Wendell Berry Quote

“Several years ago I argued with a friend of mine that we might make money by going ahead and marketing some inferior lamb.  My friend thought about this for a minute and then he said “I’m in the business of producing good lambs, and I’ll not go selling the other kind. He also said he kept the weeds out of his crops for the same reason that we washed his face.  Surely no one would question that the human race has survived by that attitude.  It still survives by that attitude, though now it can hardly be said to know it, much less acknowledge it.  But this attitude does not come from technique or technology.  It does not come from education.  In more than two decades in universities I’ve rarely seen it. It does not come even from principle. It comes from a passion that is culturally prepared.  A passion for excellence and order that is characteristically and maybe exclusively handed down to young people by older people whom they respect and love.  When we destroy the possibility of that succession, we will have gone far for destroying ourselves.” -Wendell Berry

Taken from the documentary “Look & See: A Portrait of Wendell Berry”

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Analysis of my difficulty with primary care (please rebut)

I feel the need to examine my 2-year foray back into primary care.  I failed miserably at it.  I did not necessarily fail in my medical decision-making (though looking back I can think of several individual major short-comings that I wish I had managed differently).  I did get great compliments from patients and there are several patients I will miss.  But I did fail in that I was not able to sustain my job and my satisfaction therein.  Even though I literally only worked in clinic 4 days per month on my off-weeks from my full-time hospitalist role, I could no longer bear the thought of continuing.  Why?  The answer, it seems, is complicated.  But I feel the need to examine some of the reasons.  I’m not going to go into my little “pet peeves” I dealt with such as always having to fill out paperwork, insurance denying first-line medications, patients showing up late, and so on.  Others have dealt with why they think physicians are getting burned out (EMRs are often cited as a large part of the problem).  My thoughts deal with more deep-rooted problems with health in America and how this affects primary care.

I will start by saying that I think it takes a very, very special type of person to be a good or great primary care provider.  Not only is there the obvious need for good social skills (e.g. making a good interpersonal connection, knowing how to stop a tangential patient, etc.), but they have to be good at time management and familiar with diagnosis and management of hundreds of problems that range from orthopedic to cardiac to psychiatric and so on.  They also, ideally, need to have genuine sympathy in dealing with the kind of patients I am going to describe.  That some people do this kind of work 4 or 5 days a week every week is extremely impressive to me.  I do not have the fortitude or skills to do that.

I feel my biggest personal problem in primary care is the dilemma of the doctor caring more about the health of the patient than the patient himself. It is encountered all the time.  I’m thinking of the COPDer on 3L of oxygen who still smokes.  I’m thinking of the 45 year old with three coronary artery stents who eats bacon and sausage nearly every day who has no interest in a heart healthy diet and does not think (or perhaps care) that many of his problems can literally be reversed by strict lifestyle changes.  It’s clear to the physician that the patient is a ticking time bomb.  It’s like you see someone on a raft heading toward a waterfall, but when you tell them what to do, they really don’t seem to care.  Motivational interviewing can only do so much.  Attempts at education can only go so far.  Usually they know that what they’re doing is unhealthy.  The problem is that they do not care.  They have decided that the costs outweigh the benefits.  What is life if they cannot enjoy their meat-based American diet?  For me this is a hopeless feeling that I personally struggle with.  How am I supposed to help someone when I care more about the situation than they do?  We like to think of sick patients as those who yearn for a cure, such as a patient with a heart defect or infectious disease in a 3rd world country.  But in rural America chronic diseases are often tied to lifestyle and social ills, and countering such diseases is often not only takes a lot of work and sacrifice on the part of the patient but also requires changes that are countercultural…too much of a leap.  Diet and lifestyle in the U.S. is such that it is actually countercultural to live healthily.  An individual’s level of care about his or her own health is a spectrum – from suicidal on one end to “health-obsessed”/health-anxiety on the other.  When a patient is more toward the former, trying to education them is often futile.  Since I am by nature closer to to the latter, it is hard for me to empathize with those on the other end.

