnosed me or correctly assessed my well-being?

Please indulge me.  Allow me to present a nonfictional narrative.  Eight years ago, after a serious automobile accident, an Orthopedic Surgeon told me I would not be able to walk for at least a half a year, probably more.  He assured me that one leg would be shorter than the other for the rest of my life.  I needed full bed rest for at least six months, maybe seven.  The specialist said he could not speak to the pain I had in my chest and ribs.  He saw nothing in the X-Rays.  Weeks later, another bone MD whom I thought it wise to consult, was shocked to discover my broken sternum and four fractured ribs.  

That Surgeon, I will call Doctor Thom, was more than a second opinion; he saved my leg, heel, my life.   Dr Thom told me that I needed to begin an exercise regime immediately!  He then showed me exactly what he wanted me to do as soon as possible.  While he concurred, I could not walk or bear even the slightest weight on my heel, I could get around on my hands and knees.  My father, relieved went to the store and purchased the best fluffy-filled cotton kneepads money could buy.

Dr Thom helped me realize that the pain in my chest was very real.  He helped me to feel safe, secure in the knowledge of what I could to.  Dr Thom spoke of a means for stability, and provided time frames.   Most importantly he attended to my needs, not as just another “patient,” but as me, Betsy!

Thankful that this physician asked of my history, and accepted that two past injuries necessitated a regular daily swim, I was able to feel comforted by his care.  Indeed, months before I was authorized to walk, with a promise from me that I would not place my leg on the ground, not even in water, Dr Thom prescribed a return to the pool.  Yes Doctor, he wanted me to swim unlike you who said, stop the swim or at least cut the time in the water done to near nil.  Fifteen minutes or less a day?  Doctor, have you read the research and recommendations for minimal daily exercise? Perhaps you have no desire to do other than prove yourself right.

For me, what is right is a healthy relationship with one’s body and other beings.  If only we had genuine caring, sharing exchanges.  I believe we do not.  In each of our talks, your trepidation for what you feel is my impending death, is inescapable.  It seems to shade your every diagnosis..

Doctor, I know you are not G-d. You do not have the power to give me life.  However, a professional such as you, can cause my demise.  The innumerable reports that document a patient’s passing at the hands of his or her physician cannot be ignored.  

Certainly, I may have over-reacted or reacted as any healthy person would to your decree; I lie or I die, possibly both.  Imagine my surprise, I entered your office the picture of health, and was pronounced a perishable commodity.   You said, were you to review my chart in a hospital, you would order a full body transfusion.  Until you were certain why results of the blood tests were so dire, you wanted me to see four specialists and a therapist.  A therapist?  

That statement alone spoke volumes; however it was a hush in comparison to the stated accusation.  You were concerned that I had returned to the world of bulimia.  Oh had you, or most any Doctor who diagnoses, what professionals call an eating disorder, experienced the thrill of leaving that past behind, you might understand how wonderful it is to have my life back.  

For years now, days, weeks, months, decades, devoted to food do not consume me.  Close to a decade has passed since I spent more time bingeing and purging than you do sleeping or working. Can you imagine? What might you feel if you were finally free of all that constrained your very being?

Oh Doctor, I know you cannot conjure up such a connection.  Were you able to relate to my reality you would not have said and done as you did.

You dismissed my words, my truth, all that I had learned, felt, and experienced in the twenty-five years and three months that I battled with the bulimia.  More significantly, you concluded that the many years since I last vomited were null and void.  In your infinite wisdom, you decided that a Doctor knows much more about an individual than the person, his or her self, does.

With few visits in our past, and little conversation, you know what is real for me?  You think practitioners who have never met me before will assess my health more accurately.    Based on what, more standards of “normal.”

Your counsel crushed any sense of a connection.  Your stated distrust of me is as a surgical knife; it cuts to the core.  When a Doctor doubts a patient, the effect is profound.  At least it has been in my experience.  However, it seems you are not truly interested in my experience or that of others.  Oh, how I wanted to explain my truth when we spoke on the telephone today.  Your response, “He, she, or I am not a trained medical Physician.” may have cured me of that desire.

However, happily I was able to sneak in one thought whilst we chatted.  A Doctor I am acquainted with has often expressed, medical school is like a technical college.   Practitioners and Surgeons are analogous to Mechanics.  For each, diagnosis is the greatest challenge.  An educated guess, or “evaluation” only captures what is typical.  You offered no thought on what another Physician pronounced his truth.  Perchance, you are still of the mind that you know what you know.  

As an Educator and an observer of humanity, I share what I believe.  Knowledge is not power!  Empathy empowers.  If only you chose to be empathetic, to consider what is beyond book knowledge. Perhaps, then, people, patients, might be real to you rather than fall into one or two categories. Terminal or test-proven fit as a fiddle.

Dear reader, you may wish to peruse Chapters One through Seven. Please do. These reflective diaries discuss my life as an anorexic, bulimic, a person.

Or Similar Discussions . . .

Reference for review and reflection . . .

“Right of Conscience” Protections; Be Patient


copyright © 2008 Betsy L. Angert.

She said, “If one is to pass, it will have to be my sister.”  Jennifer would not allow a baby to die.  Although the newborn had yet to take a single breath, and was still safely tucked away in her mother’s belly, Jenn decided the infant must live.  Had she been an employee of one of more than 584,000 health-care organizations her word would have been considered a “right of conscience.” Jenn would not be held responsible if she refused to treat the soon-to-be Mom who was also her sibling.

A Bush Administration rule would protect physicians, nurses, pharmacists and other employees who decline to participate in care they think ethically, morally or religiously objectionable, from any repercussions.

Medication, information, or any other assistance need not be given to someone a medical staffer considers immoral.  If the Bush Bill is allowed to stand, those who take the Hippocratic Oath and those who work with Doctors need not do a deed they believe violates personal beliefs.  On December 18, 2008, the White House decreed it would protect all Health Care Workers.  This provision is thought to be a gift from G-d for those who are as Jennifer was, pious believers.

As a devoutly religious soul, when confronted with the choice of who might live or who would die, Jennifer decided the relative she knew and loved for all her life could go.  Jenn announced, “Babs had been a beautiful child, terrific as a teen.  As an adult, Barbara was the best.  Her existence on Earth had been short.”  “Yet,” Jennifer cried with tears in her eyes, “Now, it is time for the baby to realize the joy of an Earthly existence.”  Jennifer had faith.  ‘G-d knows’ were the words she oft uttered.  It is not ours to question why.  “The Lord giveth and the Lord taketh away.  Blessed me the name of the Lord,” was the sentiment secure in the heart of one who saw herself as mere mortal.

However, hurt by the thought that their beloved Barbara might pass, and Jenn would embrace such an event, relatives attempted to reason with the woman who would refuse her own sister’s life.  Jennifer, certain of her “Right to Conscience,” made it clear she knew.  The baby-to-be must have the same chance to evolve that Barbara had.  She or he, since at that moment the sex of the fetus was unknown, must survive and thrive just as G-d planned.”  Jennifer reminded her relatives, “Barbara was in her twenties,” at the time of this crisis.  Jenn was near thirty, old enough to have experienced life, and established enough to be considered for her wisdom.  The religious woman recognized, she too had rights. Now, under the new Bush Administration imposed rule. Jennifer, or hospital staffs of today, will have more power to exercise their conscience then they had in the past.

Leavitt [Mike Leavitt, Secretary of the Department Health and Human Services, which issued the novel rule] initially said the regulation was intended primarily to protect workers who object to abortion. The final rule, however, affects a far broader array of services, protecting workers who do not wish to dispense birth control pills, Plan B emergency contraceptives and other forms of contraception they consider equivalent to abortion, or to inform patients where they might obtain such care. The rule could also protect workers who object to certain types of end-of-life care or to withdrawing care, or even perhaps providing care to unmarried people or gay men and lesbians.

While primarily aimed at doctors and nurses, it offers protection to anyone with a “reasonable” connection to objectionable care — including ultrasound technicians, nurses aides, secretaries and even janitors who might have to clean equipment used in procedures they deem objectionable.

However, in that moment, , the family was aghast.  They could not come to terms with what Jenn believed best.  Thankfully, Jennifer did not have the authority to choose what would be done, as medical workers might if the “Right to Conscience” is made law.  Family, and the patient herself, had the power to select what for them seemed the best treatment.

Apprehensive, as she contemplated assessments that seemed purely emotional, Jennifer, worked to put her personal feelings aside.  She trusted human sensibilities could not be her priority.    G-d would show her the way.

