Thursday, October 16, 2014

Understanding an Unchanging God

One concept shared by many of the world's major religions - Christian, Muslim, Jew, at least - is that of God, eternal, unchanging, creator of the universe (in the Bible, for example, in Psalm 90, v 2; or Isaiah ch 40 v 28). Instinctively, we accept the basic forces of the universe - gravity, motion, heat, light, etc. - as dependably stable and unchanging. Such things, as best we can learn, always behave the same, day after day, year after year.

There are some sincere Christians who believe that the Bible is word-for-word [in the original language] direct dictation from God, not subject to interpretation: "The Bible says it, I believe it, that settles it!"

This raises some questions: Have they ever read the whole Bible themselves? And for those who have, do they ever think about what they have read? And do they take into consideration how much the meaning of words change from generation to generation, let alone century to century?

A Pharisee asked Jesus what is the greatest commandment in the law; Jesus readily replied (in Mt 22: 37 - 40 NRSV): "Love the Lord your God with all your heart, with all your soul, and with all your mind." It is okay to use your mind, to think about what you read, and ask questions about interpretation.

Consider the story of Creation in Genesis Chapter 1: "the earth was a formless void and darkness covered the face of the deep, while the spirit of God swept over the face of the waters. Then God said, 'Let there be light'; and there was light." Modern scientists would agree with the beginning of the creation story; they would envision a plasma of subatomic particles, but in ancient times "waters" would be the closest word in human vocabulary, and the "big bang" certainly produced an instantaneous, massive burst of light.

The Bible itself modifies the concept of all creation taking place in six days: (Psalm 90 v 4: For a thousand years in your [God's] sight are like yesterday when it is past, or like a watch in the night.

Some of Moses' laws in the Old Testament have changes even by the time of the New Testament:

Exodus 21, the next chapter after the Ten Commandments: the laws about slave ownership. The history of slavery goes from "anything is permitted" to "owner and slave both have the same master . . ." And nowadays, slavery is not permitted at all in most nations.

In Leviticus ch 11: the laws about food declare many animals unclean and not to be eaten. Has God changed his mind about these? In Mark 7:19, Jesus declared all foods clean.

Deuteronomy 21 v 18 - 21: The law for a disobedient son: Stone him to death. Not legal nowadays in any country that I know of.

Deuteronomy 22 v 28 - 29 - The law about rape victims. The rapist shall pay the girl's father a fine; The rapist shall then marry her, and cannot ever divorce her. But where is justice for her?

Slavery was justified for centuries by quoting Genesis 9, where one of Noah's sons, Ham, somehow offended his father, and his descendents were cursed to forever be the slaves of the descendents of Noah's other two sons. Did Noah's curse justify slavery, thousands of years later? Southern Baptists, many of whom are descendents of slave owners, finally issued an official apology 120 years after slavery was abolished in America.

The history of vengeance, from maximum force, through eye-for-an-eye, to forgiveness and loving your enemy: Is the world ready yet for peace? Can we handle it? There are many such questions that could be discussed.

But the central question is, Does God change?

Is not the Bible a history, rather, of the changing human understanding of the eternal unchanging God, down through the ages? (and also, perhaps, the history of God eternally reaching out to humans, waiting for them to trust and obey?)

And on into the future? There is a hymn sung by some Christians; not a quotation from the Bible, but a thought worth pondering, nevertheless. Written by poet James Russell Lowell, one verse goes:

By the light of burning martyrs, Christ, Thy bleeding feet we track,
Toiling up new Calvaries ever with the cross that turns not back;
New occasions teach new duties, time makes ancient good uncouth;
They must upward still, and onward, who would keep abreast of truth.