Another qualm with primary care was the sheer burden of deep rooted psychological turmoil of high complexity.  In rural areas this is exacerbated by very limited availability of psychiatric or psychological services.   There is something about poverty which has a strong association with high levels of abuse, trauma, cycles of violence, etc. that really mess people up.  I think it’s more than just a “normalization” of bad behavior or “growing numb” to dysfunction.  This early exposure to evil (direct and indirect) literally changes one’s neuronal circuitry leading to more socially-deviant behavior, self-destructive practices, severe mental health issues, and (VERY fascinatingly to me) somatic dysfunction like problems with chronic back pain, dysmenorrhea, etc.  They often end up on multiple psych meds and many times end up on chronic narcotics.  In a lot of cases they get back surgery.  They almost universally smoke.  Marijuana, alcohol, and other forms of mental “escape” are common coping mechanisms.  For me, these are difficult patients to take care of for many reasons.  1) Their problems are in part due to and interwoven with their entire background which cannot be changed.  2) They engage in very unhealthy behavior, making it seem as though they are apathetic about their own health.   3) They never really “get better” but go through various cycles of ups and downs.  You invariably go through various SSRIs, SNRIs, atypical antidepressants, and antipsychotics all in various iterations trying to find something that will make the patient less depressed and/or less anxious and/or in less pain and/or more able to sleep.  You may or may not find something that works.  A lot of times you don’t.  Or they really need psychotherapy but this is not available to them or they are not willing to go.  This is a “normal” patient in primary care, especially in rural America.  Yet it’s clear that nothing here is normal (as it should be).  Nothing here is physiologic.  Nothing is working properly at it was designed to do.  What’s going on here?  They were born into excessively high levels of sin and dysfunction.  Maybe they were abused, leading to severe permanent neuronal damage.  Maybe they inherited some genetic predisposition toward alcohol abuse.  They have disordered and unhealthy family relationships.  They try to cope with the drama and turmoil as best they can, but have practically none of the biopsychosocial tools to do so.  They are not only victims of their own immediate surroundings, but they are also victims of the food system, corporate advertising, and the general consumer culture in which things are made obsolete within a few years.  They are victims and victimizers at the same time.  I want to help them, but I feel helpless because the only solution is a world without sin and suffering.  So I try to pray with them or share the Gospel, but this is hard in the office setting.

Another, although less frequent, issue to be dealt with is the patient with complex psychosomatic symptom(s) who frequently request expensive and unnecessary diagnostic testing and referrals to specialists.  Examples of this would be a patient with fatigue who is convinced she has chronic Lyme disease or hypothyroidism (and does not think a normal TSH rules it out).  They are usually swayed by what they read on the internet and heavily by pseudoscience and/or personal experiences of family or friends (N of 1 anecdotal evidence).  On many occasions I would come across patients so deeply steeped in pseudoscience that getting them to understand something of their own health would actually require them to erase everything they know about the issue and actually go back to high school biology and physiology class.  Examples of such insanity include systemic “yeast overgrowth”, benefits alkaline water, vaccinations causing diseases, high levels of heavy metals in the body (with no objective signs), and so on.  Internet communities and online articles are making all of these absurd notions much more common than they otherwise would be.  They erode confidence in doctors, medicine, science.

I know this comes off very cynical.  It is.  That is why I’m taking a break from primary care.  I wish I could offer solutions to these problems, such as coming up with ways to educate people such that making healthy decisions weren’t so bizarre.  I would guess that the answer most would give me is that physicians are by nature reactive (treating whatever disease that presents itself regardless of why it occurred).   I think of people like Dr. Tom Catena who alone treats patients (surgical and non-surgical) in the Nuba Mountains of South Sudan.  I’m sure if I were to glimpse into his practice a lot of my qualms with clinic would seem pretty trivial.

Internal Changes in 2018

I entered 2018 with skeptical reservation.  In 2017 I was still steeped in student loan debt and work, but was still mostly my old self.  I was at a new but stable baseline of being pissed off at my fellow “evangelicals” for their love for Trump and making him President.  I’m still steeped in debt (essentially at the same level).  Much to my great surprise, I have changed a somewhat shocking degree.  I feel I’ve changed more in 2018 than I have in the last 4 years combined.  Maybe it’s just aging.  I don’t know.

Vegetarian.  I’m following the science.  It was hard.  Still is at times.  But also very pleasurable.  My palate has changed for the better.  I can taste subtle nuances and honestly feel I can critique food very well.  If the science directs me otherwise, I will follow it.  I reversed course on omega 3’s, so I’ve done it before.

More introverted, hermit-like.  This is bad.