Her faith in the Almighty, and Jenn’s belief that a new life cannot be aborted, were her only considerations.  She had no animosity towards Barbara, not then, or ever.  Indeed, she loved her sister’s sensational soul.  Even in the moment she declared, it is better that Barbara’s life be sacrificed, Jenn thought of her young sibling as a close friend.  Yet, no matter how she felt about the person who was so real to her, Jennifer was sure G-d would want the newborn to survive.  “He” had given Babs a good life.  Now it was time for her to go home, to be with her savior once more.

It hurt Jenn’s heart to think of her sister’s departure.  When Babs was but a tot, Jennifer, the older sister, served as a second Mom to the sweet little bambina.  She was as fond of Barbara throughout their younger years, just as she was on that day. However, her affection for the woman who now held an infant in her womb could not negate what Jennifer thought G-d had decreed. A new life must not be killed.  

During that turbulent time, Jennifer might have said as Deirdre A. McQuade of the U.S. Conference of Catholic Bishops declared when news of the “Right of Conscience” proposal was released. “Individuals and institutions committed to healing should not be required to take the very human life that they are dedicated to protecting.”

This moral, ethical, Christian woman trusted as many do today; people enter this world and then, when they have completed their mission, the Lord invites them to return home to the heavens.  We all must depart when it is our time, Jennifer intellectualized, or justified what she thought to be true.  Had this conversation taken place in late December 2008 any hospital employee, even a hospital custodian could refuse Barbara care.  All those years ago, Jenn was certain she would have let her sister die.  

David Stevens of the Christian Medical Association would concur.  As the “Right of Conscience” becomes reality, a leader of the faithful reminds opponents, “We will do all in our power to ensure that health-care professionals have the same civil rights enjoyed by all Americans. These regulations are needed, do not change the law, but simply stop religious discrimination.”

Jenn did not think she needed to be a victim of circumstance.  She too would wish to invoke her “Right of Conscience.”   She did not share her family’s sense of fairness.  Favoritism for the born seemed principled to one so dutiful.  Jenn thought it essential to honor the divine, and not discriminate against her for the values she held dear.

An allowance for a mother did not make sense to Jenn when she was but a young lovely.  Nor does the unexpected exodus of a baby seem reasonable to the more mature Jennifer.  Nonetheless, the daughter of Eve, who today maintains her faith in Jesus wonders whether a medical professional should have the power to chose what is right for another human being.  At this time in her life, Jennifer fears what would have been had the “protection” for someone such as her been in place.  Today, she inquires; what of the patient.

As she aged, Jennifer experienced what she could not have imagined all those years earlier.  Barbara, who lived, gave birth to one, then another bouncing beautiful baby.  As an Aunt, Jenn learned to love these children as if they were her own.  Upon reflection, she felt sorrow when she thought of what she might have missed had her sister passed.  Time with her treasured sibling Babs had truly been a treasure.

Jennifer also realized she was the Aunt to a lesbian woman.  No, the niece was not Barbara’s daughter.  Jenn’s sister Kathy had two children.  Susan, born before Babs was ever pregnant, developed into an intelligent, insightful, inspirational female whose gender preference was also female.

Years ago the religious person she is would have perhaps rejected and other relative.  However, she could not.  It was never a thought in her mind.  Jennifer helped raise the younger lady, now classified as gay.  Oh, how she was.  Susan was and is a bundle of joy.  Yet, a hospital worker may think her gender preference alone is despicable.  Jenn wondered of the care her loved one might not receive in a time of need.  She knew that a “Right of Conscience” provision might protect a physician, a nurse, a pharmacist or a janitor, but what would become of Susan if she were to be hospitalized or even enter a clinic for emergency care,

Then there was Susan’ significant other to consider.  The two became Mom’s, twice.  Susan carried each child to term.  Their children, conceived through artificial insemination, were the apples of Jenn’s eye.   What might have been were a medical worker to invoke her or his “right of Conscience” when Susan was a patient.  Great Aunt Jennifer shudders to think.  Instead, she takes pleasure in the time she spends with the littlest ones.  She frequently volunteers to baby-sit for children who, had a health care worker snubbed Susan, might not exist.  

Jenn has come to realize she feels no obligation to be there for her family, gay or straight.  She no longer ponders protections from what the Almighty did not prevent.  Her conscience is not troubled by the circumstances.  Jennifer had grown to see G-d, and all life in a different light.  Perchance Jenn thinks, she had become more enlightened.  However, no one could have told her then, when Babs first baby was born, that one day her beliefs might change.

Often, over the years Jenn had to grapple with her truth.  She remained forever faithful to the Lord and his teachings.  Tradition, for her was paramount.  She did not think herself omnipotent; yet, earlier in her life she was certain of what was right.  Her scruples dictated her decisions, and Jenn, of then, was decisive.

Today, as she is confronted with novel truths, she wonders of what might have been the error of her ways.  More than one physician has advised Jenn to seek relief for feminine problems.  Although, she is considered a middle age woman, Jennifer has only engaged in intimate sexual contact with one man, and even then, for only one year of her life.  Near celibate, it has been a score since Jennifer might have thought to use a contraceptive to avoid pregnancy.  Today, however, she is urged to ingest the birth control pill.  Were it not for the pain she experiences without the medication, Jenn would simply say “No!”

After much personal conflict, trials, and tribulations, Jennifer decided she would succumb. Yet, as she attempts to fill her prescription she is confronted with what was once her truth.  Might this believer in G-d repeat, “We reap what we sow.”  Jenn who teaches in a Catholic institution cannot obtain medicine that might prevent fertilization of an egg.  That she has no eggs to fertilize is for her Insurer and employer a moot point.  The Bush Administration thinks the regulations that restrict Jenn are just.

The rule comes at a time of increasingly frequent reports of conflicts between health-care workers and patients. Pharmacists have turned away women seeking birth control and morning-after emergency contraception pills. Fertility doctors have refused to help unmarried women and lesbians conceive by artificial insemination. Catholic hospitals refuse to provide the morning-after pill and to perform abortions and sterilizations.

Experts predict the issue could escalate sharply if a broad array of therapies becomes available using embryonic stem cells, which are controversial because they are obtained by destroying very early embryos. Obama is poised to lift the Bush administration’s restrictions on federal funding of embryonic stem cell research.

“Doctors and other health-care providers should not be forced to choose between good professional standing and violating their conscience,” said Mike Leavitt, Secretary of the Department Health and Human Services.

As Jennifer reflects, she knows not whether to laugh or cry.  She has rights; she has a conscience.  Yet, she has discovered one may not preclude the other.  She wonders how many will realize as she has before it is too late.  How many might die at the hands of professionals who think themselves principled.

References for Rights and Conscience . . .

Condition; “Critical”


copyright © 2008 Betsy L. Angert.

Twas the night before Election Day and my mind, heart, body, and soul were filled with fright.  I fear I did not do enough; nor could I have, to truly bring about change.  I more needed time with those that trust me or were still open to reflection.  When last I made calls for candidate Barack Obama, I was slammed, damned, and spoken to with much disdain.  Similar occurred when I stood on a street corner and waved my signs.  Granted, I saw and heard there was much support.  Still, I had friends who would not vote for Senator Obama.  Several were sure that they preferred John McCain and Sarah Palin.  Then, there was John Michael Rubens.  John is eligible, older; he is registered.  This fine fellow has cast many a ballot in his lifetime.  Doctor Rubens is prominent pillar of the community.  The well-trained physician is a scholar.  He cares.  Yet, he would not cast a ballot for either candidate.

John’s positions affected my faith.  Everywhere I went, other people told me to believe, to be hopeful.  However, I knew that no matter who entered the Oval Office, blood would be spilled.  On battlefields abroad and on the streets of America, brutality born of terror would continue to flow.  For some people weapons wield strength.  Innumerable individuals use words to kill.  Some take advantage of signatures on insurance forms, benefits no longer offered with salaries, or just the Health Care system.

Hours before Americans went to the polls, my very close friend, a man familiar with the field of Health Care and the coverage necessary to treat illness and injury, spoke of what time, or a national election tally would not easily erase.  Doctor Rubens avowed, the tangible that he thinks is in need of serious attention, is  the way in which medicine is taught, practiced, and paid for.

John believes the Health Care system is a mess.  He fears it is too far-gone.  No Doctor, Democrat, or Republican, can revive a lifeless body that is virtually dead.  Doctor Rubens offers his diagnosis; the institution known as medicine is virtually dead.

Doctor Rubens has long felt antipathy for elections.  For years, I have endeavored to persuade him to vote.  I did not have, nor did I express, disdain for his decision not to cast a ballot.  I only hoped life’s daily doings would encourage him to go to the polls.  As he shared his personal narrative, I inquired.  “Will you vote in hopes that coverage, costs, and the circumstances for practitioners and patients are improved?”  “No,” was the immediate response.