Wednesday, October 8, 2014

When you can't get a doctor's appointment soon

Although I am retired from medical practice now, friends often complain to me that their doctor's office can't work them in until six weeks from now.
"But I'm sick now! The pain just started Friday, and it's getting worse! His office clerk told me to go to the hospital emergency room, but the doctor there just gave me a prescription for hydrocodone and told me if it didn't work, to see my doctor Monday. When I told the ER doc that I'd already tried get an appointment and the first opening wasn't till six weeks from now, he acted like that wasn't his problem. And the ER visit cost me $160."
It's true, most doctors keep busy. There may be several reasons for difficulty getting an appointment. Office appointment secretaries often book the schedule full for days in advance, instead of leaving room for walk-ins. Sometime in the year, the doctor will take vacation time, or maybe update his knowledge at a medical conference, or maybe need some sick-time himself. And there may be times when he has a big emergency at the hospital or office that wipes out several appointments and delays everyone.
That being said, the doctor can remedy long waits by using a different appointment policy, and here it is. I used it for fifteen years of solo office practice, and I know it works. It should work even easier when several doctors share an office (if they don't all demand the same day off.)
Doctors: Leave space open for the walk-ins, and make life easier for yourself, your staff, and your patients.
Walk-ins happen. Half the patients you see only got sick or injured a day or two ago. So leave time for them. Here's how it works:
Figure out how long it takes you to see the average return visit, or minor new complaint. In my case, it averaged around 15 minutes - 4 patient appointments each hour, If my secretary knew it would be a new OB or a diagnostic workup, she scheduled it for 2 or more time slots. I was dependably in my office from 10 to 5 Mon-Tues-Thurs-Fri, + Wed and Sat from 10 till noon. An hour off for lunch. I did hospital rounds and/or minor surgery from 8-10. Work out your own schedule as you choose, then stick to it and let your patients know it.
Now, I told the front office to fill two of those four slots each hour ahead of the day. If those fill up six weeks in advance, so be it; they are only routine return checkups. That leaves two slots for each hour when each day begins. The secretary knows she can fill one of those for each hour for anybody who phones in that morning - Mrs. Jones' kid, who developed a fever in the night; or Mr. Smith with a cold that now has cough and chest pain, whatever. That leaves one opening each hour for emergency walk-ins, and they do happen. But done this way, it doesn't mean making your other patients wait past their appointment time. Sometimes there will still be waits. But your patients will be more likely to accept that because they know they can usually get in on the same day they phone in. If you're in surgery or the delivery room, or going to be away next week, the secretary makes sure the patients know that right away, and she offers to reschedule those who wish.
Sometimes a slot never filled. No problem; I used that time to catch up on my medical journals or correspondence. And I usually was able to accept new patients at their first call. It requires a doctor to stick to his office hours and start on time - read the newspaper later. It requires a knowledgeable person on the front desk, and you need to pay her wages accordingly, and instruct her how to handle calls. A good helper rarely has to call you out of an examining room, but be sure to answer your phone messages or e-mails promptly.
Readers: You can help make the visit easier, too, by doing some preparation before seeing the doctor: (1) If there is any question of fever, take your temperature (preferably in the evening, when it's likely to be highest) before you see the doc. It doesn't help him for you to say, "well I felt my forehead and it didn't feel hot."
(2) Write down a brief list of whatever problems you need to talk to your doc about. The reason you are coming, of course, with the major symptoms; and perhaps some ongoing problems you want to be sure to remind him of. Don't hit your doc with an "Oh, and by the way . . ." as he or you are going out the door. Take time to communicate - no essays or orations are necessary - just so long as he is aware of your major problem(s) of the day. Let him get to the next sick person on time, if you can.
(3) have a list of your allergies and medications written down, in case the doc or the nurse asks."I take a white pill and a green one," is not adequate. Spell the medicine's name and dose.
(4) It helps to let the doctor know you appreciate the pleasant surprise of getting an appointment the same day you called.

Monday, October 6, 2014

Who Can Afford American Drug Prices

Who Can Afford American Drug Prices?
Last night I watched 60 Minutes with my daughter, who manages the Critical Care Unit of a large hospital. The topic was prices pharmaceutical companies are charging for their products. Some cancer drugs now cost more than eight thousand dollars a month (and must be taken for months or years.)
How did this ever get started? Somehow, Congress enacted a law that forbade the VA, Medicare, etc. from negotiating prices, leaving the drug companies free to charge as much as they liked. In other nations the drugs cost about one tenth the price, even though they come from USA. And it doesn't affect only cancer drugs. I get the same story many times from with former patients (I am retired.)
A chapter from my 2008 book Access to Medical Care seems worth repeating here:

Chapter Four: The Medicine She Never Took
"My doctor gave me a new medicine for my stomach pain," a friend answered when I expressed hope that she was feeling well. "It works fine, but I can't take it."
"I'm sorry to hear that," I said. "Too many side effects?"
"No, the free samples he gave me helped a lot. But when I took his prescription to the pharmacy, a month's supply was four hundred dollars. That's almost half my Social Security check! How am I going to pay my utility bills and buy my groceries? So I'll just keep on with the antacids."
"Did you tell your doctor you couldn't pay that kind of price?"
"I phoned him, and he said he had no idea it was that high."
"Did you ask him about any of the over-the-counter medicines? Some of them are about one-tenth that price, or less."
"No, I didn't know anything about that. He had his nurse make me an appointment for two weeks from now for follow-up. But I never had the prescription filled when I found out the cost."
If you think that's an isolated example, a
nother patient had had at least six back surgeries over the years (laminectomy) and no surgeon would now touch his scarred back. His local doctor was trying to manage the pain with various pills and patches, some of which eased his steady pain, but not the "lightning spasms" that struck when he moved wrong. Additonally, over the years, he had developed unacceptable reactions to some of the medicines, and the doctor was trying a new one. His medical insurance refused to pay for it. The doctor's office clerk said she would try and straighten the matter out, and would call him back. She never did, nor even to let him know the problem. He finally called his pharmacist to see if he could afford to pay for it himself, and found to his horror that a month's supply was $525.00, half his entire monthy income. Presumably, the doctor's clerk could have found that out, but if she did, she never let him know.
These illustrate a basic flaw in the American way of marketing medicines. The manufacturers have well-paid "detail persons" who make regular calls at each and every doctor's office to inform him/her about their company's latest and most advanced product. They sometimes used to appear around noon, with enough pizza for the whole office staff. Friendly people, well trained and informed in their field, they are a principle source of information for busy doctors who don't spend as much time as they might with medical journals and Internet search. The pharmaceutical rep has free samples to leave with the doctor, along with note pads or pens bearing the product's name.
Sometimes the reps really do have valuable updates for the doctor, but they rarely mention the price of their product, or that the older remedies still work as well as they always did. And the doctor will try the samples on his patients because (a) he doesn't want them to buy a whole month's supply of any medicine unless he knows it works for them, and/or (b) he may want to help a patient he knows is having difficulty affording care.
Most doctors don't keep up with the present-day price of what they prescribe. But they could. Every doctor gets an annual free update of Physician's Desk Reference listing all prescription medicines with their uses, side effects, and precautions (about 4,000+ pagesold copies make good doorstops), and a supplement with all the non-prescription medicines is available as well. Plus an annual update of Redbook (not the women's fashions one, but current drug retail prices) with the option of subscribing to monthly updates.
So -
here's what a patient can do. Don't be afraid to ask what a new prescription will cost, and if necessary, ask if there is a less expensive generic that will be adequate. Sometimes there will be, sometimes not.
Doctors, here's what you can do. Be aware that the latest drug is pushed by the drug rep because that's what he/she is hired to do. It's good to keep that product in mind, but ask yourself, "Is this what this patient sitting here in front of me really needs, or will an older, less expensive drug be effective?" And stay away from reps who want to buy you meals or pay for a vacation trip. Your patients have to pay for that in the cost of their medicine.
And all you readers in the general public, pressure your reps in Congress to reasonably regulate the charges for medicines. Why should a drug that has been on the market fifteen years now cost thirty dollars per pill when the company was raking in high profits at the original price of ten dollars per pill? Why should an injection aimed at mass use be selling for thirty-five dollars, when it originally wholesaled forty years ago at one dollar? Or why should a drug, manufactured in USA, sell for less in Canada or Europe than it does here where it was made?
Even in a free market economy, the customer should get as much consideration as the company's stock holders get.

Returning to the Sixty Minutes report, I asked my daughter how her hospital handles these exorbitant costs. "Often we talk with the doctor, especially in cases where the drug is likely to prolong life only a month or two. More and more, hospitals are buying out the doctor's practice [that is, it's the same doctor, but now employed by the hospital.] Medicare can't negotiate the price, but we can, and we can buy in bulk, getting a much lower price."
Granted, new medicines sometimes do cost a lot to develop, but that ill-advised law forbidding federal agencies to negotiate the price should be repealed. Or perhaps USA should go to a single payer system like most other countries have. As things stand now, even insured patients are going bankrupt.