Borderline if not frank OCD:  Clean lines, symmetry, order are high on the priority list.  Pleasurable dopamine release when I attain a clean kitchen.

More cynical of the world.  Disgusted with the path of humanity, man’s greed, abuse of the planet.  Disgust with politics (I’ll call this the “Trump effect”).

Struggling with the level of sin and suffering.  Not the existence thereof, but the level.  The fact that it is the rule, not the exception.  It is ubiquitous.  The general rule seems to be 95% suffering, misery, pain, and sin, with perhaps 5% great joy and pleasure, then they die and go to hell.  I struggle with that.

Desire for simplification of life.

Interest in cuisine: plethora of ingredients and methods of preparation.  Traditions.

Nutrition: From (essentially) an LDL doubter promoting low-carb intake to “whole food/plant based,” low fat/animal protein/dairy.  I eat legumes every day.

Less concerned with maximizing medical knowledge and skills and more concerned with the above (balance).

Growing feeling of disenfranchisement within the local Baptist church due to its complacency on social justice and its bold support for Republican political candidates.  It’s actually not really the support as much as the fact that they are so vociferous about it AT CHURCH.  Of course I do not have the time or willpower to list out everything wrong with all of this, but suffice it to say that I’m fed up.  It actually stirs up a visceral reaction in my gut when I dwell on it at length, so I will just leave it at that.

Springs of Water

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Springs have always garnered a very deep fascination with me.  Most of the time I did not understand why.  But at times over the years I’ve thought about it, and I’ve come to more of an understanding of this fascination.

Constant.  Perpetual.  Overarching.  Provided the water table is high enough, springs continuously flow in their usually peaceful setting all year long, regardless of who the president is, what national tragedy occurred that day, or whatever bad diagnosis you’ve been given.  As the Lord is on his throne, so springs are a symbol of stability, and in that way they are “overarching.”

Beautiful.  It’s a subjective thing but I’ve seen springs that all would agree are stunning.  Springs are things of either simple allure or stunning beauty.  “Blue Spring” east of Eminence, MO is probably one of the most tranquil and stunning places I’ve seen.

Mysterious.  From where does the water come?  What pores, rocks, caves, channels, etc. does all the water pass through to finally break free?  How to all the corridors converge onto this one exit point?  Its miles and miles and miles of darkened passageways man shall never know.

Source of life.  The plant life that lives year-round in the spring water is almost translucent green.  The water has sustained wildlife and human life alike for thousands of years.  The water is pure enough to drink from (even now).

Appreciate the “little things,” though I would argue that what seems little or trivial by the world can actually be profound and meaningful.  The opposite is true.  What some would kill for is actually a worthless chasing after the wind.

As I think of other reasons of my appreciation for springs, I will add them to this list.

 

The Silence of the Dead

Mass killings chill me to the core, as I’m sure they do most people when they dwell on them.  They are stark in my mind (compared to other forms of murder such as crimes of passion, drunk drivers, drive-by’s, etc) because of the extreme intentionality.   It requires a systematic approach taken by the killers who are specifically targeting a group of people deemed unworthy of life.  I came across a photograph on Twitter recently of a fake shower head used in a German concentration camp.  Such a small thing blew my mind – A human mind thought to create a fake which was installed only to trick victims into thinking they were actually taking a shower (they were also handed a towel and a bar of soap).  As I thought about it, it was the intentionality that shook me to the core.  Intentional deception to intentionally kill in startling numbers.

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Dachau “Shower Room” (gas chamber)

The prevalence and frequency of genocides is startling to me and the fact that humanity does not have a general mass “consciousness” that such atrocities 1) will happen again, 2) can be monitored for, and 3) can thus possibly be prevented or curbed is depressing to me.  Why do I feel this is important?

First, the obvious stance of the sanctity of human life.  Given my view on the supernatural/spiritual, good, evil, sin, redemption, etc, I firmly hold that each individual human life is sacred.  It seems like this should go without saying, but it is 2018…..and it is abundantly clear that this is not agreed upon.  Arguing such things as the existence of God, the problem of evil, when human life begins, and other contentious issues are for others to do.  I have settled on the opinion that some things just need to be left as a matter of faith, in order that this world will make more sense.  But the objective reality of the world is that human life (and all life in general) is treated as flippantly as throwing away junk mail.  Murder is ubiquitous.