He laughed.  John Rubens was not joyous or jovial.  The physician was pensive.  He pondered aloud.  No amount of money, and neither of the Presidential candidate’s plans will do anything to improve what John just experienced.  John Michael Rubens recently returned from an extended hospital visit.  He was the patient, not the physician.  

While in the hospital, it became increasingly obvious to the man I love, hospital staffs are underpaid.  Personnel are scant.  Each day more and more positions are cut.  The economic downturn has had a direct effect on employee benefits, on whether ill or injured persons seek care, and on the ratio of attendants to individuals admitted to the hospital.

J.M. Rubens, M.D. observed nurses, physical therapists, and specialists in surgical procedures are asked to stretch them selves beyond what any person could physically, or emotionally endure.  He recounts his own medical history, as a Doctor, and in treatment.  John marvels.  Surgeons, who may stand for as long as seven hours in the course of a single operation such as his, make less per hour than he earned decades earlier.  The number of people medical practitioners in every field serve has increased.

Among specialists, invasive cardiologists’ compensation declined (0.18 percent loss) even before inflation.  Conversely, noninvasive cardiologists’ compensation increased 11.72 percent.  Compensation for emergency medicine physicians and hematology/oncology also failed to keep up with inflation.  Specialists who fared better included anesthesiologists (6.43 percent increase above inflation) and urologists, posting a gain of 5.5 percent above inflation – compounding a similar gain in 2006.

“Although primary care physicians posted modest gains in compensation as a result of increased productivity and re-weighting of evaluation and management codes, overall practice costs continue to rise at staggering rates,” said William F. Jessee, MD, FACMPE, president and CEO, MGMA.  “The continued uncertainty of the reimbursement environment creates an untenable situation for physician groups.”

Compensation, when it comes, is inadequate.  In truth, the doubtful delivery of reparation is, in part, why John retired early.  If the patient is “covered” by Medicare, reimbursement is less.  The time needed to evaluate is not considered in the repayment.    Little is.

Doctors have complained for years that Medicare rates haven’t kept pace with costs, such as new technology and the added paperwork required by insurance companies.  The formula for determining reimbursement rates has basically been unchanged since Medicare was created in the 1960s, said Gondo.

Medicare reimburses doctors for about 46 percent of their fees while private insurance pays from 60 to 65 percent, said Dr. Timothy Melhorn, medical director at Cornerstone Medical Clinic, which is owned by Yakima Valley Memorial Hospital.

Medical practices incurred a 7 percent increase in operating costs in 2005, but Medicare reimbursed doctors less than half that amount, according to the Medical Group Management Association, which advocates for medical practice managers.

Doctor Rubens reminds me of what he received when I was a Medicare patient.  The payment was very low by today’s standards.  Even then, before he saw me, he told me he would not take on another patient who did not have private insurance.  His office maintained a waiting list. Quality referrals were my entrance into his office for one visit.  All those decades ago, John agreed to see me for a single appointment.  Fortunately, for me, during our first encounter, he realized we had so much in common.  John Michael Rubens, thankfully, decided to add me to his workload. Rarely, do the millions on Medicare list have this opportunity.

Today, in territories such as Texas, more than forty percent [40%] of physicians will not accept new Medicare patients.  Before 1990, ninety percent [90%] of medical professionals were willing to take on the persons now turned away.

At the time, Doctor Rubens saw me, he felt he could afford one more “charity” case.  Today, he observes medical professionals do not have the time to be so benevolent.  They work more hours than is healthy.  Money does not motivate them.  Indeed, the profession is no longer a fruitful pursuit.

The physical condition of the health care system is not what it was a score ago when John saw me as a patient.  On many occasions, Doctor Rubens has said, “Physicians’ income fell 7 percent between 1995 and 2003 after adjustments for inflation.”  I have heard the many stories.  I recall what he shared of his last years in practice.

When John Michael Rubens was eight years out of Medical School, he was able to purchase a house in an exclusive enclave.  That property is now worth millions.  The lot looks over the Pacific Ocean.  From what was once his window years ago, he had a panoramic, breathtaking view of the surf and shore.  Today’s Doctors, John declared with a deep sense of distress, even after many years in practice, cannot begin to pay for what he had after less than a  decade.

In 2006, in what feels like an eternity ago when we consider today’s economic crisis, the greater number of jobs lost, and a reduction in employer provided benefits, it was reported that Doctors’ income falls over eight years.   Primary care physicians are impacted more than specialists; although at the time of this survey, surgical specialists’ revenue dropped 8.2%.  Young persons who, in the past, thought a future in medicine would be wondrous, are affected by reduced returns on an ample investment.  Fewer wish to enter the medical profession.  

Earnings are but one consideration.  Malpractice premiums, technology for an office and personnel are large expenses.  Then, there is the paperwork, and telephone calls not paid for.

“Every day, I spend at least an hour after my workday to call patients back, to discuss lab results, to discuss test results,” Ryan Mire said.  “That’s not compensated.” . . .

“Just in the last three weeks, I have actually noticed three medication errors from specialists who prescribed medications for my patients because they did not have the full history,” Mire said. “I received those consultation notes, saw what the specialist prescribed, and said, ‘Absolutely not, do not take that medicine.'”

Yul Ejnes, a Rhode Island internist also on the panel [part of an internal medicine conference in DC] added a couple other typical primary care tasks that aren’t reimbursable: “talking with family members,” and “just sitting down and thinking” about a case.

“Sometimes I wonder whether I want to keep doing this,” Ejnes said.

These doctors are not alone.  John Michael Rubens wrestled with the question for quite some time before he decided emotionally, physically, economically, the career he once loved was not worth the toll it took on his personal and professional life.

Recently, for two long weeks, Doctor Rubens laid in a hospital bed, listened to the tales of sickroom staff, and observed what occurred before and after his operation.  John took time to reflect on his earlier evaluations, his money, his health, and his life.  When circumstances were not as bad as they were today, John chose the retirement that has provided him greater perspective.  Frequently, he has mused, ‘There is so much I missed, or just did not understand in the way I do now.’

Time with family, friends was perhaps less than he had hoped it might have been, although he was sincerely committed to his relationships at home, and in the office.  John, the Medical Doctor, in private practice, was more often than not, on call.  Doctor Rubens loved his work.  He chose his profession for the love of people.  Physician Rubens entered a consultation room with a desire to heal.  He yearned to lend a hand to the patient who wished to help him or her self return to good health.  

John took the time to talk and more importantly to listen to his patients.  John Michael Rubens was invested in the Doctor Patient Relationship.  As he speaks with younger Practitioners, who drop in and then quickly out of his hospital room, John grasps, for them, the Hippocratic oath is a luxury they cannot afford.  The current Health Care culture dictates, money matters are the vital sign to be considered.  Empathy for a patient has been eliminated from the profession.  In the latter years of his practice, Doctor Rubens prescribed as practitioners have, “The changes in medicine are at odds with many of the values that defined the profession I joined”

The physician realized there was a transformation when  health insurance companies identified him as a “provider.  He was assigned a number.  His name was as meaningless as his diagnosis.  He spent hours on the telephone in an attempt to advocate for patients.  The ill and injured were denied treatment.  Payment for prescriptions could not be secured.   John recalls when he worked with a particular hospital, months passed and he received no pay.  His children, now attorneys argued he should sue.  Doctor Rubens preferred to just walk away.  Today, he expresses with trepidation, litigation is more prevalent than quality licensed health care.

As the Doctor reminisces, he reflects on the education young interns receive.  He hears tales of woe from his daughter-in-law, who is enrolled in a teaching hospital.  He reads of how these premier institutions are in crisis.  Some experts are anxious.  While no one believes the refuge for research, development, and the place in which a patient can receive better medical care will disappear permanently, the money needed to maintain such stellar institutions is no longer a priority in a managed care culture,

As a physician in practice, John knew times were tough.  However, he did not fully imagine what it must be like for those who are captive to coverage plans that do not consider the wellness of a patient.  Life as one who is in dire need of medical treatment has also opened his eyes.  Only days ago, John was in critical condition.  He had been rushed to the hospital.  Repairs made in a crucial operation years earlier ruptured. Toxins spread throughout his body. The medical professional needed to place his faith, his life in the hands of those who he trusted had stresses of their own.  The surgical procedure was deemed a success.  Physical pain nearly paralyzed John.  His ability to toss or turn was trivial.

Every movement required great effort.  When he rang for a nurse, often, no one came, or they arrived long after he alerted them.  Ultimately, Doctor Rubens realized if he was to receive adequate care and attention, he would need to hire his own personal nurse to perform tasks that hospital employees could not get to.  John Michael Rubens, who is an avid reader, knows the research.

[H]igher patient-to-nurse staffing ratios are associated with higher mortality rates and greater incidence of medical complications and errors, lower job satisfaction, and more burnout among nurses.  The findings that follow in this report provide additional insight into the effects of nurse staffing levels from the perspective of the nurses directly providing patient care in hospitals today.

The survey data demonstrate that nurses view understaffing as a serious problem when it comes both to the quality of care that patients receive and to nurse burnout.  For example, three in five (59%) hospital nurses say that the staffing level at their hospital is having a negative impact on the quality of care patients receive . . .

The study’s data on patient-to-nurse ratios explain why nurses are so concerned about staffing levels today. Med-Surg nurses report that on average they are caring for 8.0 patients per shift

There are so many people to care for.  Yet, circumstances, realities in the Health Care system make this career choice less desirable.  The once sought after benefits, and a superior sense of service have virtually been eliminated from the medical profession.  

As Doctor Rubens may have heard amongst paid health care specialists, the occupation has been reduced to rituals.  Physicians push papers and pills.  Nurses administer shots and sponge up urine. Blood is spilled and no one has the time or resources to repair a medical system in distress.  The condition is critical.  

John feels the pain in the profession he loves.  I too worry and wonder.  Since we spoke of the dire crisis on the day before this decisive election, I inquired as I had so many time in the past, “Will you vote tomorrow?”  Doctor Rubens quickly replied “No.”  John sad with apparent sorrow; he assessed John McCain’s Health Care agenda.  John saw the Republican leader did not put his country or the citizenry first.  Barack Obama, the Physician proclaimed, offers no change that he, personally, could believe in.  John Michael Rubens laments today as he did before there was a President-elect, ‘Yes we can; yet, we do not provide adequate care for Americans.’

Sources for a dire situation; Health Care and Medical Coverage in America . . .

Overweight Children – Adults Face Widespread Stigma and Strain

copyright © 2007 Betsy L. Angert

In America and the European Union Overweight Kids Face [a] Widespread Stigma.  Only days ago, I contemplated this truth.  As I watched a family shop, I was struck.  She was young, perhaps ten years old.  She was very heavy.  I wondered how could one little girl carry so much weight on such a small frame. 

The lass was sweet, quite petite, although clearly troubled.  She had been shopping with her Mom, her grandmother, and her younger brother.  From appearances, it seemed this family was in Target gathering wares for Grandmamma.  They did not give the impression of being poor; nor did they look to be wealthy.  They were average folks; they could have been you or me. 

This family did not dress well.  Their clothes were clean, just not stylish.  Were this group more fashion conscious pants, shirts, and shoes would have been color-coordinated.  Patterns might have blended in a manner that was more appealing.  However, I guess they were comfortable in casual apparel.  After all, making purchases in a discount department store does not require a person to dress with finesse.  Simply covering your body is sufficient for such a chore.

The family of four entered the checkout line.  I was standing behind them.  Their exchanges were pleasant.  The children each chose to purchase an item for themselves.  Grandmother and Mom paid for their goods, as did the boy.  Then the young woman did her transaction.  The cashier rang up the sale.  Dollars passed from one hand to another.  There was change.  The school age girl went to place her pennies, nickels, quarters, and dimes into her tiny purse.  A single nickel fell to the ground.  The coin made a sound as it plunked to the floor.  The girl heard the noise and saw the shiny nickel.

She looked at the currency longingly.  Then, this lass turned and glanced at her family.  They were walking away.  Her brother, mother, and grandmother had not noticed what occurred.  The group was not far and yet, not near to the girl.  It would only take a moment to pick up the coin and move towards the others.  Pensively, the female child considered the nickel.  She looked down and then up and down again.  Finally, she fled in haste, leaving the lonely coin behind.  She never bothered to pick it up, although she did think too.

It did not seem to me that this little lady thought a five-cent piece was not worth much.  From appearances, or perhaps I am projecting, recalling my own struggle with excessive weight, her greater concern was the effort involved in bending over to retrieve a small piece of anything.  I remember the days, and not too fondly.  My heart went out to this child.  There, but for the grace of G-d, go I.

I am reminded of the time when I was obese, not pleasing plump, chubby, or fat; I was corpulent.  I grew into a size that was twice that of normal quickly.  I did not consume gross quantities of food.  The portions on my plate, or in hand were not large.  It was actually quite startling to see the weight pile on.  Pound after pound was added to my body mass.  There was no index to guide me.  Indeed, I was eating less than I had for years before this gain.

However, my weight gain was not an anomaly.  For me, fighting with my body mass was normal.  My family was substantial mentally and physically.  Many of my relatives are big people, not tall, just wide.  The little girl and I seem to share a family shaping, or might I say out of shape.  Her mother and Grandmother were large.  Her brother was not as rotund; however, he seemed to be ready to tip the scale.

In my family, some were fit.  My Grandpop walked for miles, each and every day.  He was active and agile; a  few relatives are.  However, it seems on average, the propensity toward plump was prominent in my world.  The younger generations in my own family might have mirrored their elders, or perhaps more accurately did as their parents had.  This is true in most families, even the thin ones.  However, patterns change.  In recent years, Americans are shorter and more stout.  For generations, Americans were taller than those in other nations; however, this is changing.

[H]eight has been stagnating in the US for a decade, and Americans are now shorter on average than many Europeans, including not only the very tall Dutch and Scandinavians, but even the citizens of the former East Germany, see John Komlos and Marieluise Baur (2004).

While Americans are not expanding upwards, they continue to expand outwards, and the average American, like the average Briton, is now heavier than the weight that would minimize mortality risk given average height.

This is troubling for many reasons.  Not only is our health and life expectancy effected, so too is our income.  For years, Economists told us tall persons earn more money than the diminutive do.  An inch can increase your net worth by at least a thousand dollars per year.  However, recent research reveals the height you achieve in adulthood may not determine your income.  Stature may not be the key to financial success.

Tall men who were short in high school earn like short men, while short men who were tall in high school earn like tall men.

That pretty much rules out discrimination.  It’s hard to imagine how or why employers could discriminate in favor of past height.  If tall adolescents?even those who stop growing prematurely?grow up to be highly paid workers, it’s got to be because they’ve got some other trait that employers value.  [Nicola Persico, Andy Postlewaite, and Dan Silverman of the University of Pennsylvania] believe that trait is self-esteem.  Tall high-school kids learn to think of themselves as leaders, and that habit of thought persists even when the kids stop growing.

If, during our younger years we do not think we are worthy, excellent, brilliant, or outstanding than likely we will not believe we are the best later in life.  Often, we trust we are admirable when others act as if we are. 

For the fatter child, the need for approval weighs on their minds.  Much embarrassment is felt, and experienced early on.

Overweight children are stigmatized by their peers as early as age 3 and even face bias from their parents and teachers, giving them a quality of life comparable to people with cancer, a new analysis concludes.

At the age of two, nearly three, I recall sitting in the den with a ballpoint pen in hand.  I drew lines on my thighs designating exactly where I wanted the excess meat removed.  I do not recall being ridiculed at home; nor do I remember peers speaking of my weight. 

I did attend summer camp at that age.  At two and one half years, I was the youngest camper.  Perhaps, being four years younger than all other campers had an effect on me.  Indeed, I was left out of much.  The counselors were not willing to teach me to swim.  My bunkmates did not wish to include me in games.  Being a person that loathes and avoids competition, and always did, I had no desire to participate.  I was somewhat sedentary. 

Possibly the situation demanded it.  I could not go off and play on my own.  I needed to stay with the group.  Yet, I was separate.  I sat still for hours while my bunkmates engaged in recreational activities.  My situation, although different, mirrors much of what occurs today.

Lack of exercise is a major factor in the growing problem of obesity, both for children and adults, according to Dennis Styne, a UC Davis Medical Center pediatric endocrinologist who is a recognized authority on issues of childhood obesity.  “Obesity has become a serious health risk in America, and it is reaching epidemic proportions, even in the pediatric population,” Styne says. “Close to 25 percent of America’s children and adolescents are now considered overweight, and the numbers are increasing.”

I developed habits that hurt my already hurting heart.  The children ran, jumped, laughed, and enjoyed each other’s company.  I could not join in.  They thought me too young.  At an early age, my less active life took its toll.  The pounds piled on.  Later, as the years passed, I was just lethargic.

They say obese children are victim to teasing, rejection, bullying, and other types of abuse because of their weight.  I was fortunate, I did not experience much, if any of this in my youth.  However, when I reached the age of sixteen, and added a few more pounds, a phrase was used by a loved one to describe me, “butterball.”  To this day, every year from Thanksgiving to Easter when the company with the same name advertises their turkeys, I cringe.

“The stigmatization directed at obese children by their peers, parents, educators and others is pervasive and often unrelenting,” researchers with Yale University and the University of Hawaii at Manatoa wrote in the July issue of Psychological Bulletin.