Meriam-Webster defines sacred as “set apart for service or worship of a deity; worthy of religious veneration; highly valued and important; holy,” and so on.  When applied to “human life” this is a lofty description full of deep theologicial underpinnings.  This elevation of the value of human life flows from my spiritual beliefs as a Christian mentioned above.  Others, who do not share my beliefs, should not therefore be expected to hold this standard regarding human life.  But I feel most people understand the concept of “life is sacred” and agree with it to some extent (even though the perpetrators of genocide would likely argue that certain qualities exclude some lives from being regarded as “sacred”).

Second, if life is sacred, then something of sacred value is lost when a human dies.  All the more so in genocides.  In the case of genocides the magnitude of evil is so large that the dead are often forgotten for who they were as a person (as complex as that can be) and they are therefore defined by how they died (e.g. a Tutsi mother of 5 killed in Rwanda in 1994).  But simply knowing names and numbers of dead without emotion doesn’t accomplish anything or honor the sacredness of life lost.  It must be accompanied by action (faith without works is dead).  Therefore, I feel that we must, as a society, develop a general mass-conciousness of the reality of man’s tendency toward genocide.  So genocide museums, history eduction, media coverage, etc all have an extremely important role.  The opposite of this would be to deny that the genocide took place (e.g. Holocaust denial).  Denying that a particular murder (or thousands or millions) took place is to deny the existence of the human themselves which is to deny the sacredness therein.  This may not be as bad as turning the gas valve at Auschwitz but I think it’s pretty close.

The dead cannot speak.  There absence from the earth is powerful, heavy, like a vacuum, although no one feels it.  Their silence is the direct result aimed for by the people doing the planning and killing.  In that sense, the killers have won.  The dead cannot speak of what it felt like to realize that they had been singled out for a particular ethnic or religious trait and feel death closing in in absolute horror.  We can only have glimpses of how that feels from the survivors.  And because of the finality of death their silence and absence becomes the new “normal” for the rest of the population.  Like someone who doesn’t show up at a party to which they were invited, the party-goers have no idea of what the party would have been like if that person had shown up.  It doesn’t even enter the party-goers’ minds.  It’s an absence to which they are completely unaware, except maybe by the host who invited them.

Thus, in conclusion, this is why I will teach my children about history and the reality of evil and genocide (as morbid and depressing as that is) – so that they will learn to be vigilant and to care.

Run-On Sentence

boxley-valley-farm-james-barberStruggling with the idea that a life of missional evangelism partly depends on gifting of the Holy Spirit and/or certain (more extroverted) personalities, I’ve delved deeper into things concerning the meaning of life, into the writings of Wendell Berry thinking that harmony with God’s creation (“nature”) may be it, only to realize that

  1. Nothing stays clean or organized or symmetric with kids,
  2. Dry seasons will kill grass and plants,
  3. Disease like a random lymphoma or other illness can hit at any time, and
  4. Even if everything around you is “Perfect” there will still be days where it seems like things are too quite and you’ll get bored, not having anything to do (like striving to attain perfection before things were perfect).

Then I come closer to the conclusion reached by Solomon in Ecclesiastes when he said that all is meaningless, chasing after the wind.

 

Food Elitism and Unattainable Ingredients

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I watch certain cooking shows for inspiration on how to cook – methods, ingredients, combinations, etc.  I bought a cookbook (“Charlie Trotter’s Vegetables”) for the same reason.  A problem that I run into with 98% of recipes in the book is that they use ingredients that are essentially impossible for me to obtain.  As an example, here’s a recipe that calls for adzuki beans, red icicle radishes, French morning radishes, white carrots, and fiddlehead ferns, among other (more obtainable) ingredients.  That is very typical of this cookbook.  Tonight I was watching “Mind of a Chef” and one recipe, which the chef called avocado sushi, was described by him as “very simple” and consisted of sushi rice, avocado, a bit of a honey lime vinaigrette…and “salted cod cream.”  One may ask how one would make “salted cod cream.”  By salting a piece of fresh raw cod overnight, cooking it in cream that has been INFUSED with garlic, fresh thyme, and fresh rosemary, and then emulsifying all of this into a smooth liquid.  At this point the liquid is put into a siphon gun with CO2, and then magically placed on a plate in mousse form.  After that you add the rice, avocado, and vinaigrette.  SIMPLE!  That is probably more complex than any recipe I have every made.  It does look and sound amazing though.  Because of the complexity of following the advice of professional chefs who essentially have unlimited access to any ingredient, I resort to trying to prepare vegetables and other foods simply with very few ingredients in order to maximize the flavor of the original plant.