The paper was based on a review of all research on youth weight bias over the past 40 years, said lead author Rebecca M. Puhl of Yale’s Rudd Center for Food Policy and Obesity.

Research determined the heavier child exposed to such pressure is two to three times more likely to report suicidal thoughts.  Frequently, the young and hefty suffer from other health issues.  High blood pressure and eating disorders are not uncommon.  Yikes, there I am.  I was anorexic, then bulimic.  My eating was out of order.

I have long been certain that my bingeing and purging was not related to my weight.  Indeed, doing as I did, did not help me maintain a stable mass.  The process stressed my body and my mind.  Anorexia and bulimia are burdensome.  They are as obesity in many ways.  There is great shame associated with starving oneself.  Over-eating and puking do not leave one feeling proud.  People judge those that do not appear perfect or act in a manner that pleases others.  We all criticize ourselves.

“The quality of life for kids who are obese is comparable to the quality of life of kids who have cancer,” Puhl said, citing one study.  “These kids are facing stigma from everywhere they look in society, whether it’s media, school or at home.”

Even with a growing percentage of overweight people, the stigma shows no signs of subsiding, according to Puhl.  She said television and other media continue to reinforce negative stereotypes.

“This is a form of bias that is very socially acceptable,” Puhl said.  “It is rarely challenged; it’s often ignored.”

In a time when children are growing fatter, we can no longer avoid an issue that is pervasive.  We must consider that they way people treat us when we are young has an effect throughout our lives.  Height and weight evoke a response.  That reaction stays with us.  At a time when childhood obesity overwhelms the planet, we must consider the effect of this epidemic.

By 2010, almost 50 percent of children in North America and 38 percent of children in the European Union will be overweight, the researchers said.

While programs to prevent childhood obesity are growing, more efforts are needed to protect overweight children from abuse, Puhl said.

At times, we as a society must shield children from those that love them most, us.  Sadly, parents, teachers, and friends do not realize how they hurt a fragile heart and soul.  Teasing is thought to be just in fun.  Expecting less of a fat child is considered realistic.  Reacting to personal guilt for not caring for a child as you thought best, in a moment, might seem reasonable.  However, the harm we do is immeasurable.  Children internalize their pain.

A growing body of research shows that parents and educators are also biased against heavy children.  In a 1999 study of 115 middle and high school teachers, 20 percent said they believed obese people are untidy, less likely to succeed and more emotional.

“Perhaps the most surprising source of weight stigma toward youths is parents,” the report says.

Several studies showed that overweight girls got less college financial support from their parents than average weight girls.  Other studies showed teasing by parents was common.

“It is possible that parents may take out their frustration, anger and guilt on their overweight child by adopting stigmatizing attitudes and behavior, such as making critical and negative comments toward their child,” the authors wrote, suggesting further research is needed.

Lynn McAfee, 58, of Stowe, Pa., said that as an overweight child she faced troubles on all fronts.

“It was constantly impressed upon me that I wasn’t going to get anywhere in the world if I was fat,” McAfee said. “You hear it so often, it becomes the truth.”

Her mother, who also was overweight, offered to buy her a mink coat when she was 8 to try to get her to lose weight even though her family was poor.

“I felt I was letting everybody down,” she said.

Other children would try to run her down on bikes to see if she would bounce. She had a hard time getting on teams in the playground.

“Teachers did not stand up for me when I was teased,” McAfee said.

A study in 2003 found that obese children had much lower quality of life scores on issues such as health, emotional and social well-being, and school functioning.

“An alarming finding of this research was that obese children had (quality of life) scores comparable with those of children with cancer,” the researchers reported.

Sylvia Rimm, author of “Rescuing the Emotional Lives of Overweight Children,” said her surveys of more than 5,000 middle school children reached similar conclusions.

“The overweight children felt less intelligent,” Rimm said.  “They felt less popular. They struggled from early on.  They feel they are a different species.”

Fat children are distinct.  They stand out in a crowd.  Actually, in their own mind they are often larger than life.  I know I was.  I was so surprised years later when I saw photographs of myself as a camper.  I was not obese then.  I only thought I was.  For me, it was as Lynn McAfee stated, “You hear it so often; it becomes the truth.”  Even if the words were heard only in my head, they were repeated routinely.  The belief that I was fat became my reality.  In my teens I grew into the person I long thought I was.  I became obese.

Anyone that has ever struggled with their weight knows, trying to take off a few pounds can be a challenge.  Eliminating the weight of years of mistreatment takes more effort than most can imagine.

Heavy children are insulted, ignored, rejected, and ultimately resent themselves.  They misuse food.  The weighty wonders may not appear malnourished; however, they are.  The obese do not eat well.

[P]oor nutrition remains an impediment to health in much of the world today, Much less obvious is the idea that nutritional deficits are an important part of the health story in the rich world today.  Yet there is a good deal of evidence, even?and in some cases particularly?in populations whose most obvious nutrition-related problem is obesity and over nutrition.

Such mass consumption does not serve our children well.  Nor do our eating patterns benefit us as we age.

“Obesity rates are increasing fastest among children, and they will carry obesity-related health risks throughout their lives,” Ludwig says.  “An adult who gains a pound or 2 a year through middle age will be at increased risk.  But that is much less dire than the overweight 4- to 6-year-old who gets diabetes at age 14 or 16 and has a heart attack before age 30.”

Ludwig — director of the obesity program at Children’s Hospital, Boston — says the childhood obesity epidemic has three phases. The first came in the last decade, when child obesity became common but the public health effects weren’t yet felt. Phase two is right now, as we begin to see serious complications such as type 2 diabetes in very young people.  Phase three, Ludwig predicts, is coming soon.

“But we still have a little time before these children become young adults with diabetes and start to have heart attacks, stroke, kidney failure, and increased mortality,” he says. “It is a massive tsunami headed for the United States. One can know it is coming. But if we wait until we see the ocean level rising over the shore, it will be too late to take action.”

Sadly, some of those that were heavy as children are already adults.  Older persons, for the most part, do as they did in their childhood.  Even if individuals lose the “baby fat,” the feelings and ill effects associated with obesity often linger.  Lifestyle, habits, health problems are more difficult and daunting than poundage.  There are infinite influences on our body and mind.  The marketplace matters. 

The advent of processed foods altered the physique and psyche.  Motor vehicles and machines have an effect,  A commuter and computer culture counts.  The number of calories we consume and do not burn off as earlier generations did effects our overall well-being.  There is ample cause for concern.

  • Poor nutrition and lack of physical activity are responsible for an estimated 300,000 to 600,000 preventable deaths each year.

  • An estimated one third of all cancers are attributable to poor nutrition, physical inactivity, and being overweight.
  • Today, we stunt our growth upward and expand our girth outward.  Perhaps, we need to advance our awareness for what motivates us.  Why do we torment the portly?  How easy it is to ridicule and judge.  Frequently, the tall, the thin, those that appear healthy blame the obviously wounded one.  These saintly souls think obesity is a choice.  People are not born fat.  Perchance that is, in part, true.

    It was once thought diabetes or the tendency for this illness was inherited; however, there is ample to reason to believe that is not always true.  Might we imagine that nothing occurs in isolation.  If we are to cure what ails us, we must be open to options that are not easily observed.

    Might we assess why those that gain so easily gravitate to food.  I believe for too long we have presumed the answers are simple.  It is often claimed obesity runs in families.  The genes prime the pump.  Numerous researchers prefer placing the blame on parents.  Habits are learned.  Mothers and fathers are our primary teachers.  Schools receive their fair share of culpability.  Surely if educational institutions supplied more nutritious fodder children would not eat as they do.  Restaurants, food manufacturers all can claim an ounce of responsibility. 

    We too bear a burden; each of us decides what we will eat and enjoy.  We believe we can easily forego exercise.  We all are as the little girl.  Bending down to pick up the nickel is not a simple task.  Our mind may wish to do what we think wise; yet our body says we cannot.  The two work in unison.

    I believe, too often we do not honor the mind body connection.  Possibly, we all are vulnerable to whatever affliction inhabits our bodies.  In recent years, we are realizing that many ailments, once thought to be the result of natural causes are related to diet.  What we eat has power; it effects the brain and bulk.  Might we consider victuals feed us in ways we rarely explore.

    To learn how to work with your appetite center, you must first understand it.  It’s time for you and your brain to become better acquainted.

    As soon as you bite into any food, sensory stimulation of nerve endings on the tongue leads to the release of a number of chemicals, including opioids, into the bloodstream.  You release more opioids — the body’s natural versions of drugs like morphine — when you consume foods high in sugar and fat, creating a powerful, neurochemical drive to overeat those foods. 

    These opioids and other chemicals enter the bloodstream and carry their messages to the hypothalamus, which sends out yet another set of chemicals to regulate appetite.  The more flavors your taste buds register, the more stimulated the hypothalamus becomes, releasing the hunger-promoting hormone neuropeptide Y.  When you taste a lot of flavors at once, the brain releases a lot of neuropeptide Y.

    Meanwhile, in response to the smell and taste of food, your stomach produces the hormone ghrelin, which also stimulates appetite.  It continues to produce this hormone until you eat enough food to literally fill your stomach and stretch the stomach wall.  Farther down the line, in your intestines, levels of several hormones rise to varying degrees — depending on the nature of your meal — either inducing more hunger or turning off hunger..

    Perchance, we might empathize with the chunky little lass.  She is you and me.  Might we consider that our culture provides us with foodfare that harms us.  Society teaches us habits that hurt us.  Some lessons are learned subliminally.  Others are fashioned at the dinner table.  Possibly, we all would be wise to teach and treat the children well.  If we do not attend to the biological, physiological, intellectual, and emotional needs of our progeny, they will suffer as will we all.  If one man, woman, or child is diminished, we all are.  Little girl, may I help you reach for more than a nickel.

    The thick of it . . .

  • Why We Overeat, By David L. Katz, MD, MPH, with Catherine S. Katz, PhD., Authors of The Flavor Point Diet: The Delicious, Breakthrough Plan to Turn Off Your Hunger and Lose the Weight for Good
  • Overweight Kids Face Widespread Stigma By John Christoffersen.  The Associated Press.  The Washington Post. Thursday, July 12, 2007; 3:54 AM
  • pdf Overweight Kids Face Widespread Stigma By John Christoffersen. The Associated Press.  The Washington Post. Thursday, July 12, 2007; 3:54 AM
  • Poor Nutrition and a Sedentary Lifestyle. The 21st Century Plague. 2001 Community Health Needs Assessment
  • The Great Escape: A Review Essay on Fogel’s The Escape from Hunger and Premature Death, 1700?2100.  By Angus Deaton. Princeton University. April 2005
  • Hey, Gorgeous, Here’s a Raise! As For You Fatties, We’re Cutting Your Salaries. By Steven E. Landsburg.  Slate. Monday, July 9, 2001, at 9:00 PM ET
  • Sedentary children Less active kids a weighty problem, UC Davis Health System. October 2000
  • Will Obesity Shorten the American Life Span? Study: without action on child obesity, U.S. life span to get shorter.  By Daniel J. DeNoon. WebMD Medical New. March 16, 2005
  • Miracle of Medicine Kills President Garfield and More

    © copyright 2007 Betsy L. Angert

    I have long been fascinated by the juxtaposition of miracle and malady as it relates to medicine.  As modern physicians assess the findings of an autopsy, they too ponder.  Scientists discovered President James A. Garfield did not die from an assassin’s bullet; medical science killed him.  Currently, in an exhibit at the Walter Reed Army Medical Center, the perforated vertebrae of our last log cabin President is on display. This show offers photographs and other images that tell the Garfield story, or so we are lead to believe.  I think what is evident is only a small portion of the tale.  For me, what we are able to see is not the most important part of the parable.

    Granted, observers of the Garfield collection can view the three pieces of spine removed from the body of the James Garfield.  They can evaluate the placement and path of the red plastic probe, which represents the pellet that pierced the body of the President.  All while onlookers are asked reflect upon what was not known on July 2, 1881, the day Charles Julius Guiteau shot the late President.  It is hoped that they realize that if the same occurred today, the President would have lived.  According to a professor of surgery at the University of Medicine and Dentistry of New Jersey and a medical historian, Dr. Ira Rutkow, “Garfield had such a non-lethal wound.  In today’s world, he would have gone home in a matter of two or three days.”  I inquire, would he?

    President Garfield, once hit by buckshot, lay on what was to become his deathbed for 80 long days.  Doctors did little to help him; in truth, they harmed him.  This does not surprise me.  I have longed questioned the sanctity of medical science and surgery.  I surmise, practices may not be safer now, than they were then.  Still, I know nothing with certainty.  I understand only what I observe, as do those strolling through the Garfield exhibit.

    Spectators at this current showing, doctors and patients among these, marvel at how medicine and surgery have improved.  Still, mishaps, those that occurred more than a century ago, and those that occur now do not amuse me.  The numbers of persons that have been misdiagnosed or operated on in error causes me great dismay.  The myth of miracles does not bring me solace or a sense of security.  I rarely think surgical treatments are truly a cure.  For me, the events surrounding Garfield’s death do little to ease my mind; they only affirm my sense of doubt.

    As I contemplate my reservations, I ask you to consider these.  Please compare and contrast the story of James A. Garfield with those you know of personally.

    Assistant Curator of the National Museum of Health and Medicine, Dr. Lenore Barbian, spoke of the President’s passing.  She stated, “No one expected Garfield to live through the night.”  At least a dozen medical experts probed the president’s wound.  They used their bare hands.  Metal instruments were not sterilized.  These practices were common at the time, at least in the States.  Ultimately, sepsis set in, and after eighty long and difficult days, James A. Garfield passed.

    It was not that sanitary practices and procedures did not exist.  They did.  These methods were in use and available in France, Germany, and other parts of Europe.  It was only in America that these systems were not widely accepted.  For me, this validates what I believe is typical in medicine, particularly in American medicine.  Innovations are thought too avant gardé.  They are considered untested, or untrue.  Thus, they are not utilized. I think what was true than is truer now.

    As I appraise the American Medical Association, the Food Drug Administration, and other health care commissions I am concerned.  The influence of Pharmaceutical Corporations and the power they wield disturbs me.  The deliverance of insurance is disquieting to say the least.  Anxiety overtakes me as I assess the way medical decisions are made in this country.

    I offer a few tales, sad, and true.

    Closed-Door Deal Makes $22 Billion Difference. GOP Negotiators Criticized for Change In Measure on HMOs, By Jonathan Weisman.  Washington Post.  Tuesday, January 24, 2006; Page A01

    House and Senate GOP negotiators, meeting behind closed doors last month to complete a major budget-cutting bill, agreed on a change to Senate-passed Medicare legislation that would save the health insurance industry $22 billion over the next decade, according to the nonpartisan Congressional Budget Office.

    The Senate version would have targeted private HMOs participating in Medicare by changing the formula that governs their reimbursement, lowering payments $26 billion over the next decade.  But after lobbying by the health insurance industry, the final version made a critical change that had the effect of eliminating all but $4 billion of the projected savings, according to CBO and other health policy experts.

    While I might wish more money were spent on medical science, on prevention of illness, research, and development, I do appreciate the finer details of this story.  Lobbyists loom large.  Dollars doled out for preserving a flawed system benefit no one but the insurers.  We, the citizens of this country, with thanks to the Grand Old Party negotiators will spend twenty-two billion dollars that perhaps, we need not spend.  Apparently, the rates paid to Medicare may be out-of-balance; assessments may have been skewed.

    Private insurers attract healthier seniors than the traditional government-run Medicare system, so their payment rates — based on the elderly population as a whole — exceed the actual cost of treatment.

    I think this next article speaks for itself.  The echoing effects are quite loud.

    FDA’s Lobbying Questioned, By Brody Mullins. Published on Thursday, July 24, 2003 by Roll Call (Washington, DC)

    In a rare lobbying campaign by a federal agency, the Food and Drug Administration has formed an unofficial alliance with the pharmaceutical industry to urge House Members to vote today against a bill that could flood the nation with cheap prescription drugs from Canada and overseas.

    The FDA’s extraordinary moves to kill the bill ?” and the informal lobbying partnership between a federal regulator and the industry it oversees ?” has come under fire from several Members who support the legislation.

    “What they did might not be illegal, but it certainly was untoward,” said Rep. Sherrod Brown (D-Ohio), whose office received a call from an FDA lobbyist.  “In my 11 years, I’ve never seen anything like this.”

    In the last week, Administrator Mark McClellan and other FDA officials have spoken with key Republicans and Democrats to highlight the agency’s opposition to a bill sponsored by Rep. Gil Gutknecht (R-Minn.) that would allow “reimportation” of less expensive drugs sold abroad.

    Meanwhile, a pair of officials in the FDA’s Congressional affairs office spent last week calling key lawmakers in both parties to say, among other things, that the bill would cost the industry $2 billion a year because of new packaging to guard against counterfeits.

    The FDA’s lobbying effort against the bill is the latest example of the close ties the Bush administration shares with the pharmaceutical industry, one of the biggest financial backers of President Bush and GOP leaders, who oppose the legislation.