I have realized that the world of complex preparations and presentations of food is meant for “special occasions” and are done that way for that reason (to be special, artistic, hopefully taste good, etc….).  No normal person has or will use edible flowers for their dinner plate.  Do they make food look really awesome?  Yes.  Are they essentially devoid of all practical and nutritional use?  Also yes.

Recently I have delved into the world of what I will call “food elitism” as presented by the likes of shows like “Chef’s Table” and food blogs such as “A Life Worth Eating.”  It is clearly food elitism for the very simple fact that this sort of fine dining experience is unattainable to 99.999% of humanity.  The flavors presented at these types of restaurants will never been known to the general population most of whom throughout the world struggle to get enough micro- and macronutrients.  Obviously there is nothing intrinsically wrong with enjoying such food.  But…the aversion I have to it (and I will freely and openly admit that jealously plays a part in my aversion) is that I feel that something so good should not be restricted to the highest echelons of society … that it is so unattainable.  The very concept of the tasting menu is a little crazy to me because if someone is eating at such a place on an extremely rare occasion (as I assume many who eat at such restaurants are doing), a very rare and amazing food item will only be enjoyed for a split second before it is gone…probably never to be had again.  But is anyone at fault?  I think the answer is yes.  I believe there is an intentional effort to keep such food rare, expensive, and fine…like the makers of private yachts.

The frustrating thing to me as a human and as a doctor is that oftentimes the fancy and expensive foods are healthy foods (I’m not referring to steak here).  In that regard one is paying for the work of the chef…and for the experience.  But I would like to hope that with proper access and education one can eat healthy food that is also delicious (albeit not “Chef’s Table” caliber) for very little cost.  The solution to this is to buy fresh whole foods and learn to prepare them at home.  Examples: 1) whole/rolled oatmeal with fresh fruit, 2) romaine lettuce and/or spinach with homemade dressing, 3) spinach sautéed with garlic.  Of course, even this recommendation is from a vantage point of elitism, as such foods are not accessible to those who cannot afford it, especially those who live in inner cities and other “food deserts.”  And not only is there an accessibility factor and an economic factor, but there is also a time factor.  If you are a parent who has to work two jobs, then you simply will not have time to prepare healthy foods.  You will be 100% required to eat 100% processed and ready-to-eat foods high in sugar, fat, and refined carbohydrates.

What is crazy to me is that food deserts are not just in inner cities.  They are also in Indian reservations and very rural America, which tells me that we have completely disengaged from the land around us and its ability to provide food.  Put another way, we as a culture are reliant on the industrial food complex and the food we eat is produced hundreds or thousands of miles away.  To me it is completely absurd and paradoxical that a person in poverty in rural Appalachia will be eating a meal of macaroni and cheese assembled from wheat from North Dakota and cheese from cows in California, all assembled at a Kraft plant in Missouri…when that person is surrounded by lush green mountains that sustained their ancestors and Native Americans before them.  But the notion of eating foods that grow around you naturally is so completely foreign to our culture…for so many reasons.  It is not practical on a daily basis.  It unable to feed the masses.  And such knowledge is essentially lost and unknowable and unreachable by the general population.  To grow native plants on native land is only attainable by chefs with wealthy investors and their food suppliers, at least in the present food climate.  Unfortunately I have no proposed solutions to these problems.  But the best I could recommend is the adage “Eat the best plants you can afford.”

Here is an old but interesting article by Michael Pollan that better summarizes my thoughts on this issue.

On a side note, Bob Dylan wrote a line in one of this Christian songs that goes

I was eating with the pigs off a fancy tray

I was told I was looking good and to have a nice day

It all seemed so proper; it all seemed so elite

Eating that absolute garbage while being so discreet

But You changed my life

Came along in a time of strife

From silver and gold to what man cannot hold

You changed my life

Do not make food an idol.  Do not make healthy eating an idol.  It is a reminder to myself more than anyone.  One could argue that it is a good thing to enjoy God’s creation by enjoying as many good foods as possible.  But these things will not bring ultimate satisfaction or fulfillment.  There is a place for healthy eating, but it should not supercede our primary purpose of living.