    I also wish to address the issue of a doctor in tow. U.S. Senate Majority Leader Bill Frist, M.D. has quite a record.  This man is a doctor, the Senate Majority Leader, and a mogul.  Dear reader, you might recall his expert testimony in the case of Terri Schiavo.  This profoundly professional physician thought himself able to accurately diagnose a “patient” from afar.  This good doctor is know as the Bad says Journalist Doug Ireland.

    The Bad Doctor. Bill Frist’s long record of corporate vices, By Doug Ireland.  LA Weekly.  Thursday, January 9, 2003.

    While TV gushed last week over the Republicans’ new Senate majority leader, Bill Frist, intervening in a traffic accident, portraying the former heart surgeon as a “Good Samaritan,” in truth the GOP has simply replaced a racist with a corporate crook.

    Frist was born rich, and got richer” thanks to massive criminal fraud by the family business. The basis of the Frist family fortune is HCA Inc. (Hospital Corporation of America), the largest for-profit hospital chain in the country, which was founded by Frist’s father and brother. And, just as Karl Rove was engineering the scuttling of Trent Lott and the elevation of Frist, the Bush Justice Department suddenly ended a near-decade long federal investigation into how HCA for years had defrauded Medicaid, Medicare and Tricare (the federal program that covers the military and their families), giving the greedy health-care behemoth’s executives a sweetheart settlement that kept them out of the can.

    Yes, there is much to assess as we study medical science, then and now.  In science as in life, what is known seems to have greater credibility than what might be.  A Food and Drug Administration, though corrupt is a known entity.  A Pharmaceutical industry, that has its own best interests at heart, is better than no drug production at all.  An endearing doctor that speaks well and looks good, even as he steals from Medicare and Medicaid, is far superior to a fumbling bumbling fool, or are these one in the same?  I understand this.  Humankind is comfortable with what they know; change is a challenge, one we as humans hardly ever accept.

    However, I wonder if what we think we comprehend is often not valid.  We seek expertise; yet, I theorize, no one knows our body better than we.  Each individual has an intimate knowledge of what is within, or they can know if they choose to be sensitive and informed.  We want the wisdom of those that are trained to diagnose and treat illness and injury.  Are they truly wise?  “The number of people that doctors kill per day from medical malpractice is roughly equal to the amount of people that would die if every day, three jumbo jets crashed and killed everybody on board,” stated Dr. Welch.

    Thus, again I wonder what James Garfield was thinking as he lie, awaiting his own demise.  Did he know that he did not need to die, if only doctors would listen to him?

    In mid-August, the doctors insisted that Garfield be fed rectally, and he received beef bouillon, egg yolks, milk, whiskey, and drops of opium in this manner.  “They basically starved him to death,” said Dr. Rutkow, noting that the president lost over 100 pounds from July to September.

    People, physicians included, work to be objective; they wish to cause no harm.  Yet, this can truly be a challenge.  Still, humans attempt to be impartial, to be helpful; they endeavor to learn from history.  Hence, we have this display.

    We review the findings and acknowledge Garfield was struck down during a time of transition in medical science.  The doctors attending the President could not determine the location of the bullet and this became their primary concern.  We understand that perhaps, this need distorted their perception.  They were no longer able to look at the life and the man.  They thought only of their diagnosis.  They feared their own flaws and the possibility their failure.  [This attitude is still true today.  Consider doctors and their fear of malpractice and how their apprehension distorts their view of their patients.]

    We can muse that in the 1860s, more than two-decades before the assault, British surgeon Joseph Lister established the “Sterile Technique.”  We can accept that, twenty years later, this scientific method was frowned upon in America.

    We know that historians agree; the massive infection that took the life of the President resulted from practices that were not germ-free.  Nevertheless, due to negligence, the President, and his family suffered needlessly.

    Call me old fashioned and you will not be the first; still, I do not necessarily trust doctors.  A friend of mine, a physician, has long said that medical school is as a trade college.  Diagnosis is the most difficult procedure.  My acquaintance, the doctor, muses that a surgeon is as a mechanic.  S/he must use the tools at his or her disposal to determine ailments.  A distorted skeletal structure does little more than signal where an injury might be.  The details are often obscured or invisible.  Musculature gives clues to matters of concern; however, it does not direct a diagnostician to the specific source of pain.

    Years ago, ignorance and an unwillingness to change may have hindered the Hippocratic oath.  Diagnosis a weighty issue, as it is today.  In 2006, lack of knowledge and a reluctance to adopt new practices still affect our medical systems.  Passing up the dollar may be a more dire concern for many a doctor.  Political affairs also cloud the clear minds of numerous physicians.  Again, the patient suffers.

    In modern times, “Do no harm,” is not the cry that comes from those in medicine. It is for this reason I wonder; would a patient in modern America be better off than President Garfield was.  I think not.

    I offer the following articles for your further review.  These were not used within the body of this text; though, I think they are equally important.  I believe an assessment of these might broaden our view of American medicine in the year 2006.

    Superfluous Medical Studies Called Into Question, By David Brown.  Washington Post. Monday, January 2, 2006, Page A06

    In medical research, nobody is convinced by a single experiment.

    A finding has to be reproducible to be believable.  Only if different scientists in different places do the same study and get the same outcomes can physicians have confidence the finding is actually true.  Only then is it ready to be put into clinical practice.

    Nevertheless, one of medicine’s most overlooked problems is the fact that some questions keep being asked over and over.  Repeated tests of the same diagnostic study or treatment are a waste — of time and money, and of volunteers’ trust and self-sacrifice.  Unnecessary clinical trials may also cost lives.

    All this is leading some experts to ask a new question: “What part of ‘yes’ don’t doctors understand?”

    Former FDA Chief Joins Lobby Shop, By Marc Kaufman.  Washington Post. Wednesday, February 8, 2006; Page A06

    Former Food and Drug Administration commissioner Lester M. Crawford, whose sudden resignation last fall after less than three months in office remains a mystery, has joined a lobbying firm that specializes in food and drug issues.

    Crawford is listed as “senior counsel” to the firm Policy Directions Inc.  Among the companies and organizations listed as clients are Altria Group Inc. (formerly Philip Morris Companies), Merck & Co. Inc., the Pharmaceutical Research, and Manufacturers of America (PhRMA,) the Grocery Manufacturers of America, and the American Feed Industry Association.  A spokesman for the firm said neither Crawford nor anyone else wished to discuss his appointment.  When he resigned in September, Crawford said simply that it was time for someone else to lead the agency.  Sens. Mike Enzi (R-Wyo.) and Edward M. Kennedy (D-Mass.) have asked the Department of Health and Human Services inspector general to look into whether Crawford resigned because of an undisclosed financial conflict of interest.

    Prescription for Power. Drug makers’ lobbying army ensures their legislative dominance, By M. Asif Ismail.

    Washington, April 28, 2005  “The deep-pocketed pharmaceutical and health products industry has lobbied on more than 1,400 congressional bills since 1998 and spent a whopping $612 million* during that period, a Center for Public Integrity review of lobbying records revealed. Drug companies and manufacturers of health products have used more professional lobbyists in the last six and a half years?”almost 3,000?”than any other organized interest, the analysis also found. In comparison, the insurance industry, second-largest in terms of spending, spent $543 million* in the same period and employed just over 2,000 lobbyists.

    In recent years, the pharmaceutical industry has scored a series of legislative victories on Capitol Hill, which could potentially translate into tens of billions of dollars of additional revenue to drug companies annually. The federal government will buy drugs worth at least $40 billion from the companies every year once the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 goes into effect next year.  In addition, critics have accused the industry of having undue influence over the Food and Drug Administration, the agency that regulates pharmaceutical interests.

    Industry-watchers say the drug companies’ recent successes in Congress and with the FDA show how effective their lobbying campaign is.  “The [lobbying] money is very well-spent,” said Dr. Jerry Avorn, author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs. “The fact that we are the only country in the industrialized world that does not have any provision for negotiating drug prices, the fact that we are spending far more per capita on drugs than any other country and the fact that when legislation is written it often seems to be exactly the kind of legislation that benefits the pharmaceutical industry [shows] they are getting their money’s worth.” 

    Prescription Drugs – Leading Killer in USA

    According to information we have received, a statistical study of hospital deaths in the U.S. conducted at the University of Toronto revealed that pharmaceutical drugs kill more people every year than are killed in traffic accidents.  The study is said to show that more than two million American hospitalized patients suffered a serious adverse drug reaction (ADR) within the 12-month period of the study and, of these, over 100,000 died as a result. The researchers found that over 75 per cent of these ADRs were dose-dependent, which suggests they were due to the inherent toxicity of the drugs rather than to allergic reactions.

    FDA Advisers Tied To Industry, By Dennis Cauchon

    More than half of the experts hired to advise the government on the safety and effectiveness of medicine have financial relationships with the pharmaceutical companies that will be helped or hurt by their decisions, a USA TODAY study found.

    These experts are hired to advise the Food and Drug Administration on which medicines should be approved for sale, what the warning labels should say and how studies of drugs should be designed.

    The experts are supposed to be independent, but USA TODAY found that 54% of the time, they have a direct financial interest in the drug or topic they are asked to evaluate.  These conflicts include helping a pharmaceutical company develop a medicine, then serving on an FDA advisory committee that judges the drug.

    Please Review the Rays.  They may not be X-Rays; however, they may reveal much.

    Diagnostic and Statistical Manual of Mental Disorders, Duping Doctors©

    A recently released study reports that the famous and often used, Diagnostic and Statistical Manual for Mental Disorders is not the reliable source it was once thought to be. The DSM offers definitions and analysis of mental, or personality disorders.  Treatments are also prescribed.  More often than not, these require drug therapy.  For decades, psychiatrists, psychologists, pharmacists, and other medical specialist have turned to this guidebook for counsel; it was considered the Holy Grail. This large book was looked upon as an objective reference; it is not.

    Apparently, according to a recent study published in the Journal Psychotherapy and Psychosomatics, most of the expert authors have financial ties to the very drug makers whose medications they promote.  56 percent of 170 psychiatric experts who worked on the most recent 1994 edition of the Diagnostic Manual, had at least one financial encounter with a drug maker between 1989 and 2004.

    The relationships ranged from speaking engagements to consulting fees.  Some specialist owned considerable shares of company stock.  Gifts were given.  Travel was also a frequently token.  Many “experts” were awarded funds for their research.  It is likely, all were the recipients of perks from the very drug-makers they promoted in the DSM.

    In the group of specialists working on mood disorders, schizophrenia and other psychotic disorders, all had significant ties to pharmaceutical companies.  According to the assessment, “The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.”

    After ample research, lead author of the study, Dr. Paula Cosgrove reported that this guidebook differs little from any other paid advertisements.  The integrity of the information is in question.  Now that we know how much influence these companies had on the writing of the DSM IV, this source can no longer be considered trustworthy.

    Benefits befell all tied to this Diagnostic Manual.  The doctors and researchers did well and the pharmaceutical companies prospered.  Speaking of the physicians, Lisa Cosgrove, a clinical psychologist at the University of Massachusetts in Boston said “They can certainly leverage their participation on the DSM, which is very prestigious, into lucrative consulting contracts.”

    Drug manufacturers brought in a whooping $35 Billion dollars this year from the sales of psychotropic drugs and if history is a telling sign, the number is going to grow.

    According to the Mental Health Policy and Psychotropic Drugs . . .

    The amount of money spent on psychotropic drugs grew from an estimated $2.8 billion in 1987 to nearly $18 billion in 2001 (Coffey et al. 2000, Mark et al.  2005), and the amount spent on psychotropic drugs has been growing more rapidly than that spent on drugs overall (IMS Health 2005).

    For example, spending on antidepressant and antipsychotic medications  grew 11.9 percent and 22.1 percent, respectively, in 2003, whereas  spending on drugs overall grew at 11.5 percent in 2003 (IMS Health  2005). “

    A Washington Post article, Experts Defining Mental Disorders Are Linked to Drug Firms . . .

    There is disagreement as to  the validity of this study.  One of the psychiatrists who worked on the current DSM was disparaging of the investigation. Nancy Andreasen, of the University of Iowa, headed the schizophrenia team.  She stated, this latest review is “very flawed.” She declared that there needed to be a distinction between those that had connections to the drug industry while working on the panel and those that established an association after.

    Ms. Andreasen offered, “Two out of five researchers on her team had had substantial ties to industry.” In speaking of herself, she noted ??she would have to check her tax statements to know whether she received money from companies at the time she worked on the panel.’ She did add declaratively “What I do know is that I do almost nothing with drug companies. . . . My area of research is neuroimaging, not psychopharmacology.”

    I find this interesting.  I am the granddaughter of a pharmacist, a scientist, and a curious soul.  I learned much from him.  My grandfather worked when chemicals were hand mixed.  He ground the concoctions people purchased in his own mortars and pestles.  Drugs were delivered to his store in glass bottles; some stood three-feet high.  I thought of these as toys.  Once again, I digress; my apologies; nevertheless.

    My grandfather told me long ago as did a friend, a medical doctor, a man practicing in the field of psychiatry, if you want to learn of medicines, ask a chemist, a scientist, or a pharmacist.  These persons study chemical reaction on human cells.  They know what might be beneficial or harmful; what interacts well with other medications, and what might lessen the potency of a drug.

    According to my friend, the doctor, physicians know only what the salesperson tells them.  Drug company representatives give gifts, small trinkets, and expensive dinners.  They cocktail and court a doctor while discussing the quality of their wares.  Ultimately, a physician is convinced this pill, caplet, or concoction is the best.  The doctor may know of no other.  A doctors knows what drugs representatives tells him/her.  He who enters or telephones the office is most influential.

    Considering the validity of these opinions, the reality of drug interactions and side affects is not unexpected  Drug side affects were not documented in 1994, the year the most recent DSM IV was published.  Since then questionable practices are being investigated. Conflicts of interest have become an overriding issue; actually, it is these that may have promoted this just released survey.

    While many question the reliability of the report, all seem to agree, transparency is necessary.  The researchers discovered the DSM, published by the American Psychiatric Foundation was fundamentally flawed, what was not known was its downfall.  On this, Dr. Cosgrove said, “Transparency is especially important when there are multiple and continuous financial relationships between panel members and the pharmaceutical industry, because of the greater likelihood that the drug industry may be exerting an undue influence.”

    Undue pharmaceutical influence; now there is a study that even a novice researcher can do.  Clearly, there is a recent trend in medicine, push the pills on patients, and they, in turn, will tell their doctors what they need [or want.]  We see evidence of this everywhere.  On television and radio broadcasters tell us, take the purple pill and your stomach will be settled.  The blue pill will help you perform.  The yellow pill provides power, and the green capsule will make you mellow.  Looking for love, try potion number 9.

    Commercials call us to action; they instruct.  Infomercials dominate the airwaves.  They teach the public to self-prescribe.  Of course, people are advised to consult their physicians before taking any medication.  However, it is well known in today’s world of medical malpractice suits, physicians fear denying patients their desires.  Thus, people are able to self-medicate legally.

    There was a time when individuals believed that doctors knew best; they were as father figures. It was thought that a physician would not prescribe what is not necessary.  Those days, if they ever existed are long gone.  Some within the general public assume that a person willing to devote years of his or her life to study is dedicated and altruistic.  Doctors are thought to be knowledgeable.  They truly care for people.  Some do; however, many if not most are just human.

    Rarely do health care workers engage in studies that correlate chemical and cellular interactions.  Yet, these are the persons, through the auspice of the Diagnostic and Statistical Manual for Mental Disorders prescribing drugs to treat psychological and personality maladies.

    Are they qualified?  Might they be influenced by the almighty dollars that the drug companies throw their way?  Was there any doubt?  Not for me.

    Now, there is solid proof for what my Grandfather and my friend the psychiatrist have always said.  Physicians and pharmaceutical companies are pushing pills aggressively on every front.  The public must be cautious.  Do not trust the diagnosis, the doctor, or the documentation.  Consumers and “crazies,” Be aware.  You may not be as sick as you think.

    References for Review . . .
    Who’s behind that diagnosis? Marketplace, American Public Media. Thursday, April 20, 2006
    DSM-IV-TR Library, American Psychiatric Association
    Online Psychological Services
    Bias in Psychiatric Diagnosis By Paula J. Caplan (Editor), Lisa Cosgrove (Editor)
    Diagnostic and Statistical Manual of Mental Disorders From Wikipedia
    Excerpted from  the Introduction of Bias in Psychiatric Diagnosis, Edited by Paula J. Caplan, Ph.D  & Lisa Cosgrove, Ph.D
    Mental illness writers had industry ties: study By Lisa Richwine. Reuters. Thursday, April 20, 2006 11:01 PM BST
    The drug industry’s chokehold on America’s health care By Joanne Laurier, WSWS: Book Review, January 2005
    Mental Health Policy and Psychotropic Drugs
    Mental Health Policy and Psychotropic Drugs Richard G. Frank , Renam Conti, and Howard H. Goldman
    Study: Medical manual’s authors often tied to drugmakers By Dan Vergano, USA TODAY
    Experts Defining Mental Disorders Are Linked to Drug Firms By Shankar Vedantam. Washington Post Thursday, April 20, 2006
    Mental illness writers had industry ties: study By Lisa Richwine. Yahoo News Thursday, April 20, 2006
    Psychiatry manual linked to drug money, By Lisa Richwine. Reuters
    Preparers of key guide linked to drug firms By Judith Graham. Chicago Tribune